A prospective study of a new protocol for 'in situ' diagnosis of central venous catheter related bacteraemia

59 patients with suspected central venous catheter related bacteraemia (CRB), while receiving parenteral nutrition, were studied prospectively. 41 (Group 1) were managed conservatively: cultures were taken from the catheter hub lumen, skin at the catheter entry site and peripheral blood; the catheter was then heparinised and locked for 24-48 h. The catheter was withdrawn only if cultures were positive; otherwise parenteral nutrition was resumed. In 18 patients the catheter was immediately withdrawn (Group 2) and the same cultures plus tip culture were performed. 13 patients of Group 1 with positive hub or skin cultures, had their catheters removed and 12 had blood cultures matching for the same micro-organism. Negative skin and hub cultures had a negative predictive value for CRB of 96%. A positive hub culture had a 100% positive predictive value for CRB. CRB was diagnosed in 11 patients out of the 18 in whom catheters were withdrawn immediately (Group 2). Thus, 1 out of 41 catheters and 7 out of 18 catheters were removed unnecessarily in Groups 1 and 2 respectively (p = 0.001, Fisher's test). In all, 24 CRBs were documented and 15 were due to coagulase negative staphylococci. The catheter hub was the commonest origin of CRB followed by the infusate and the skin. In febrile patients on parenteral nutrition, negative skin and hub cultures accurately predict or rule out CRB and should be used more often to avoid withdrawal of sterile catheters.     

Percutaneous, tunneled silicone elastomer central venous catheters for total parenteral nutrition: low sepsis and thrombosis rate. A prospective study of 315 catheters

Silastic catheters were inserted by the percutaneous route, and tunneled subcutaneously, in 315 patients who needed venous access for total parenteral nutrition. The catheters were managed with a daily program that included heat sterilization of the metal hub with an electrical soldering iron. This study aimed to evaluate prospectively the incidence of catheter-related sepsis and thrombosis. There was one case of pneumothorax. All catheters were x-rayed post-insertion: eight catheters were malpositioned initially. The median catheter duration was 18 days with a range of 2-138 days. The total duration was 240 catheter-months. Twenty-seven catheters were removed due to mechanical problems. Nine were removed because of suspected sepsis; six patients had negative blood and catheter cultures, while three grew pathogens. The sepsis rate was thus 0.95%. There were no clinical signs of thrombosis. Pull-out venography was performed in 93 patients. Fibrin sleeves were seen in the majority of cases. Two patients had wall-adherent, non-occlusive thrombus masses (2%); they both had proximal catheter positions. We conclude that there is a low risk of catheter-related sepsis and thrombosis with this technique.     

Hub Colonization as the Initial Step in an Outbreak of Catheter-Related Sepsis Due to Coagulase Negative Staphylococci during Parenteral Nutrition

A prospective study was carried out to determine the pathogenesis of coagulase negative staphylococci catheter-related sepsis during parenteral nutrition. Forty-three catheters were cultured by semiquantitative and quantitative methods. The skin around the puncture site was cultured at the time of catheter removal and three segments of the catheter were cultured apart: the hub, the proximal subcutaneous segment, and the tip. Skin cultures were negative (89%) or yielded different coagulase negative staphylococci from those recovered in catheter and/or blood. Seventeen catheters were the source of sepsis. In 15 cases an infected hub was associated with an infected tip. In two cases the hub was negative (one sepsis due to mixture contamination and the other due to hematogenous seeding of the catheter tip). Sixteen cases of sepsis were due to coagulase negative staphylococci. Staphylococcus epidermidis has been the species most commonly isolated, followed by Staphylococcus haemolyticus, Staphylococcus saprophyticus, and Staphylococcus hominis. In our patients most catheter sepsis have their origin in an infected hub and are not due to migration of skin bacteria along catheter subcutaneous tunnel. (Journal of Parenternal and Enteral Nutrition 8:668–672, 1984)     

Predictive value of surveillance skin and hub cultures in central venous catheters sepsis

In a prospective study of septic complications of central venous catheters used for total parenteral nutrition, daily surveillance catheter hub cultures and twice weekly skin cultures at the catheter entry site were evaluated for their predictive value for catheter sepsis, i.e. bacteraemia with an identical species as that recovered from the catheter tip, or catheters which grew greater than or equal to 15 cfus by a semiquantitative method and/or greater than or equal to 10(3) cfus by a quantitative method. Of 142 catheters studied, 29 were identified to have catheter sepsis. For these the sensitivity of the surveillance hub culture was 34.5% and the sensitivity of the skin culture was 37.9%. When either the hub or the skin culture result was considered as an indication of catheter sepsis, the sensitivity increased to 79.3%. The positive and negative predictive value of the combined result was 44.2% and 93.3% respectively. This study suggests that simultaneous hub and skin cultures are required for a satisfactory surveillance.     

TPN catheter sepsis: lack of effect of subcutaneous tunnelling of PVC catheters on sepsis rate

In an effort to diminish the incidence of catheter related sepsis in total parenteral nutrition, the effect of a 10-cm long subcutaneous tunnel was studied in a prospective randomized manner. This tunnel created a longer anatomical distance between puncture site of the catheter and the subclavian vein. In the control group, a direct puncture technique was employed. Eighty-one catheters (group A) were inserted according to the direct technique, 69 (group B) were tunnelled. Catheter sepsis was defined as an episode of clinical sepsis for which no other cause can be identified and which resolves upon removal of the catheter. No significant differences were noted between the two groups, suggesting that tunnelling of subclavian PVC catheters does not diminish the incidence of catheter related sepsis.     

Long-term central venous access vs other home therapies: complications in patients with acquired immunodeficiency syndrome.

One hundred and forty silicone catheters were inserted in 127 patients for long-term intravenous access with a cumulative follow-up time of 21,125 catheter-days (58 patient-years). Fifty-six patients had acquired immunodeficiency syndrome (AIDS); 44 were not AIDS patients and were receiving ambulatory home parenteral nutrition, whereas the remaining 27 did not have AIDS and were receiving home antibiotic therapy. Patients had a mean of 1.1 catheters inserted, and the rate of Hickman catheter-related sepsis was 0.18 per 100 catheter days or 0.6 septic episodes per patient year of treatment. Catheter-related sepsis was higher in AIDS patients (p < .01) and in patients receiving parenteral nutrition (p < .05) compared with those receiving antibiotic therapy. Prior catheter infection and AIDS were the most significant predictors of catheter infection (p < .01). Staphylococcus aureus was the most commonly isolated pathogen (61%) in AIDS patients. Fever (p < .001) and relative leukocytosis (p < .02) were the most common signs of infection. Only 14 infected catheters (37.8%) were salvaged by antibiotic therapy after the initial infection episode, and 6 of these catheters (42.9%) had recurrent multiple infections. In addition, inflammatory bowel disease was found to be a risk factor for venous thrombosis (p = .018). We conclude that because immunocompromised patients have a high risk of infection, catheter-related sepsis in these patients should be treated by catheter removal and antibiotics.     

Antibiotic-lock technique is an effective treatment of bacterial catheter-related sepsis during parenteral nutrition

Catheter-related sepsis is one of the most frequent and troublesome complications of parenteral nutrition. In a 2-year survey of 19 home parenteral nutrition patients, with a total of 25.2 years of cyclic nocturnal parenteral nutrition, the annual incidence of catheter-related sepsis was 1.27, of which 84% were due to bacterial catheter infection without any cutaneous focus. These 27 episodes were treated by a daily, 2 ml injection of antibiotic-saline solution, mainly amikacin, locked for 12 h per day within the infected catheter for 15 (7-20) days. On admission the parenteral nutrition was halted for 2 days and the catheter hub was changed. In 7 cases, an average of 3 days (2-5) of systemic antibiotic therapy was given in addition to the 2-week antibiotic-lock. Control of catheter-sepsis was achieved in 93% of the 27 episodes and parenteral nutrition was resumed using the same catheter with only one episode of recurrent sepsis. The present data confirm our preliminary report of the efficacy of the antibiotic-lock technique for the control of bacterial catheter-related sepsis. This treatment offers the advantage over current therapies of avoiding repeated catheter change and 2-6 weeks of systemic antibiotic therapy.     

Heparin does not reduce catheter sepsis during total parenteral nutrition

Although it is recognized that the addition of heparin to total parenteral nutrition solutions reduces subclavian vein thrombosis from percutaneous polyethylene catheters, it does not affect the low thrombosis rate associated with polyurethane catheters. It has been suggested that heparin also reduces catheter sepsis during total parenteral nutrition. We reviewed the sepsis rate in 86 patients randomized to receive iv nutrition with or without heparin through polyethylene, polyvinyl, and polyurethane catheters. Blood was drawn from febrile patients for culture; if positive, catheters were removed and the tips cultured. Catheters were considered infected if blood and catheter tips were positive, or if fever disappeared within 48 hr after catheter removal, even if cultures were negative. Catheter sepsis occurred in two patients in both groups. It appears that heparin does not reduce sepsis from percutaneous subclavian vein catheters. Although its use may be indicated to reduce thrombosis associated with polyethylene catheters, there is no indication for its use to reduce sepsis with either type of catheter.     

Catheter sepsis during parenteral nutrition: the safety of long-term OpSite dressings

A prospective controlled study of the safety of various catheter dressing protocols was carried out in 168 patients receiving parenteral nutrition via an infraclavicular central venous catheter. Four protocols were compared: 36 patients received gauze dressings changed three times per week; 31 received OpSite dressings changed every 7th day (OpS-7), 32 received OpSite changed every 10th day (OpS-10), and 69 received OpSite changed twice weekly (OpS-ICU). Mean duration of parenteral nutrition was approximately 2 weeks and all groups were well matched except that OpS-ICU patients suffered more frequently from an acute illness. Catheter-related sepsis was identified by clinical signs of systemic sepsis, positive peripheral venous blood and catheter-tip cultures and/or defervescence of fever after catheter removal. Catheter-related sepsis rates were low in all groups: 1/36 for Gauze, 0/31 for OpS-7, 1/32 for OpS-10, and 2/69 for OpS-ICU. Septicemia attributable to causes apart from catheter sepsis occurred in two, two, three, and four patients, respectively. Bacterial colonization of skin beneath OpSite was no more common in the OpS-10 than in the other groups. Signs of inflammation at catheter insertion sites were common in all groups but did not relate closely to skin colonization. OpSite can be safely applied to central venous catheters inserted under strict aseptic conditions, even in patients with open septic drainage. Dressings can be left in place for 7 days with a margin of safety lasting to 10 days, thus saving on cost of materials and nursing time.     

Risk of infection accompanying the use of single-lumen vs double-lumen subclavian catheters: a prospective randomized study

A prospective study was undertaken to compare the risks of a multiple-lumen catheter to bilateral subclavian catheters in patients receiving total parenteral nutrition (TPN). All patients had one preexisting subclavian catheter. Patients were randomized into two groups: one group received a double-lumen catheter via a guidewire change of the preexisting single-lumen subclavian catheter. In the second group, a second single-lumen subclavian catheter was inserted and the preexisting single-lumen catheter was changed over a guidewire. Patients were followed by the Nutrition Support Service and were managed identically with regard to solutions given, catheter care, dressing changes, monitoring of mechanical complications, and evaluation of fever. Total infection rates in both groups were identical (22.7%). The difference in mechanical complication rates in the double-lumen catheter group (9%) and the group with bilateral single-lumen catheters (22.7%) was not significant by Fischer's exact test. The multiple-lumen catheter is superior in convenience and as safe as bilateral single-lumen catheters.     

A Seldinger technique for the insertion of tunneled fixed-hub total parenteral nutrition catheters

Total parenteral nutrition lines are commonly tunneled subcutaneously to decrease rates of sepsis. The history of line tunneling is discussed briefly, noting that to date a surgical approach, a detachable hub catheter or more recently a tunneling rod and 'peel away' introducer have been necessary for this form of central venous access. These systems have problems associated with cost, catheter type and insertion technique. A simple technique for insertion of tunneled total parenteral nutrition catheters is described. The device used consists of a polyurethane catheter with a fixed-hub. The applications of this approach are discussed.     

Polymicrobial catheter sepsis in long term central venous catheters

We present 2 cases of polymicrobial catheter sepsis in patients with long term central venous catheters who were receiving home parenteral nutrition. Both patients were generally unwell with haemodynamic instability. Attempts at catheter salvage by combined antibiotic and fibrinolytic administration through the central line were unsuccessful and resulted in patient deterioration. Catheters were removed in both patients. We conclude that catheter salvage should be considered very carefully in patients with polymicrobial catheter sepsis and there should be a low threshold for catheter removal in these cases.     

Occlusion of silastic broviac catheters as a result of twisting between the catheter and hub assembly

Occlusion is a common cause of catheter malfunction during home parenteral nutrition (HPN). We report 5 cases of central venous catheter occlusion, encountered over a 24 month period, which were associated with twisting of the catheter at the hub assembly. One catheter was replaced before the cause of the occlusion was identified. In 4 cases, twisting was noted prior to catheter removal, and this was corrected in three, allowing HPN to continue without catheter replacement. In 1 case the catheter was repaired. The current design of silastic Broviac catheters allows the catheter to twist around the hub assembly. Over-enthusiastic tightening of the cap of the catheter leads to twisting which causes catheter occlusion. A high index of suspicion should be maintained when dealing with catheter occlusion associated with silastic Broviac catheters. Recognition of the problem allows catheter salvage without recourse to catheter replacement.     

Low catheter sepsis rate in a hospital-wide nutrition support service

Four hundred and seventy-nine catheters were inserted into 471 patients over a 6 year period for the administration of total parenteral nutrition. Catheter insertion was carried out only by surgical members of the nutrition support service. Complications were recorded prospectively and stored, with all other details of treatment, on a microcomputer. The mechanical complication rate was 6.4% of catheters used and the incidence of catheter related sepsis (CRS) 2.9%. Catheters which grew organisms, but were not associated with CRS, occurred in 3.7% of catheters used. Catheter care was performed by nurses throughout the hospital under the supervision of the nutrition nurse. The results of our work indicate that restriction of catheter care to specialised nurses is unnecessary providing there is staff education and support. In addition, the value of routine catheter tip culture in patients, not suspected of having infection, is questionable.     

Prevention of catheter-related sepsis during parenteral nutrition: effect of a new connection device.

A prospective study was carried out to determine the clinical effect of a newly devised catheter connection method (I system) and piggyback access system. Previous studies have demonstrated that the I system avoided bacterial contamination in vitro during tubing change that Luer-Lock connectors did not. The purpose of this study was to investigate the ability of this device coupled with a new closed-system piggyback technique for multipurpose access to reduce catheter-related sepsis in clinical practice. Two hundred and thirty patients receiving total parenteral nutrition were divided into two groups. Group I (n = 106) used the I system connector and group L (n = 124) used a Luer-Lock connector. Catheters in both groups were used for multipurpose access for infusion and blood sampling. In group L, a three-way stopcock and/or pig-gyback system was used for multiple access. In group I, a newly designed closed-system piggyback was used. The incidence of catheter-related sepsis was significantly lower in group I (1.89%/catheter) than in group L (12.10%/catheter) (p < .01, chi 2 analysis), and the average duration of use of each catheter was significantly longer in group I than in Group L (p < .01 by generalized Wilcoxon test). The results of this clinical study suggest that the newly designed connection method and piggyback access system are able to reduce catheter-related sepsis.     

Management of catheter-related infections in pediatric patients

Broviac catheters are commonly used to provide parenteral nutrition and access for infusion of blood products and drugs to pediatric patients. Sepsis is the most common serious complication of continued catheter use. Although removal of the catheter is generally recommended when it becomes contaminated, it may not be feasible to do so without compromising patient care. We evaluated the management of catheter-related infections in pediatric patients with and without removal of catheter. Seventy-seven episodes of catheter sepsis were evaluated in 61 pediatric patients; 24 were neonates and 37 were older children. The catheters were used for multiple purposes in 75% of cases. The most common microorganisms isolated were Staphylococcus epidermidis in 26%, Klebsiella pneumoniae in 9%, and Streptococcus viridans in 8% of cases; other pathogens included group D Enterococcus, Staphylococcus aureus, and Escherichia coli. Pseudomonas aeruginosa was isolated in four older children. Thirty-five patients were treated with antibiotics without catheter removal. Thirty patients received appropriate antibiotic therapy based on the susceptibility data. Twenty-six of these 30 patients responded within 5 days of therapy whereas the others required 15-39 days of treatment. Lack of response was mainly associated with the presence of abscess, immunocompromised status, and organisms P. aeruginosa and Candida albicans. Based on the sensitivity and minimum inhibitory concentration data, a combined regimen of gentamicin and vancomycin would be an effective initial therapy. These findings suggest that (1) catheter sepsis can be managed with appropriate antibiotics, and (2) when continued use of Broviac catheter is desired, a trial of antibiotic therapy should be attempted before catheter removal.     

Which central venous catheter for neonatal use?

Complications in 100 percutaneous central venous catheters used for parenteral nutrition were monitored prospectively in patients on a regional neonatal medical and surgical unit. Infants were randomly allocated to receive either a Vygon Epicutaneous catheter or Dow Corning silastic tubing. The majority of lines -63 - were removed electively when parenteral feeding was no longer required. The most common serious complication was catheter sepsis for which 11 lines were removed; all patients made a complete recovery. Minor mechanical complications were encountered with 17 catheters. There was no difference in performance or complication rate comparing the two types of catheter. Percutaneous central venous catheters provide a suitable and safe means of administration of parenteral nutrition to preterm infants over an extended period of time.     

Environmental Risk Factors for Developing Catheter‐Related Bloodstream Infection in Home Parenteral Nutrition Patients

Background: Tunneled, cuffed, central venous catheters, including Hickman catheters and peripherally inserted central venous catheters (PICCs), are the most commonly used venous access for home parenteral nutrition (HPN) therapy. Catheter‐related bloodstream infection is the most prevalent and severe complication. This study investigated whether environmental risk factors, including smoking, catheter management by a home care nurse, colectomy with stoma, number of infusion days per week, and C‐reactive protein at catheter insertion day, influenced the time to first catheter‐related bloodstream infection (CRBSI). Materials and Methods: In this 6‐year (2008–2014) observational cohort study, adult patients with intestinal failure receiving HPN through either Hickman catheters or PICCs were included. Data were obtained by reviewing medical records, and the environmental risk factors were analyzed with the Cox proportional hazards model. Results: A total of 295 catheters (Hickman catheters: n = 169 and PICCs: n = 126) inserted into 136 patients were registered. Using the PICCs, 1 additional infusion day per week showed to significantly decrease the time to first CRBSI by a factor of 2.47. Hickman catheters managed by a home care nurse had a significantly increased mean (SD) incidence of CRBSI of 1.45 (0.68) per 1000 catheter days. Hickman catheters not managed by a home care nurse had a mean (SD) incidence of 0.56 (0.24). Conclusion: Using the PICC, 1 additional infusion day per week decreased the time to first CRBSI, while having the Hickman catheter managed by a home care nurse increased the mean CRBSI incidence. No other risk factors were found.     

Peripherally Inserted Central Catheter for Use in Home Parenteral Nutrition

Background: Peripherally inserted central catheters (PICCs) are a relatively new device for home parenteral nutrition (HPN). Usually, tunneled central catheters such as the Hickman catheter are used for this purpose. However, severe complications (eg, pneumothorax) have been reported in association with the insertion of the central catheter. In contrast, PICCs may offer some advantages due to the peripheral insertion. There are only few studies on the use of PICCs for HPN. Method: A retrospective study (2008–2012) was performed in our Center for Nutrition and Bowel Disease. Patients receiving parenteral nutrition through PICCs were identified, their files examined, and indication, dwell time, cause of removal, and complications recorded. Results: Fifty‐six patients (aged 28–81 years) had a total of 94 lines. Total catheter days were 9859. Mean catheter days per patient were 179.1, and mean dwell time of each line was 104.9 days (longest, 572 days). There were no major complications in relation to the insertion of the catheters. The catheters were removed due to catheter‐related sepsis, mechanical reasons, and thrombotic complications in 1.7, 2.1, and 0.2 per 1000 catheter days, respectively. Conclusion: This study demonstrates that PICCs are appropriate for use in HPN for at least 3–4 months (a period that sometimes unexpectedly becomes long term). The complications equal those reported for tunneled central catheters. We conclude that PICCs are a relevant alternative to patients receiving HPN, especially if they cannot handle a central line. At present, the choice of catheter must be determined on an individual basis.