Infectious complications during peripheral intravenous therapy with Teflon catheters: a prospective study

Infectious complication rates and associated risk factors occurring during peripheral intravenous therapy with Teflon catheters were determined during a prospective study of 286 cannula insertions. Suppurative phlebitis, cannula-related sepsis or suspected sepsis did not occur. Semiquantitative cannula cultures revealed a colonization rate of 10.4% (12 of 115). Coagulase-negative nonadherent Staphylococcus was the most common colonizing organism occurring in 10 of 12 positive catheters. Alpha Streptococcus and adherent coagulase-negative Staphylococcus colonized the remaining catheters. Colonization was not related to the rate of phlebitis, extravasation or cannulation time. No patient- or catheter-related factors increased the risk of colonization. In children in a general pediatric ward the risk of catheter colonization and subsequent sepsis should not be used as reasons for routinely removing complication-free peripheral Teflon catheters at 72 hours.     

Septicaemia with Coagulase Negative Staphylococci in a Neonatal Intensive Care Unit Risk Factors for Infection, and Antimicrobial Susceptibility of the Bacterial Strains

Eshali, H., Ringertz, S., Nyström, S. and Faxelius, G. (The Department of Paediatrics, Karolinska Hospital and St. Göran's Children's Hospital and the Department of Clinical Microbiology, Karolinska Hospital, Karolinska Institute, Stockholm, Sweden). Septicaemia with coagulase negative staphylococci in a neonatal intensive care unit. Risk factors for infection, and antimicrobial susceptibility of the bacterial strains. Acta Paediatr Scand Suppl 360: 127, 1989.
Septicaemia caused by coagulase negative staphylococci is a problem in the neonatal intensive care units (NICU). The very low birthweight (VLBW) infants are at a special high risk because of their immature host defense. In this study the potential risk factors were compared between the VLBW septicaemia patients and the VLBW infants who had not contracted septicaemia in the NICU. The factor most clearly related with septicaemia was the use of umbilical artery catheters. The strategy against neonatal septicaemia includes restriction of the use of intravascular catheters. Also enhancement of the host defense by immunoglobulin therapy is considered. The coagulase negative staphylococci were multiresistant to antibiotics. The combination of netilmicin and benzylpenicillin covered the bacteria found in septicaemia cases in the NICU, and is now the standard treatment in suspected cases. Coagulase negative staphylococci are treated with vancomycin or netilmicin.     

Efficacy of subcutaneous tunneling for prevention of bacterial colonization of femoral central venous catheters in critically ill children

BACKGROUND: Blood stream infections are a common and serious complication of central venous catheters (CVCs). To decrease catheter colonization, some authors advocate tunneling the catheter in the subcutaneous tissue during insertion. This technique has proved effective in adults, but there are no data on its safety and efficacy in critically ill children. Our objective was to evaluate the efficacy and safety of subcutaneous tunneling of short term, noncuffed CVCs for the prevention of CVC-related infections in critically ill children. METHODS: A prospective randomized controlled trial was performed at a tertiary children's medical center in Israel and included children ages 0 to 18 years admitted to the pediatric intensive care unit or the pediatric cardiac intensive care unit from September 2000 to April 2001 who required placement of a femoral central venous catheter for >48 h. The children were randomized for tunneled or nontunneled insertion. The main outcome measures were bacterial colonization of proximal and distal catheter segments tested by semiquantitative technique and infectious or noninfectious complications of the CVC. RESULTS: Of 98 eligible children, 49 received tunneled catheters and 49 received nontunneled catheters. Patients' age ranged from 1 month to 16.5 years (mean, 3.07 +/- 2.48 years). There were no significant differences between the groups in age, sex, disease severity [Pediatric Risk of Mortality III (PRISM) score], duration of catheterization and underlying diseases. Bacterial colonization was found in 11 (22.4%) catheters in the nontunneled group compared with 3 (6.1%) in the tunneled group (P = 0.004). Proximal segment colonization occurred in 7 (14.2%) nontunneled catheters and 2 (4.8%) tunneled catheters (P = 0.07), and distal segment colonization occurred in 3 (6.1%) and 9(18.3%) tunneled and nontunneled catheters, respectively (P = 0.053). The main pathogens were coagulase-negative staphylococci, Pseudomonas spp. and Klebsiella spp. There was no statistically significant difference between the groups in the rate of bloodstream infection (2 in the tunneled group, 3 in the nontunneled). Except for 1 case of subcutaneous hematoma, which resolved, there were no immediate or late complications of the tunneling procedure. CONCLUSION: Subcutaneous tunneling of CVCs in the femoral site is a safe procedure and decreases significantly the rate of CVC colonization in critically ill children.     

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目的了解NICU中住院早产儿的细菌定植状况及定植菌的耐药性。方法对2002年5月至2003年4月间在北京协医院NICU住院治疗的早产儿进行细菌学监测,于入院时和入院后每周常规做咽拭子及直肠拭子培养。收集每位早产儿的临床及实验室资料,对结果进行统计学分析。结果147例早产儿共培养出183株定植菌。入院当天即有细菌定植者11例,入院后发生细菌定植者52例。定植菌以革兰阴性杆菌为主(占62.8%)。早产儿获得细菌定植与胎龄小、出生体重低、住院时间长、应用机械通气、胃肠外营养、长时间使用抗生素等因素有关。美罗培南在目前所用抗生素中对革兰阴性杆菌敏感性最高,但与耐甲氧西林凝固酶阴性葡萄球菌(MRScoN)定植之间具有相关性。败血症以革兰阴性杆菌为主,细菌定植1周左右为败血症高发期。结论应对在NICU住院的早产儿进行细菌学监测,根据监测结果判断细菌定植状态和采取保护措施。控制抗生素使用、缩短住院时间和胃肠外营养的时间,对控制早产儿细菌定植将起到重要作用。     

Malassezia furfur: a cause of occlusion of percutaneous central venous catheters in infants in the intensive care nursery

Growth of Malassezia furfur in the intravascular catheter used for administration of lipid emulsion resulted in occlusion of deep intravascular Silastic catheters in 12 infants in 2 intensive care nurseries. At the time of occlusion visible growth was noted in the clear catheter which was connected to the Silastic intravascular line. Five infants showed clinical signs suggestive of sepsis. The yield of M. furfur from blood cultures and catheter tips was low even when oil enrichment was used. The highest yield of M. furfur was found in the connecting catheter (11 of 11). The source from and the route by which M. furfur entered the catheter remain unclear. The potential portals of entry include the proximal and distal ends of the connecting catheter as well as the colonized skin of the infants and caretakers.     

Frequency of infections associated with implanted systems vs cuffed, tunneled Silastic venous catheters in patients with acute leukemia.

A total of 75 central venous catheters were used for prolonged chemotherapy in 39 children with acute lymphocytic leukemia and 21 patients with acute myelocytic leukemia. Infection rates were 2.2 per 100 catheter days with the use of cuffed, tunneled, single-lumen Silastic catheters, 2.0 per 1000 catheter days with cuffed, tunneled, double-lumen Silastic catheters, and 0.5 per 1000 catheter days with the use of implanted venous access systems. Eighty-one percent of catheter sepsis episodes were successfully treated without removal of the catheter. All tunnel infections required withdrawal of the catheter for cure. The microorganisms were gram-positive bacteria in 15%, gram-negative bacteria in 7%, and fungi in 4%. Coagulase-negative staphylococci and Pseudomonas aeruginosa were the most commonly isolated organisms. Three of six fatal sepsis episodes were caused by disseminated fungal infections. We conclude that the use of intracorporeal venous catheter systems in patients with acute lymphocytic leukemia is associated with a lower infection rate than that with cuffed, tunneled Silastic single- or double-lumen catheters and that most septicemias can be cured with antimicrobial therapy without removal of the catheter.     

Central venous catheter sepsis in surgical newborns

We examined central venous catheter (CVC) sepsis in newborn surgical patients, as this group appeared to have a higher incidence of this complication. During a 3-year period 79 patients on the surgical service required a tunneled, cuffed, Broviac CVC. Nineteen patients (24% or 9.9 episodes per 1000 catheter days) had proven sepsis and 8 (10% or 1.9/1000 catheter days) had suspected sepsis. An intestinal stoma was definitely related to CVC sepsis (p<0.001). Other risk factors included lower gestational age, more operations, and younger age at first stoma. Temperature, white blood cell (WBC) count, and platelet count did not correlate with CVC sepsis. We found no better indicator of CVC sepsis than the presentation of an ill child. Certainly temperature, WBC, and platelet count are not reliable indicators. Surgeons have little control over the factors that were found to be related to CVC sepsis. It would appear reasonable from these results to maintain a high index of suspicion in the high-risk groups, to use peripherally inserted central catheters (PIC lines) as the first line of long-term vascular access, and to bring CVCs out of a nonabdominal site, perhaps the scalp, in patients with stomas.     

Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study

BACKGROUND: Infections of short term, nontunneled, intravascular catheters are often caused by migration of organisms from the insertion site. The aim of this study was to evaluate the effectiveness and safety of a chlorhexidine gluconate-impregnated dressing for the reduction of central venous catheter (CVC) colonization and CVC-associated bloodstream infections in infants and children after cardiac surgery. METHODS: This prospective, randomized, controlled study was conducted in the pediatric cardiac intensive care unit of a tertiary care pediatric medical center. Patients 0-18 years of age who were admitted to the pediatric cardiac intensive care unit during a 14-month period and required a CVC for >48 hours were randomized to receive a transparent polyurethane insertion site dressing (control group) or a chlorhexidine gluconate-impregnated sponge (Biopatch) dressing covered by a transparent polyurethane dressing (study group). The main outcome measures were rates of bacterial colonization, rates of CVC-associated bloodstream infections and adverse events. RESULTS: Seventy-one patients were randomized to the control group and 74 to the study group. There were no significant between group differences in age, sex, Pediatric Risk of Mortality score or cardiac severity score. CVC colonization occurred in 21 control patients (29%) and 11 (14.8%) study patients (P = 0.0446; relative risk, 0.6166; 95% confidence interval, 0.3716-1.023). Bloodstream infection occurred in 3 patients (4.2%) in the control group and 4 patients (5.4%) in the study group. Local redness was noted in 1 control patient and 4 study group patients. CONCLUSIONS: The chlorhexidine gluconate-impregnated sponge is safe and significantly reduces the rates of CVC colonization in infants and children after cardiac surgery.     

Critical appraisal of surgical venous access in children

Central venous catheters (CVC) have become an important adjunct to the overall management of paediatric patients, but their use is associated with frequent complications resulting in premature removal. This report evaluates the insertion techniques and complications of 295 consecutive surgically inserted CVC from 1987 to 1991 in a paediatric hospital. Fully implanted catheters had significantly less incidence of catheter-related problems necessitating removal (infection, dislodgment, leaking, blockage, or migration — 31%) compared to exteriorised catheters (58%). One-third of catheters were removed because of infection, one-third as they were no longer needed, and the remaining for multiple reasons. Infected (110±18 days), dislodged (18 ± 4 days), or migrated (44 ± 6 days) catheters were removed significantly earlier than those removed because they were no longer needed (195 ± 24 days). Catheters became dislodged more frequently in the younger patients. Catheters with the tip in the subclavian vein (29%) migrated more frequently than those in the right atrium. There was a significantly increased incidence of infection in catheters inserted into the saphenous vein (43%) compared to those in the internal jugular vein (11%). Some episodes of catheter infection were managed with antibiotics, with short-term resolution of symptoms and signs. However, all 71 infected catheters ultimately required removal for further sepsis. Fully implanted catheters had 1.1 episodes of catheter-related sepsis per 1,000 catheter days compared to 3.7 for exteriorised catheters. The position of the catheter tip, vein used for insertion, training of young surgeons, and location of the subcutaneous tunnel need particular attention in order to reduce catheter complications.     

Infections related to vascular catheters in a pediatric intensive care unit

We determined the rate and risk factors for colonization of 103 peripheral intravenous catheter and 32 central venous catheters. 52.5% peripheral catheters had colonization. Common organisms isolated were Pseudomonas (33.3%) and coagulase negative Staphylococci (29.6%). Colonization was higher in catheters inserted in the lower limb. Overall 62.5% of the central catheters were colonized, chiefly by coagulase negative Staphylococci, Pseudomonas and Candida. All central catheters in place for more than 11 days were colonized. Subclavian vein catheters had a higher rate (68.2%) of colonization in comparison to femoral vein insertions (40%). We conclude that upper limb placements are preferable to lower limbs when using peripheral lines. Changing peripheral intravenous catheters every 48 hours and central venous catheters every 10 days may decrease the rate of colonization.     

Late-onset infections of infants in neonatal units

Objective : To examine regional variations in the incidence of late-onset neonatal infections in Australian and New Zealand neonatal units.
Methodology : A longitudinal, prospective surveillance study of systemic sepsis (septicaemia or meningitis) in 11 neonatal units: 10 in the Australian States of the Northern Territory, New South Wales, Queensland, Victoria and Western Australia, and 1 in Christchurch, New Zealand. The results are reported of late-onset neonatal infection (defined as sepsis after 48 h) for the second year of prospective surveillance, data being collected from 1 October 1992 to 30 September 1993.
Results : Data were available on 24 535 live births in Australia, representing approximately 10% of all live births in the country. There were 320 episodes of sepsis in Australian units affecting 294 babies. One hundred of these episodes (31%) were earty-onset; 3.0% of babies admitted to six tertiary care neonatal units attached to maternity hospitals developed late sepsis, and this rate did not differ between units. The proportion of babies infected was inversely related to birthweight: 22.6% of babies under 1000 g, but 0.6% over 2000 g. Coagulase negative staphylococci were the commonest cause of late-onset sepsis. There were 26 episodes of S. aureus septicaemia, of which only one was due to MRSA. Meningitis occurred in 13 babies (5.9%) with late-onset sepsis. The mortality from late-onset sepsis was 7.7%.
Conclusions : Coagulase-negative staphylococci are the commonest cause of late-onset sepsis of babies in neonatal units. There were no major regional differences in the incidence of, or the organisms causing, late sepsis.     

Central venous catheter placement in children: a prospective study of complications in a Brazilian public hospital

Central venous access is frequently used in infants and children with a wide variety of conditions. This report evaluates our experience and the complications from central venous catheters (CVC) placed percutaneously in children at a public hospital of a developing country—Brazil. To identify associated complications, data were collected prospectively and 155 consecutive catheterizations in children at a public hospital over a nearly 8-month period were analyzed. Data collected included sex, age, weight, primary diagnosis, indication for placement, presence of blood coagulation disturbance, hospital department for procedure, type of anesthesia, type of catheter (diameter, lumen number, material), site of catheterization, number of attempts, number of puncture sites, complications during puncture, the time catheter remained in place, later complications (mechanical, infectious) and reason for catheter removal. A total of 155 catheters were placed in 127 patients. There were 130 neck lines and 25 groin lines. The success rate was 81.9% at the initially chosen puncture site and rose to 100% with the inclusion of the second site. Perioperative complications occurred in nine (5.8%) cases, including six (3.9%) hematomas and three (1.9%) arterial puncture. There was no pneumothorax, hemothorax or hydrothorax. During the time the catheter remained in place, there were 51 (32.9%) complications, of which 33 (21.3%) were mechanical and 18 (11.6%) suspected catheter-related infection. These complications were responsible for the removal of the catheter. Despite the relatively high complication rate there were no catheter-related deaths. Body weight was significantly lower for children who underwent more than one puncture site (P=0.01). Age, sex, type of catheter and primary diagnosis were not associated with complications. Knowledge of anatomy and familiarity with the Seldinger technique highly increase the catheterization success rate, with few surgical complications. A better nursing care of CVC is emphasized. The available modern venous catheters at a public hospital in Brazil have contributed to improve the quality of pediatric medical care. Nowadays, the percutaneous CVC is the preferred method in pediatric patients.     

Intravenous catheter infection study: A prospective trial in patients with neoplastic disease

This study was designed to determine the frequency and significance of infection at the site of indwelling intravenous catheters. Eligible patients were randomly assigned to have an intravenous infusion utilizing either a plastic cannula or a short metal needle. Both of these groups were further randomly divided into two groups, one having the intravenous catheter removed every 48 hr and the other having the catheter changed only when necessary. One hundred and eighty-seven catheters from 50 patients were cultured. Eleven (5.9%) of the catheters were found to be colonized by organisms. Metal needles and plastic cannulas were infected with similar frequency. The incidence of local infection was not influenced by concurrent antibiotic therapy, local phlebitis, or the level of the granulocyte count during the period of intravenous infusion. Six of 31 catheter tips in place for longer than 56 hr were colonized by organisms, compared with 5 of 156 catheter tips in place for less than 56 hr (p < 0.001). The study indicates that indwelling intravenous catheters should be changed at least every 48 hr in order to prevent colonization of the tip of the intravenous catheter.     

Intravenous catheter infection study: a prospective trial in patients with neoplastic disease.

This study was designed to determine the frequency and significance of infection at the site of indwelling intravenous catheters. Eligible patients were randomly assigned to have an intravenous infusion utilizing either a plastic cannula or or a short metal needle. Both of these groups were further randomly divided into two groups, one having the intravenous catheter removed every 48 hr and the other having the catheter changed only when necessary. One hundred and eighty-seven catheters from 50 patients were cultured. Eleven (5.9%) of the catheters were found to be colonized by organisms. Metal needles and plastic cannulas were infected with similar frequency. The incidence of local infection was not influenced by concurrent antibiotic therpy, local phlebitis, or the level of the granulocyte count during the period of intravenous infusion. Six of 31 catheter tips in place for longer than 56 hr were colonized by organisms, compared with 5 of 156 catheter tips in place for less than 56 hr (p less than 0.0001). The study indicates that indwelling intravenous catheters should be changed at least every 48 hr in order to prevent colonization of the tip of the intravenous catheter.     

Intestinal flora in very low-birth weight infants

Aim:  To study the early faecal microbiota in very low-birth weight infants (VLBW, <1500 g), possible associations between faecal microbiota and faecal calprotectin (f-calprotectin) and to describe the faecal microbiota in cases with necrotizing enterocolitis (NEC) before diagnosis.
Methods:  Stool samples from the first weeks of life were analysed in 48 VLBW infants. Bacterial cultures were performed and f-calprotectin concentrations were measured. In three NEC cases, cultures were performed on stool samples obtained before diagnosis.
Results:  Bifidobacteria and lactobacilli were often identified in the first stool sample, 55% and 71% of cases, respectively within the first week of life. A positive correlation between lactic acid bacteria (LAB) and volume of enteral feed was found. Other bacteria often identified were Escherichia coli , Enterococcus and Staphyloccus sp. F-calprotectin was not associated with any bacterial species. All NEC cases had an early colonization of LAB. Prior to onset of disease, all cases had a high colonization of non- E. coli Gram-negative species.
Conclusion:  In contrast to the previous studies in VLBW infants, we found an early colonization with LAB. We speculate that this may be due to early feeding of non-pasteurized breast milk.     

Central venous catheterization in infants and children with congenital heart diseases: Experiences with 500 consecutive catheter placements

Summary In a prospective study results of central venous catheter (CVC) placements in a consecutive group of 500 patients with less than 20 kg body weight undergoing cardiac surgery were evaluated. The incidence of previous cardiac surgery was 21% and the incidence of factors preventing the primary puncture of the right jugular or innominate vein was 13.4%. The anesthesiologists were free to select the catheterization technique, site of puncture, and catheter type. All CVC insertions were performed prior to surgery under continuous circulatory monitoring and optimal positioning of the anesthetized patient.Ninety-six percent of all catheterizations were successful, 81% of them on the first attempt. In the 4% of cases where catheterization failed, a CVC had to be placed by the surgeon. Of all catheters, 66% were positioned via the right internal jugular (IJV) or innominate vein (IV), 8% via the left, 16% via an external jugular vein (EJV), and 5% via other veins. Seventy-six percent of CVC insertions were performed with the Seldinger technique. Of the four catheter types used in this study, double lumen catheters were most frequently selected (38%). Placement of 22-ga single lumen catheters was preferred in infants with less than 5 kg body weight, in spite of their tendency to kink. Observed complications (10% arterial puncture, 4% hematoma, and 1% intrathoracic bleeding) never required immediate surgical intervention. Careful selection of appropriate catheters, as well as extensive experience and knowledge of the anatomical structures involved in special heart defects, helped to keep the risk of complications low.     

Percutaneous central venous catheter colonization with Malassezia furfur: incidence and clinical significance

Malassezia furfur colonization of central venous catheters has been implicated in the pathogenesis of systemic infections with this lipid-dependent yeast. To determine the incidence of catheter colonization in our neonatal intensive care unit (NICU), 25 consecutively removed percutaneous central venous catheters were examined by rinsing the lumen with saline and plating the rinse fluid on Sabouraud dextrose agar overlaid with olive oil. M furfur grew from the lumina of eight catheters (32%). Surveillance skin cultures were performed in the NICU on two occasions to determine the prevalence of skin colonization with M furfur. M furfur was found on the skin of 64% of the infants. In contrast, only 3% (1/33) of healthy, nonhospitalized infants 2 to 8 weeks of age had skin colonized with M furfur. During the 5-month study period, two NICU infants had evidence of systemic infection with M furfur. We conclude that M furfur frequently colonizes both the skin and percutaneous central venous catheters in NICU infants. Further studies are needed to determine the relationship between skin colonization and catheter colonization, and the factors contributing to systemic disease with this organism.     

新生儿重症监护病房的院内感染638例分析

目的调查NICU院内感染的发生情况,探讨其危险因素,为院内感染的防控提供依据。方法对我科2003年5月至2004年12月,住院的638例新生儿进行院内感染的监控,并进行分析和总结。结果638例新生儿中74例发生88次院内感染,发生率为11．6％;住院日相关的院内感染率为14．9／1000NICU病例一天;导管相关血行感染率为18／1000血管内导管一天（2／111）;呼吸机相关肺炎发生率为63．3／1000机械通气一天（15／237）;平均开始出现感染时间（7．98±4．58）d。发生院内感染者比未感染者的胎龄及出生体重低、住院时间延长。新生儿发生院内感染的危险因素包括胃肠外营养、出生体重≤1500g及呼吸机治疗等（P〈0．05）。感染部位中,以肺炎占首位（45．4％）。院内感染病死率为4．1％。入院后有细菌定植者较无定植者院内感染率高（Х^2=79．7,P〈0．001）。结论充分了解NICU中新生儿发生院内感染的高危因素、尽量减少肠外营养及侵袭性操作的次数和时间、明确NICU中患儿个体细菌的定植情况将有助于控制院内感染并对临床合理用药提供参考。     

Adherence of bacteria to pediatric intravenous catheters and needles and its relation to phlebitis in animals

The adherence of bacteria to pediatric IV catheters and needles was studied. Scanning electron micrographs showed that bacteria adhered well to the catheters and needles, mainly to non-smooth surface areas. In vitro quantitative determination, with the use of radiolabeled bacteria, revealed differences in the affinity of bacteria for the various IV cannula materials. The adherence per square area was greatest for plastic catheters, less for steel needles, and least for siliconized needles. Mean values for the adherence of Staphylococcus aureus to these cannulae were 37.9-40.3 X 10(5) bacteria/cm2 for the plastic catheters; 10.2 X 10(5) bacteria/cm2 for the steel needles, and 7.2-7.6 X 10(5)/cm2 for the siliconized needles. Removal of the glutaraldehyde-fixed bacteria adhered to the cannulae, after their placement in veins of rabbits, was lower for the plastic catheters than the IV needles. The appearance and severity of venous phlebitis produced by the various cannulae was determined in an animal model. The degree of the inflammatory response elicited correlated with the in vitro bacterial adherence, indicating that bacterial adherence plays a role in the appearance of cannula-associated phlebitis. In view of our results and other previous observations of lower rate of infections with the use of IV needles, it is suggested that needles should be preferred to plastic catheters whenever possible. The described in vitro assay for bacterial adherence can be used to determine the adherent properties of IV cannulae, which should be considered in any future cannula design.     

Complications of central venous access in children

Central venous access has become a frequent requirement in the management of seriously ill or injured infants and children with a wide variety of conditions. This report evaluates the complications observed with the use of central venous catheters in 1,378 cases. Central venous catheters (n = 2,281) were placed in 1,378 children (728 boys:650 girls). There were 1,012 temporary catheters (noncuffed/percutaneously placed) while 1,268 were inserted operatively, including 37 portacaths and 1,231 with dacron cuffs (Hickman, Broviac) for long-term use. A single catheter was inserted in 542 cases and multiple catheters in 836. Indications for catheter insertion included emergency resuscitation or access (501), malignancy (462), and intestinal dysfunction (415). Catheter infection occurred in 430 cases (18.8%). Of 219 infected temporary access catheters, 123 were removed while 96 were changed over a guide wire. Of 211 infected permanent catheters, 18 were immediately removed while 193 were treated with i.v. (vancomycin, gentamicin) antibiotics. Forty-seven of 193 (24%) catheters were eventually removed because of persistent or recurrent infection (16 cases) or subsequent fungal sepsis due to Candida albicans (31 cases). Only 3 of 37 portacaths were removed because of infection. Bacterial isolates were single in 125 cases and multiple in 86. Organisms included Staphylococcus epidermidis in 104 cases, Staph. aureus in 65, Klebsiella pneumoniae in 51, Escherichia coli in 51, and others in 18. Catheter complications occurred in 107 (5%) cases, including symptomatic vessel thrombosis in 49, pneumothorax in 26, catheter migration in 25, vessel injury in 5, and catheter embolus in 2. Despite the relatively high complication rate there were no catheter-related deaths. Multiple-lumen catheters had twice the complication rate and infection rate of single lumen catheters (P < 0.05). Temporary percutaneous catheters had a complication/infection rate 1.5 times greater than permanent catheters (P < 0.05) that were operatively placed. Bacterial infection cleared with antibiotics in 76% of cases with catheter sepsis, however secondary fungal infection necessitated prompt catheter removal. These data indicate that percutaneously placed catheters and multilumen catheters are associated with significantly higher complication and infection rates. Surgeons should balance the risks of convenience vs. complications in their choice of catheters and methods of insertion.