Central Line-Associated Bloodstream Infection in Children
Central Line-Associated Bloodstream Infection in Children
Long-term central venous catheters (CVCs) are essential for modern pediatric practice. These devices terminate in a large central vein, usually the superior vena cava, and are used for administration of drugs, fluids and blood products; for blood collection and for hemodialysis. The most common, serious complication of CVC use is central line–associated bloodstream infection (CLABSI). Rates of CLABSI vary widely according to device type and patient population and can range from approximately 0.2 episodes per 1000 catheter-days in children with sickle cell disease to 11 per 1000 days in infants with intestinal insufficiency.
The most common infecting organisms are coagulase-negative staphylococci (especially Staphylococcus epidermidis), Staphylococcus aureus, Enterococcus spp., Escherichia coli, Klebsiella spp., other enteric Gram-negative bacteria and Candida spp. Microorganisms are introduced predominantly through the hub during routine use or at the time of catheter insertion. After the first 14 days, intraluminal colonization is the most important source of infection. Important consequences of CLABSI include extended hospital stay (median of 12 days in 1 study), interruption of chemotherapy or other treatment, catheter removal (up to 50% of episodes), intravascular thrombosis, endocarditis, sepsis (up to 10%c) and rarely death.
Techniques to prevent CVC colonization during insertion, such as maximum sterile barrier precautions, reduce the risk of CLABSI. After insertion, appropriate CVC dressings, careful catheter access technique, alcohol catheter caps and the use of prophylactic lock therapy with taurolidine, antibiotic or preservative-containing heparin solution can reduce the risk of infection in some groups.
This review focuses on the management of CLABSI in children, outside the neonatal period, who have long-term tunneled CVCs (eg, Broviac or Hickman catheters, Bard Access Systems, Salt Lake City, Utah) or implantable ports (eg, Port-A-Cath, Smiths Medical, Dublin, Ohio). Major controversies include duration and choice of systemic antibiotic therapy, indications for catheter removal, screening for complications and the roles of adjunctive treatment and secondary prevention techniques. This review assesses the available literature and identifies pragmatic treatment strategies based on the best available evidence basis. The Infectious Diseases Society of America guidelines, which focus predominantly on adult patients, are referenced where a consensus recommendation is required but evidence is limited or conflicting.
Introduction
Long-term central venous catheters (CVCs) are essential for modern pediatric practice. These devices terminate in a large central vein, usually the superior vena cava, and are used for administration of drugs, fluids and blood products; for blood collection and for hemodialysis. The most common, serious complication of CVC use is central line–associated bloodstream infection (CLABSI). Rates of CLABSI vary widely according to device type and patient population and can range from approximately 0.2 episodes per 1000 catheter-days in children with sickle cell disease to 11 per 1000 days in infants with intestinal insufficiency.
The most common infecting organisms are coagulase-negative staphylococci (especially Staphylococcus epidermidis), Staphylococcus aureus, Enterococcus spp., Escherichia coli, Klebsiella spp., other enteric Gram-negative bacteria and Candida spp. Microorganisms are introduced predominantly through the hub during routine use or at the time of catheter insertion. After the first 14 days, intraluminal colonization is the most important source of infection. Important consequences of CLABSI include extended hospital stay (median of 12 days in 1 study), interruption of chemotherapy or other treatment, catheter removal (up to 50% of episodes), intravascular thrombosis, endocarditis, sepsis (up to 10%c) and rarely death.
Techniques to prevent CVC colonization during insertion, such as maximum sterile barrier precautions, reduce the risk of CLABSI. After insertion, appropriate CVC dressings, careful catheter access technique, alcohol catheter caps and the use of prophylactic lock therapy with taurolidine, antibiotic or preservative-containing heparin solution can reduce the risk of infection in some groups.
This review focuses on the management of CLABSI in children, outside the neonatal period, who have long-term tunneled CVCs (eg, Broviac or Hickman catheters, Bard Access Systems, Salt Lake City, Utah) or implantable ports (eg, Port-A-Cath, Smiths Medical, Dublin, Ohio). Major controversies include duration and choice of systemic antibiotic therapy, indications for catheter removal, screening for complications and the roles of adjunctive treatment and secondary prevention techniques. This review assesses the available literature and identifies pragmatic treatment strategies based on the best available evidence basis. The Infectious Diseases Society of America guidelines, which focus predominantly on adult patients, are referenced where a consensus recommendation is required but evidence is limited or conflicting.
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