Central venous catheter exchange by guidewire for treatment of catheter-related bacteraemia in patients undergoing BMT or intensive chemotherapy

Abstract

Summary:Current guidelines for the treatment of catheter-related bacteraemia (CRB) advise against central venous catheter (CVC) exchange because of the potential risk of prolonging infection. However, there are no consistent data proving this recommendation. We evaluated prospectively the usefulness of CVC exchange by guidewire for the treatment of CRB in patients undergoing BMT or intensive chemotherapy. CVC exchange was considered when fever and positive blood cultures persisted after 2 days of adequate antimicrobial therapy and no potential source of bacteraemia other than CVC could be identified. The guidewire exchange was preceded and followed by a slow infusion of adequate antimicrobial therapy. Bacteraemia was confirmed as catheter-related by demonstrating concordance between isolates from the tip and blood cultures by pulsed-field electrophoresis of genomic DNA. This procedure was performed in 19 episodes of bacteraemia during a 1-year period. Fourteen episodes (74%) were catheter-related and 71% of these were due to coagulase-negative staphylococci. Guidewire replacement was accomplished uneventfully 4 days after development of sepsis (range 3-6). In all cases, clinical signs of sepsis disappeared in less than 24 h after replacement. Definitive catheter withdrawal was carried out a median of 16 days (range 3-42) after guidewire exchange; in all cases, the tip culture was negative. We conclude that CVC replacement by guidewire under adequate antimicrobial therapy may be a reasonable option for the treatment of CRB when antimicrobial therapy alone has been unsuccessful. Keywords: catheter-related bacteraemia; infections treatment; catheter exchange Bacteraemia is the most frequent life-threatening complication of central venous catheters (CVC). 1 Catheter removal is usually required for the diagnosis and the treatment of catheter-related bacteraemia (CRB). Nevertheless, the catheter may not be the source of infection in as many as three out of four suspected cases of CRB. 2 CVC exchange by guidewire is currently accepted in the management of suspected CRB, although the catheter should be relocated to a new site if the tip culture confirms the diagnosis of CRB. [3][4][5][6] This recomendation is based on several studies 7-9 reporting anecdotal cases of immediate tip contamination of the guidewire-inserted catheter. However, in BMT patients and other high-risk patients with thrombocytopenia, this policy constitutes a potential risk for haemorrhage. We hypothesized that, as it occurs in replacement surgery of infected prosthetic devices, adherence of microorganisms and subsequent biofilm formation on the CVC exchanged by guidewire would be unlikely if a high concentration of an appropriate antibiotic were present on the surface of the catheter at the time or shortly after the arrival of the pathogen and were maintained for a critical span of time.To evaluate the safety and efficacy of CVC exchange by guidewire after unsuccesful antimicrobial therapy in patients undergoing BMT or intensive chemotherapy with a...

Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America

“…Microbiologic data suggestive of true CRBSI caused by potential skin flora rather than contamination include the following: multiple blood samples with positive culture results obtained from different sites; quantitative blood cultures performed on samples drawn from a catheter with growth of >15 cfu/mL of blood or isolation of the same organism from a catheter culture and a percutaneous blood culture, especially if a culture performed on blood drawn from the catheter shows growth at least 2 h earlier than a culture performed on blood drawn from a peripheral vein [72]. Although several studies suggest that catheter exchange over a guidewire can be used successfully to manage CRBSI associated with long-term catheters [73], most of these were small, uncontrolled studies with poor definitions, and none of these studies used antimicrobial catheters as a replacement for the infected catheter [73–77]. Management of CRBSI for patients with a long-term CVC or implantable device is summarized in tables 5 and 6 and in figure 2.…”

Catheter-related infections in children treated with hemodialysis

“…Another option to consider is changing the CVC over a guidewire instead of removing it and replacing it with a new CVC at a new site. In the absence of exit-site infections, this approach seems to be safe and effective in adult HD patients (even in the presence of sepsis) as long as antibiotic therapy has been started [34,74,75,76,77,78,79]; however, there are no data concerning children on HD.…”

Guidewire Catheter Exchange in Pediatric Oncology: Indications, Postoperative Complications, and Outcomes

“…Most of the publications that describe GCE results are from the adult literature for patients on total parenteral nutrition, chronic hemodialysis patients, burn patients, and intensive care unit patients . Castelli et al .…”

“…Catheter‐related complications, such as malfunction and displacement, and patient/family preferences are also indications for GCE. Different studies performed in adult populations have suggested that GCE is associated with a low complication rate and without an increased risk of infection . However, these findings have not been confirmed in children with malignancies.…”