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Infections in a Child with Cancer – Catheter-related infections
Infections in a Child with Cancer – Catheter-related infections
Authors: Miguela Caniza, MD, St. Jude Children’s Research Hospital
Ayda G. Nambayan, DSN, RN, St. Jude Children’s Research Hospital
Content Reviewed by: Bonnie Williams, RN, CIC, St. Jude Children’s Research Hospital
Cure4Kids Release Date: 23 February 2007
(A-1) Intravascular catheters are indispensable for delivering oncology treatments; however,
their use puts patients at risk for local and systemic infections, including local site infections,
blood stream infections and septic thrombophlebitis.
As in adults, the majority of blood stream infections (BSI) in children are associated with the use
of intravascular catheters. In situ diagnosis of catheter-related infection relies on the use of
paired quantitative blood cultures and the difference in time to detection between the peripheral
and the central venous catheter blood. (A-2) Catheter infections are most commonly caused by
pathogens found on the skin and in the catheter hub and less commonly by organisms originating
in an infusion, the blood stream, and surrounding tissue.
The types of catheter-related infections are:
Intraluminal colonization or symptomatic bacteremia. The focus of infection is within the lumen
of the catheter and is directly connected to the circulation. This is determined when the blood
culture obtained through the catheter is positive and the peripheral blood culture is negative.
Local infections. Superficial infections may occur at the exit site of the catheter, the tunnel of the
catheter, or both. An exit-site infection causes cellulitis of the tissue immediately adjacent to the
exit site, within 2 cm of the exit site or the border of the pocket of the totally implanted catheter
(pocket infection). A tunnel tract infection is an infection that extends more than 2 cm from the
exit site through the subcutaneous tunnel; the infection can start either at the exit site or in the
tunnel itself.
Intravascular pericatheter infection. The infectious nidus is in the fibrin clot stuck to the tip or to
the external surface of the catheter. The intravascular progression of the infection can cause
septic thrombosis, fever, bacteremia, or persistent fungemia with a thrombotic occlusion.
Catheter-related bacteremia. The same organism is isolated from the peripheral blood and the
infected catheter, usually sooner in the catheter than in the peripheral blood.
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Infections in a Child with Cancer – Catheter-related infections
Infectious Etiology:
The organisms most commonly isolated from 774 catheters with positive cultures were
coagulase-negative Staphylococcus (36.4%), Pseudomonas aeruginosa (14%), enterococcus
(10%), yeast (9.2%), and less frequently, Staphylococcus aureus (5.8%), Enterobacter species
(4.4%), E. coli (3.9%), and other opportunistic organisms.
In several studies of catheter infections in patients with a malignancy, more than 50% of the
most frequently isolated organisms were gram-positive , among which coagulase-negative
Staphylococcus was the most common. Other organisms isolated were S. aureus, Streptococcus
viridans, enterococcus, gram-negative organisms such as E. coli, Klebsiella, or Enterobacter,
and Pseudomonas aeruginosa. Candida species were the most frequent fungi, and organisms
such as Bacillus species, Mycobacterium chelonae, and Mycobacterium fortuitum were rare.
Assessments:
Assessments of catheter-related infections can be challenging for the health care provider since
most patients do not present with the common signs of inflammation at the catheter exit site. If a
catheter-related infection is suspected A – 3 paired or two sets of blood cultures from the
catheter and peripheral site should be obtained in order to compare the sites to each other. It is
best to draw the cultures when the patients are experiencing the symptoms (such as fever, chills)
because it increases the chance of detecting bacterial organisms. Growth of organisms in both
cultures indicates positive bacteremia. In addition, if exudates are present at the exit site, the
drainage should also be sent for Gram stain and culture.
In cases of local skin and/or subcutaneous infections at the (A-4) exit site of the catheter, signs
and symptoms of inflammation might be evident. Erythema and pain occurring after normal
healing (7 to 10 days) are the most consistent indicators of exit, port pocket, and tunnel
infections. These symptoms might be blunted in neutropenic patients, particularly those with a
neutrophil count of <100/mm. Exudate is also absent in local infections when there are few
neutrophils to contribute to the inflammatory response.
Erythematous rash and blistering (localized skin reactions) can be confused with local infections.
The majority of these skin reactions occur secondary to transparent dressing, adhesive tapes, and
cleansing solutions; however, they are significant because they alter skin integrity, which can
lead to local infections in an immunocompromised patient.
The presence of thrombosis secondary to infection should be suspected for patients with
intravascular lines malfunctioning (such as slowed drip rates, inability to flush, absence of blood
return) that does not improve with positioning, flushing, etc. The caregiver should suspect
aseptic thrombosis of the large vessels when the patient has edema of the neck, chest, and the
upper extremity on the same side as the catheter (suggestive of superior vena cava obstruction)
and discomfort in the neck, arm and back. Septic thrombosis is most commonly caused by
infection with Staphylococcus aureus, less commonly by infection with Candida species and
Gram-negative organisms.
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Infections in a Child with Cancer – Catheter-related infections
The nurse should report any of these signs so diagnostic procedures such as Doppler
ultrasonography can be done to document thrombosis or fibrin sleeve in addition to the cultures.
Management:
Preventive Strategies:
Prevention of catheter-related infections begins with the health care provider. Good hand
hygiene is always the first step in preventing infection. Utmost care and maintenance of sterile
conditions during venous cannulation should be observed. Institutional guidelines and standards
of care related to catheter and site care must be strictly followed when patients have venous
access devices. Although the optimal dressing type (transparent versus occlusive gauze
dressings) and the optimal frequency of dressing changes have not been established, the nurse
can prevent catheter-related infections through meticulous attention to the details of catheter site
care. Astute daily assessments of the catheter site and of the patients for signs and symptoms of
exit infections are keys to minimizing the risk of infection.
Therapeutic Strategies:
When the patient develops an infection, it is important to consider whether the patient is
neutropenic, whether there is evidence of local infection, and whether treatment requires the
(A-5) removal of the catheter. For patients with neutropenia and a suspected catheter infection,
an empiric antibiotic treatment may be prescribed. Before giving antibiotics, the nurse must
ensure that blood cultures are obtained via each lumen and the peripheral blood; also, culture
swabs from the exit site of the catheter should be obtained if there is a lesion present.
For exit site infections without other signs and symptoms and without neutropenia, oral
antibiotics (e.g., dicloxacillin or cephalexin) may be given. The antibiotic regimen is adjusted to
cover any organisms isolated. If the lesion improves, antibiotic therapy is continued for 10 to 14
days. If the lesion does not improve, parenteral antibiotics may be prescribed. If the infection
persists and the lesion does not improve, catheter removal might be necessary. The nurse must
make sure that the prescribed antibiotics are given according to schedule. If the need for catheter
removal is evident, the nurse must prepare the patient and the family, especially if the catheter
removal involves a surgical procedure (as in implanted ports).
If the local infection is accompanied by fever or suspected bacteremia, parenteral antibiotics that
cover the organisms that are most common in catheter infections (e.g., vancomycin,
aminoglycoside) and/or antibiotics that cover the organisms most frequently isolated in that
service or institution may be prescribed. The nurse must monitor the infectious process through
the results of patient cultures, local site assessments, temperature measurements, and neutrophil
counts.
If the blood culture is negative and the patient improves, the antibiotic therapy is completed
(usually 10–14 days) and the catheter is left in place. If the initial culture is positive, but a repeat
culture (48 to 72 hours after starting antibiotic therapy) is negative and the patient improves,
antibiotic therapy is again continued for 10 to 14 days.
However, if the blood culture continues to be positive, the catheter is removed and antibiotic
therapy is completed depending on the type of the organism isolated. If the patient has a tunnel
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Infections in a Child with Cancer – Catheter-related infections
tract infection, the catheter is removed and antibiotic therapy is continued according to the
absolute neutrophil count. The nurse must be cognizant of the pattern of susceptibility of the
isolated organism and ensure that the antibiotics prescribed are appropriately matched to it.
If the patient with a suspected catheter infection has no evidence of local infection and is not
neutropenic, a combination of antibiotics to cover the organisms that are most common in
catheter infections, such as vancomycin and aminoglycoside, are generally prescribed.
If the patient has neutropenia and the culture is negative, follow the institution’s guidelines for
the management of fever and neutropenia. If the culture is positive and remains positive in
successive cultures despite appropriate antibiotic treatment, the catheter is usually removed and
antibiotics are administered according to institutional guidelines.
The management of septic thrombosis depends on the location, size, and extent of the thrombosis
and on the organism isolated. If there is septic thrombosis, remove the catheter. If the thrombosis
is in a peripheral blood vessel and is suppurating, surgical management such as debridement
along with antibiotic therapy might be necessary. The nurse must prepare the patient and the
family for the procedure and do post-procedure patient care according to institutional guidelines.
Thrombosis in a central blood vessel should be suspected if bacteremia persists beyond 72 hours.
In such cases, an anticoagulant (e.g., heparin) may be added to the antibiotics to resolve
thrombus-related infections. The nurse must confirm (by laboratory analysis) that the patient has
adequate serum levels of antibiotics before initiating anticoagulation therapy. This is important
to prevent overwhelming septicemia, since organisms are released into the bloodstream when
the thrombus disintegrates).
Antibiotic therapy is continued for 4 to 5 weeks (as for endocarditis). Amphotericin B or
fluconazole may be prescribed for a prolonged period if the isolated organism is of the Candida
species. The nurse must monitor and manage the patient’s responses to the anticoagulant and
(A-6) amphotericin therapy.
In immunocompromised patients, (A-7) antibiotic lock therapy (ALT) may be used in
conjunction with systemic antibiotic therapy. ALT consists of instilling into the lumen of the
infected catheter a high concentration of an antibiotic to which the isolated microorganism is
susceptible. With this treatment modality, it has been possible to save more than 60% of infected
catheters.
The nurse must monitor the patient for side effects of antibiotic therapy and prepare the patient
for catheter removal. The nurse must reassure the patient and family and explain the possible
reasons for infections. The patient and family also should be taught self-care behaviors
(http://www.stjude.org/patient-information/0,2584,472_2105_4247,00.html) that will help them
prevent, contain and manage the infectious complications of cancer.
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Infections in a Child with Cancer – Catheter-related infections
Helpful Web Links:
Post Graduate Medicine online, New York, NY
http://www.postgradmed.com/issues/2004/11_04/slaughter.htm
Mortality and Morbidity Weekly Report – Center for Disease Control
Guidelines for the Prevention of Intravascular catheter-related infections
http://www.cdc.gov/mmwr/PDF/rr/rr5110.pdf
Medithesis.com
Long Term Central Venous Catheter: Issues for Care
http://www.meditheses.com/997-962.bard
The Chinese University of HongKong
Intravascular lines and Infection
http://www.aic.cuhk.edu.hk/web8/Lineinfection.htm
The University of Pennsylvania
Amphotericin
http://www.uphs.upenn.edu/bugdrug/antibiotic_manual/ampho.htm
Venous Access Port Problems – eMedicine
http://www.emedicine.com/aaem/topic472.htm
St. Jude Children’s Research Hospital
Central Venous Access Device
http://www.cure4kids.org/ums/home/courses/detail/download_document.php?courses_id=9&document_id=674
Related www.Cure4Kids.org Seminars:
Seminar #82 The Child With Cancer: Complications and Infections Part I
Miguela Caniza, MD
http://www.cure4kids.org/seminar/82
Seminar #71 El Niño con Cáncer: Complicaciones Infecciosas Parte I
Miguela Caniza, MD
http://www.cure4kids.org/seminar/71
Seminar #227 IV Insertion - Practically Perfect Peripheral Pediatric Punctures
Lunetha Britton, RN
http://www.cure4kids.org/seminar/227
Seminar #1020 Preventing Vascular Access Device (VAD) Infection
Presenter: Miguela Caniza, MD
http://www.cure4kids.org/seminar/1020
Seminar 1021 Prevención de la Infección en Dispositivos Intravasculares (DIV)
Presenter: Miguela Caniza, MD
http://www.cure4kids.org/seminar/1020
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Infections in a Child with Cancer – Catheter-related infections
Appendix:
A – 1 Intravascular catheters commonly used for cancer patients:
Catheter Type
Peripheral Venous
Catheters (short)
Ex: butterfly,
angiocath
Peripheral arterial
catheters
Midline catheters
Ex: angiocath
Entry Site
Usually inserted in the
veins of forearm or hand
Length
< 3 in
Usually inserted in radial < 3 in
artery; can be placed in
femoral, axillary,
brachial, posterior tibial
arteries
Inserted via antecubital
3 – 8 inches
fossa into proximal
basilica or cephalic veins;
does not enter central
veins
Non-tunneled central
venous lines (CVC)
Ex:
subclavian/jugular
lines
Peripherally Inserted
Central Catheters
(PICC)
Ex: PICC lines
Tunneled CVCs
Ex: Hickman,
Groshong
Percutaneously inserted
into central veins
(subclavian, internal
jugular, or femoral)
Totally Implantable
Ex: Portacath,
Mediport
Tunneled beneath the
skin; subcutaneous port
accessed with a Huber
needed; implanted in
subclavian or internal
jugular vein
Inserted to basilica,
cephalic, or brachial
veins and enter the
superior vena cava
Implanted into the
subclavian, internal
jugular or femoral veins
8 cm or
longer;
depends
upon patient
size
20 cm or
longer,
depending on
patient size
8 cm or
longer,
depending
upon patient
size
8 cm or
longer,
depending
upon patient
size
Comments
Phlebitis with
prolonged use; rarely
associated with
bloodstream infection
Low infection risk;
rarely associated with
bloodstream infection
Lower rates of
phlebitis than short
peripheral catheters;
anaphylaxis reported
with certain types of
catheters
Account for majority
of catheter-related
blood stream infections
(CRBSI)
Lower rate of infection
than non-tunneled
CVCs
Cuff inhibits migration
of organisms into
catheter tract, lower
rate of infection than
non tunneled CVC
Lowest risk for
CRBSI; improved
patient self-image; no
need for local catheter
site care; surgery
required for catheter
removal
O’Grady, N., Alexander, B., et. al Guidelines for the Prevention of Intravascular Cancer-related Infections.
Pediatrics, Vol. 110, No.5, Nov. 2002
http://pediatrics.aappublications.org/cgi/content/full/110/5/e51
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Infections in a Child with Cancer – Catheter-related infections
A – 2 Types of Catheter related infections
Sherertz RJ. Catheter-Related Infections. 1997:1-29
(From Miguela Caniza, MD)
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A – 3 Paired or 2 sets of blood culture
Paired sets of cultures of blood drawn percutaneously and through the catheter. The advantage of
this method is that it does not require catheter removal for diagnosis of catheter related infections.
Interpretation of the results requires clinical judgment. In general, evidence of Staphylococcus
aureus, Gram-negative bacilli, or Candida species from either a percutanous culture or a
catheter-drawn culture, or both, represents a true bacteremia. Common skin contaminants, such
as coagulase-negative staphylococci, viridans streptococci, diphtheroids, Bacillus species,
Micrococcus species, and Propionibacterium species, can also produce catheter-related
infections; but if cultured from only one of the paired sets of cultures could indicate
contamination and requires a close evaluation of the host to make this determination.
Wing EJ, Norden CW, Shadduck RK, et al. Use of quantitative bacteriologic techniques to diagnose
catheter-related sepsis. Arch Intern Med 1979;139:482-3;
Abstract
Blot F, Nitenberg G, Chachaty E, et al. Diagnosis of catheter-related bacteraemia: a prospective
comparison of the time to positivity to hub-blood versus peripheral-blood cultures. Lancet 1999;354:10717
Abstract
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Module 8 – Document 4
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Infections in a Child with Cancer – Catheter-related infections
A- 4 Infection – catheter exit site and suture site
Exit site
Suture Sites
H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL
John N. Greene, MD
https://www.moffitt.usf.edu/pubs/ccj/v3n5/dept6.html
Port Pocket Infection
Medithesis.com
http://www.meditheses.com/997-962.bard
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Infections in a Child with Cancer – Catheter-related infections
A-5 Reasons for Catheter Removal:
1.
2.
3.
4.
5.
6.
The catheter is no longer needed.
The clinical condition of the patient worsens despite the administration of appropriate
antibiotics.
The infection relapses.
Blood cultures continue to be positive after the patient has received antibiotics for 48–72
hours.
Presence of Pseudomonas species, Bacillus species, Mycobacterium fortuitum,
Mycobacterium chelonae, Candida species, Malassezia furfur, methicillin-resistant
Staphylococcus aureus, vancomycin-resistant enterococcus, or Corynebacterium species,
which are the more difficult organisms to treat. (11)
Complications such as tunnel tract infection, formation of an abscess around the pocket,
septic thrombosis, endocarditis, or septic metastases. (12)
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A-6 Amphotericin Therapy:
Amphotericin B is an antifungal agent that is used both topically and systemically for various
fungal infections, especially invasive infections caused by Candida. It binds with the steroidal
alcohols in the organism’s cell membrane, which increases its permeability and causes leakage of
the cellular contents and death of the susceptible organism. The recommended dose for the
febrile neutropenic patient is 0.5 to 0.7 mg/kg/d. A test dose is usually administered over 1 hour
to assess for occurrence of adverse reactions.
In several cases, acute reactions to amphotericin B were seen within 90 minutes of the infusion
and usually remitted within 4 hours. Most common reactions are fever with or without rigors,
headaches, irregular heartbeat, double vision and occasionally convulsions and numbness.
Tolerance to the immediate reactions usually develops over time. Rigors are often managed with
IV administration of meperidine HCL (Demerol).
Other adverse events include nephrotoxicity (monitor renal function – BUN and creatinine
levels) and phlebitis, if administered through a peripheral vein (in which case, drug concentration
should not exceed 0.1 mg/ml D5W). If phlebitis develops, the rate of infusion should be
decreased or further diluted.
Premedications may be prescribed. Common drugs used to premedicate patients include
acetaminophen (Tylenol) and hydrocortisone, generally given 30 minutes before amphotericin
administration. If premedications are used early in the treatment course, their need should be reevaluated weekly:consider withholding premedications after several days if the infusion related
adverse effects have resolved.
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Infections in a Child with Cancer – Catheter-related infections
Related Nursing Actions:
1. Administer a test dose and monitor patient for acute reactions (check vital signs regularly
– every 15 minutes).
2. Continue to monitor patients for reactions during infusions.
3. Administer premedications on time as prescribed.
4. Monitor BUN, serum creatinine, and electrolytes to detect nephrotoxicity.
5. Monitor CBC to determine efficacy of the drug against the infection.
6. Continue to monitor patients with each dose for reactions (to determine the need for
further premedications)
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A – 7 Antibiotic Lock Therapy (ALT)
High concentrations of antibiotics are instilled into the lumen of the catheter for the purpose of
sterilizing the internal lumen. Locking the catheter with the antibiotic concentration of 100 to
1000 times the MIC of microorganism causing the infection will effectively penetrate the slime
layer, killing the microorganism on the internal catheter surface.
Success of treatment with ALT alone (i.e., without systemic antibiotics) depends on:
(1)
whether the catheter infection is accompanied by a peri-catheter infection
(i.e., tunnel tract infection or peri-pocket infection, in the case of a totally
implanted catheter), which will reduce the chance of success with ALT;
(2)
whether the infection began less than 2 weeks after the catheter was placed,
which reduces the chance of success because of the increased likelihood of
perivascular infection;
(3)
the type of organism isolated; for example, coagulase-negative
staphylococci respond better to ALT than do S. aureus, P. aeruginosa, or
fungal infections.
The procedure for ALT consists of:
1.
preparing the desired antibiotic to a concentration of 1–5 mg/mL;
2.
mixing the antibiotic solution with 50–100 U of heparin or normal saline solution
to a volume that will fill the catheter’s lumen (2–5 mL);
3.
instilling this solution into the catheter, and closing the catheter for 8–12 hours.
Vancomycin has been used at a concentration between 1 and 5 mg/mL, gentamicin and amikacin
between 1 and 2 mg/mL, and ciprofloxacin between 1 and 2 mg/mL. The instilled volume is
removed before the catheter is again used for the infusion of antibiotics, other medications, or
other solutions. In general, the duration of ALT is about 2 weeks.
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Infections in a Child with Cancer – Catheter-related infections
Acknowledgments:
Authors: Miguela Caniza, MD, St. Jude Children’s Research Hospital
Ayda G. Nambayan, DSN, RN, St. Jude Children’s Research Hospital
Content Reviewed by: Bonnie Williams, RN, CIC, St. Jude Children’s Research Hospital
Edited by: Marc Kusinitz, PhD, St. Jude Children’s Research Hospital
Cure4Kids Release Date: 23 February 2007
Cure4Kids.org
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St. Jude Children's Research Hospital
332 N. Lauderdale St.
Memphis, TN 38105-2794
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