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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. Module 8 – Document 4 Page 1 of 11 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. Module 8 – Document 4 Page 2 of 11 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 Module 8 – Document 4 Page 3 of 11 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. Module 8 – Document 4 Page 4 of 11 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 Module 8 – Document 4 Page 5 of 11 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 Go Back Module 8 – Document 4 Page 6 of 11 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) Go Back 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 Go Back Module 8 – Document 4 Page 7 of 11 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 Go Back Module 8 – Document 4 Page 8 of 11 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) Go Back 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. Module 8 – Document 4 Page 9 of 11 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) Go Back 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. Go Back Module 8 – Document 4 Page 10 of 11 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 International Outreach Program St. Jude Children's Research Hospital 332 N. Lauderdale St. Memphis, TN 38105-2794 You may duplicate and redistribute this content in its entirety for educational purposes provided that the content is made available free of charge. This content may not be modified or sold. You can assist us in the development of additional free educational materials by sending us information about how and when you show this content and how many people view it. Send all comments and questions to [email protected]. © St. Jude Children's Research Hospital, 2007 Last printed 8/4/2017 4:23 AM Last Updated: 18 February 2007; AS X:\HO\IO Edu Grp\Projects\NURSING COURSE\NCEnglish\Edited\Module 8\Final Revisions\NEM08D04V11.doc Module 8 – Document 4 Page 11 of 11