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When Would You Remove a Central Venous
Catheter from a Child with Cancer?
Lead contributor:
Hugo Paganini, MD
Hospital JP Garrahan
Buenos Aires, Argentina.
Translation by:
Nicolas Fernandez, MD
Hospital JP Garrahan
Buenos Aires, Argentina.
A. Important Issues
Each year, more than 150 million intravascular devices are used in the
United States. These devices are implanted for the management of intravenous
fluids, medications, or blood products. These devices are usually well tolerated
by patients, but complications associated with their use may develop under
certain conditions. Thrombosis and infections are the infections commonly
associated with intravascular devices. The incidence of endovascular catheterrelated infections in the United States is 80,000 every year, and these infections
are the most frequently occurring infection in pediatric hospitals. The risk of
acquiring a catheter-related infection depends on several factors: the inclusion
site, the age of the patient, the underlying disease, the experience of the
surgeon implanting the device, and the strategies used to prevent infection.
The indications and the right time for the removal of an infected catheter are
under discussion.
B. Epidemiology and Etiology
Two types of long-term central venous catheters are used for children
with cancer; totally implantable catheters such as the Port-A-Cath and tunneled
catheters such as Hickman and Broviac catheters. The catheter-related infection
rate in patients with cancer is estimated to be 0.83 for every 1000 days of use
of the implantable catheter. The incidence rate increases to 2.85 for every 1000
days of use of tunneled catheters. In Hospital Garrahan in Buenos Aires,
Argentina, the rate of infection is 1.56 catheter-related infection to every 1000
days of use.
Gram-positive cocci are the microorganisms that often cause infections
associated with intravascular devices in 50–60% cases. Coagulase-negative
staphylococci are the prevalent causative organisms, followed by
Staphylococcus aureus. The incidence of infections caused by gram-negative
bacilli depends on epidemiology. Pseudomonas aeruginosa, Klebsiella
pneumoniae, and Escherichia coli are the most common causative agents in
such cases. Finally, between 5 and 10% of catheter-related infections are caused
by Candida spp., and of these, approximately 50% by Candida albicans.
C. Treatment
Generally, treatment with antibiotics is indicated in most cases of
catheter-related infections. Initial antibiotic selection should be based on
epidemiological data from local centers. Data from studies of children indicate
that 76% of catheter-related infections in children with implanted tunneled
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catheters can be treated without removal of the catheter. Very few studies have
been conducted on the access ports of catheters.
A review of 5 studies of children with tunneled catheters revealed that
71–89% of these children were cured without removal of the device. In contrast,
in a review of 9 studies that included 121 children with implantable catheters, it
was observed that 95 of these children were cured without removal of the
catheter.
Currently, the indications for removing a long-term catheters are being
debated. The decision to remove a permanent catheter depends on the age of
the child, the underlying disease, clinical status, and the presence of cellulitis
or embolic infections. The type of pathogen causing the infection is the main
factor influencing the decision for catheter removal.
C.1 Coagulase-negative Staphylococci
Catheter-related infections are most frequently caused by coagulasenegative staphylococci. The course of the infection is usually mild and rarely
associated with severe complications. No randomized studies have been
performed to evaluate these infections in children.
Recently, Raad et al reported the results of a cohort of 188 patients
(children and adults) who developed bacteremia due to catheter-related
infections caused by coagulase-negative staphylococci. In 175 of these patients,
the catheter was not removed, and these patients were treated with antibiotics
only. Recurrent infections were noted in 10% of these patients.
In a multivariate analysis among patients needing removal of the catheter
versus those treated with antibiotics only, the results revealed that the
recurrence rate was significantly higher in patients whose implantable catheters
had been retained. These authors concluded that leaving the catheter does not
increase mortality, although patients whose device was not removed had a
higher rate of recurrent infections.
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According to the guidelines recently published by the Infectious Diseases
Society of America (IDSA), catheters infected with coagulase negativestaphylococci should be withdrawn only after antibiotic treatment has been
tried and has failed.
C.2 Staphylococcus aureus
No consensus has been reached on the indications for catheter removal
in the pediatric population when the cause of the infections is S. aureus.
Infections caused by S. aureus are more severe than those caused by other
pathogens and have a high rate of associated complications and a mortality rate
of 20%.
According to the IDSA standards (2009), all patients with catheter-related
infections caused by S. aureus should be treated with by both catheter removal
and antibiotic therapy unless (1) there is no other alternative venous access
available and (2) the patient has significant bleeding that is difficult to treat or
(3) the child has a severe clinical condition that may be seriously complicated
by catheter removal. It should be emphasized that the IDSA guidelines are
based on the results of studies of adults, and the available data for studies in
children are very scarce. In 4 pediatric studies, 70% of children were cured
without catheter removal. A similar outcome with a success rate of 62% was
observed in a small series study conducted at Garrahan Hospital, Argentina, on
13 children with catheter-related infections caused by S. aureus.
C.3 Gram-negative bacilli
Not much information is available on the treatment of children with
implanted catheters infected by gram-negative bacilli. The available data are
related to infections by specific pathogen.. The IDSA guidelines recommend
catheter removal as the primary approach for patients who have catheterPage 4 of 8
related infections caused by gram-negative bacilli, whose health status is
compromised, or who have persistent bacteremia. Infections caused by
Acinetobacter baumannii, Pseudomonas spp., and Stenotrophomonas
maltophilia, deserve special attention because these pathogens produce
substances that promote the adhesion of organisms to the light source in the
catheter.
C.4 Fungi
The importance of catheter extraction in children with candidal infections
has long been debated. In the last few years, there has been a shift in the
epidemiology of catheter-related infections caused by Candida species. An
increasing number of candidal infections are caused by non-albicans species,
especially Candida parapsilosis. Patients infected with such species usually
develop persistent fungemia and embolic infections, and have a higher
mortality rate if the catheter is not removed.
Clinical trials (most of which have been conducted with adult participants
only) revealed that removal of the infected device improves the patient’s status
and prevents emergence complications. Currently, catheter removal is
recommended for children with candidal infections.
C.5 Other indications
The other indications for catheter removal (C.Table 1) depend
on the clinical condition of the patient and the type of organism
causing the infection.
C. Table 1. Indications for removal of long-term catheters:
 Cellulitis at the catheter exit site (depending on the severity of infection)
 Severe sepsis without a focus
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



Thrombophlebitis
Endocarditis
Persistent bacteremia for 72 hours despite appropriate treatment
Infection with species of Corynebacterium, Bacillus, Micrococcus,
Enterococcus, and Mycobacterium
 Fungal infections
D. Summary
All variables must be evaluated when deciding whether to remove a longterm catheter in a child with cancer.
The most important factors to be considered are the age of the patient,
the type of infection, the pathogen involved, and the clinical condition of the
patient. The indications for the removal of a permanent catheter can be divided
into 2 categories on the basis of the factors mentioned above. Where there is
no controversy about the indication the indication has to be adapted according
to the clinical situation at hand) (D.Table 1).
D. Table 1. Summary of the indications for removal of implantable catheters in
children.
Absolute Indications
1. Severe sepsis
2. Cellulitis
3. Candidal infection
4.Endocarditis
5.Thrombophlebitis
6. Failure of medical treatment
7. Mycobacterial infection
8. Fungal infection
Relative Indications
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9. Infection with Staphylococcus aureus
10. Infection with gram-negative bacilli
11. Infection with species of Enterococcus, Bacillus, Corynebacterium,
Propionibacterium, and Micrococcus
E. Bibliography
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