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Central Venous Catheter-related Infections (CRI) in Hematology and Oncology

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Central Venous Catheter-related Infections (CRI) in Hematology and Oncology

Status: January 2012
Authors: Hans-Heinrich Wolf, Malte Leithäuser, Georg Maschmeyer, Hans-Jürgen Salwender, Ulrike Klein, Iris Chaberny, Florian Weißinger, Dieter Buchheidt, Markus Ruhnke, Gerlinde Egerer, Oliver A. Cornely, Gerd Fätkenheuer, Sabine Mousset
on behalf of the AGIHO Infectious Diseases Working Party of the DGHO

1Definition and Basic Information

Insertion of central venous catheters is a common procedure in the treatment of patients with hematologic malignancies and solid tumors. Catheter-related infections (CRI) cause considerable morbidity. They are also one of the differential diagnoses of fever of unknown origin in neutropenic patients. This guideline on diagnostics and therapy of CRI was developed by the AGIHO Infectious Diseases Working Party of the DGHO.

Categories are based on the evaluation of study results and the recommendations developed by the Infectious Diseases Society of America, ISDA, see Table 1.

Table 1: Categories of Evidence  

Category, grade

Strength of Recommendation

Definition

A

Good evidence to support a recommendation for use

B

Moderate evidence to support a recommendation for use

C

Poor evidence to support a recommendation for use

D

Moderate evidence to support a recommendation against use

E

Good evidence to support a recommendation against use

Quality of Evidence

Definition

I

Evidence from ≥ 1 properly randomized, controlled trial

II

Evidence from ≥ 1 well-designed clinical trial, without randomization; from cohort or case-controlled analytic studies (preferable from > 1 centre); from multiple time series; or from dramatic results of uncontrolled experiments

III

Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports from expert committees

2Prevention of Catheter-Related Infections

Recommendations are summarized in Table 2.

Table 2: Prevention of Catheter-Related Infections 

Recommendation

Category of Evidence

Access via the subclavian vein is associated with a lower CRI rate as compared to internal jugular vein

A-I

Compliance with hygiene principles during insertion and standardized aseptic placement help to avoid infections

A-I

Impregnation of CVCs with antiseptics (chlorhexidine/silver sulfadiazine) or antibiotics (minocycline/rifampicin) reduces incidence of catheter colonization

A-I

Education programs for nurses and physicians help to reduce the incidence of CRI

A-II

Ultrasound-guided placement helps to reduce CRI rates

B-I

Alcoholic chlorhexidine solution, alcoholic polyvidone–iodine solutions or 70% propanolol should be used for disinfection of the catheter insertion site

A-I

More frequent replacement does not reduce the incidence of infection

D-I

Systemic prophylactic antibiotic treatment prior to catheter insertion is not recommended

E-I

Topical application of antibiotic ointments for reducing staphylococcal colonization at the catheter insertion site and as a nasal ointment is not recommended

E-I

3Diagnosis

3.1Diagnostic Criteria

In clinical practice, diagnosis of central venous catheter-related infections is based on symptoms and test results not always withstanding strict definitions. In many cases, CRI can only be presumed backed-up by clinical symptoms and test results listed in Table 3.

Table 3: Diagnostic Criteria for CRI 

Diagnosis

Criteria

Definite CRI

  • Pathogen detected at the catheter tip by a standard method plus same pathogen with the same susceptibility pattern detected in blood culture

and / or

  • DTTP1 > 2 h

and / or

  • CFU Ratio2 ≥ 10

Probable CRI

  • Local infection at the insertion site

and / or

  • Remission of previously refractory fever within 48h after catheter removal plus positive blood culture

and / or

  • Colonization of the catheter tip3

Possible CRI

  • Pathogen detected in blood culture that is typically implicated in causing catheter infections (S. epidermidis, S. aureus or other coagulase – negative Staphylococci, Candida spp.)

and / or

  • Positive blood culture and no other focus identified in a patient with an indwelling central venous catheter (CVC)

1 DTTP (Differential Time To Positivity) – Difference in time between positivity of results of catheter culture and peripheral blood culture; 2  CFU Ratio – Ratio of Colony Forming Units between pathogen detected in quantitative catheter and peripheral blood cultures; 3  Results above the limit specified for the method

3.2Diagnostics

Recommendations are summarized in Table 4.

Table 4: Diagnostics of Central Venous CRIs 

Recommendation

Category of Evidence

One pair of blood cultures (aerobic and anaerobic) to be taken from the catheter and one from a peripheral vein for microbiological evaluation

A-II

DTTP1 for routine diagnostic purposes

A-I

Semiquantitative culturing for microbiological diagnosis of CRI after catheter removal

A-II

Quantitative culturing from the interior surface of the catheter, vortex and ultrasound treatment of the catheter to disengage adhesive bacteria

A-II

Endoluminal brushing if blood cultures cannot be drawn via CVC line

C-II

Ultrasound imaging along the catheter tunnel for diagnosis of CRI

C-III

Blood cultures from all lumina of the catheter

C-III

No cultures from the catheter hub

D-II

No skin swab for diagnosis of CRI

D-II

No placing of the catheter tip in broth and subsequently culturing the pathogen

E-II

1 DTTP (Differential Time To Positivity) – Difference in time between positivity of results of catheter culture and peripheral blood culture;

4Therapy

First goal is the successful treatment of CRI using systemic antimicrobial therapy. Second goal is the prevention of secondary infection.

4.1Antimicrobial Therapy

Recommendations are summarized in Table 5.

Table 5: Antimicrobial Therapy in CRI 

Recommendation

Category of Evidence

Antimicrobial treatment of suspected CRI based on the same principles as treatment of fever of unknown origin (FUO)

Prompt empirical vancomycin therapy is not required

A-II

At least 2 weeks of systemic antimicrobial treatment in immunosuppressed patients

B-III

For in vitro susceptible pathogens, therapy with a penicillinase-resistant penicillin is more effective and, therefore, preferable to treatment with glycopeptide antibiotics

B-II

Antibiotic lock in addition to systemic antibiotic therapy has shown to reduce the relapse rate of CRI

C-III

4.2Management of CVC

Recommendations are summarized in Table 6.

Table 6: Management of CVC 

Recommendation

Category of Evidence

Primary catheter removal is necessary in

  • CRI due to Staphylococcus aureus

  • CRI due to Candida spp.

  • Tunnel or pocket infection

  • Complicated CRI (e.g. metastatic organ or severe soft tissue infections)

 

A-II

B-II

B-III

B-II

Preservation of CVC may be initially attempted in clinically stable patients in the presence of the following pathogens

  • Coagulase-negative Staphylococci

  • Corynebacterium jeikeium

  • Acinetobacter baumannii

  • Stenotrophomonas maltophilia

  • Pseudomonas aeruginosa

  • Bacillus spp.

B-III

5References

  1. Wolf H. H. al.: Central venous catheter-related infections in hematology and oncology. Ann Hematol 2008;87:863-876. DOI:10.1007/s00277-008-0509-5

6Active Studies

8Authors‘ Affiliations

Dr. med. Hans-Heinrich Wolf
Südharzklinikum
Klinik für Innere Medizin III
Hämatologie, Onkologie, Hämostaseologie
Dr.-Robert-Koch-Str. 39
99734 Nordhausen
Dr. med. Malte Leithäuser
Gemeinschaftspraxis
Lakner/Decker/Leithäuser
Wismarische Str. 32
18057 Rostock
Prof. Dr. med. Georg Maschmeyer
Klinikum Ernst von Bergmann
Zentrum für Innere Medizin
Klinik für Hämatologie, Onkologie
und Palliativmedizin
Charlottenstr. 72
14467 Potsdam
Dr. med. Hans-Jürgen Salwender
Asklepios Klinik Hamburg-Altona
II. Medizinische Abteilung
Hämatologie / Stammzelltransplantation
Paul-Ehrlich-Str. 1
22763 Hamburg
Dr. med. Ulrike Klein
Universitätsklinikum Heidelberg
Kaufmännische Leitung UFHK und ZKJM
Im Neuenheimer Feld 430
69120 Heidelberg
Prof. Dr. med. Iris Chaberny
Universitätsklinikum Leipzig AöR
Institut für Hygiene /
Krankenhaushygiene
Johannesallee 34, Haus L
04103 Leipzig
Prof. Dr. med. Florian Weißinger
Evangelisches Klinikum Bethel gGmbH
Johannesstift
Klinik für Innere Medizin, Hämatologie/Onkologie
und Palliativmedizin
Schildescher Str. 99
33611 Bielefeld
Prof. Dr. med. Dieter Buchheidt
Klinikum Mannheim GmbH
Medizinische Fakultät Mannheim
III. Medizinische Klinik
Theodor-Kutzer-Ufer 1-3
68167 Mannheim
Prof. Dr. med. Markus Ruhnke
Lukas-Krankenhaus Bünde
Hämatologie/ Internistische Onkologie
Hindenburgstr. 56
32257 Bünde
Prof. Dr. med. Gerlinde Egerer
Universitätsklinikum Heidelberg
Medizinische Klinik V
Hämatologie/Onkologie
Im Neuenheimer Feld 410
69120 Heidelberg
Prof. Dr. med. Oliver A. Cornely
Uniklinik Köln, Klinik I für Innere Med.
Zentrum für Klinische Studien
Infektiologie-Hämatologie-Onkologie
Kerpener Str. 62
50937 Köln
Prof. Dr. med. Gerd Fätkenheuer
Universität zu Köln
I. Medizinische Klinik
Joseph-Stelzmann-Str. 9
50924 Köln
Dr. Sabine Mousset
St. Josefs Hospital
Medizinische Klinik III
Palliativmedizin / Onkologie
Beethovenstr. 20
65189 Wiesbaden

9Disclosure

according to the rules of the German Association of Hematology and Oncology (DGHO, Deutsche Gesellschaft für Hämatologie und Mediziniesche Onkologie) and the recommendations of the AWMF (version dated April 23, 2010) and international recommendations.

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