Outcome of central venous catheter-related bacteraemia according to compliance with guidelines: experience with 91 episodes
Introduction
An increasing number of patients require central venous catheters for a short or long period of time. However, catheter use may be subject to complications, notably thrombosis and infections.1, 2, 3, 4, 5 The incidence of long-term catheter-related bacteraemia (CRB) is estimated at 2.8–14 episodes per 1000 catheter-days.4, 6, 7, 8, 9, 10
Despite this high frequency of CRB and the high morbidity of these infectious complications, only a few clinical studies with a small number of patients have focused on the management of long-term CRB.11, 12, 13 Therefore, international guidelines were established with a weak strength of recommendation, notably for the modality of conservative treatment.1, 14
CRB usually requires catheter removal, but the loss of an access vein, the need for a new procedure to replace the catheter, and the cost of catheter replacement all argue in favour of conservative therapy of infected lines when possible. However, catheter sterilization without removal is difficult to obtain. In 1988, Messing et al. described a conservative treatment for CRB associating systemic antimicrobial therapy and antibiotic-lock therapy (ALT).15 Several studies reported the use of ALT in daily clinical practice, and recent guidelines for the management of CRB suggest using ALT in several situations.1, 2, 14, 16, 17, 18, 19 However, the clinical evidence supporting ALT use remains fragmentary.
The aims of this study were: (i) to investigate the appropriateness of CRB management, in particular the use of ALT in daily clinical practice; and (ii) to analyse the outcome of CRB according to compliance with the established guidelines.
Section snippets
Study setting
The study was conducted at the Grenoble University Hospital, a 2200-bed teaching hospital, with about 105,000 admissions per year. Medical prescriptions are individual and computerized in most departments, except the emergency and intensive care units.
The local antimicrobial commission has produced local guidelines for CRB management (Figure 1), based upon recently published international guidelines.1, 2, 14 These local guidelines are available on the hospital intranet. Practical details of ALT
Population
A total of 187 episodes of bacteraemia was recorded in 165 patients. A diagnosis of CRB was retained for 93 episodes (in 82 patients). Clinical and treatment data were missing for two episodes; consequently, 91 episodes (80 patients) were included in this study. Fifty-one (56%) involved implantable ports and 39 (42.9%) central venous catheters.
Central venous systems were mainly implanted for chemotherapy (64.8%) and parenteral nutrition (13.2%). Most patients had CRB risk factors: 70.3% had
Outcomes
Cure was obtained in 72.5% of all cases (Table III). The overall mortality rate up to the end study date was 29.7%; the mortality rate due to the CRB analysed was 5.5%. Relapse was observed in seven patients (7.7%), all patients being immunocompromised and affected by solid cancer or haemopathy. Cure was associated with the adaptation of overall medical management (P = 0.03) and with the adaptation of the systemic antimicrobial therapy (both empirical treatment and adapted therapy after
Discussion
To our knowledge, this series of 91 CRB cases is the first study evaluating appropriateness of CRB management in daily clinical practice and the largest study on the long-term outcome of CRB. Nearly two years’ worth of data were available for patient outcome analysis. Most of the earlier studies on CRB focused on one population of patients: intensive care unit patients, onco-haematologic patients, children, patients with acquired immunodeficiency syndrome, or patients with parenteral nutrition.
Conflict of interest statement
None declared.
Funding sources
None.
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