Outcome of central venous catheter-related bacteraemia according to compliance with guidelines: experience with 91 episodes

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Summary

Background

Infection is a major complication associated with the use of central venous catheters. Guidelines for medical management of catheter-related bacteraemia have been published, but no study has assessed the appropriateness of physician practices.

Aim

To assess medical practices in cases of central venous catheter-related bacteraemia (CRB) in a university hospital.

Methods

Cases were recorded over a period of 12 months and their management was evaluated. All cases of positive blood cultures based on central venous catheter sampling were analysed, and episodes of CRB were determined in this group of patients. Medical management and patient outcome were analysed independently by two physicians.

Findings

In all, 187 cases of positive blood culture were recorded and 91 cases of CRB were analysed. Systemic antimicrobial therapy was optimal in 56% of the episodes. In 51 episodes, catheter salvage was attempted, for 29 with an indication in agreement with the guidelines but without antibiotic-lock therapy in 20 episodes. The overall medical management was appropriate in 41.8% of the episodes. The overall cure rate was 72.5%. CRB-related death occurred in 5.5% of the episodes. Cure was associated with guideline compliance (P = 0.03) and with adaptation of systemic antimicrobial therapy (P < 0.01). Conservative treatment success was associated with compliance with the guidelines for the indication (P = 0.01).

Conclusion

Medical management of CRB did not closely adhere to international guidelines. CRB outcome was associated with the appropriateness of this management, particularly when conservative treatment was attempted.

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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