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Central Line Infections in Paediatric Oncology

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Shared care information

Central line infections may occur with or without neutropenia. It is important to be aware of the microbiology of both your own hospital and any resistant organisms from the oncology unit.

If a line infection is suspected please discuss with the oncology unit or paediatric oncologist on call during working hours regarding antimicrobial therapy and whether to remove the CVL.

Out of hours, if the patient is well then start first line antibiotic therapy as for neutropenia with the addition of vancomycin and discuss the next day. If the patient is unwell, contact the paediatric oncologist on call.

Central Venous Catheter infections

Line infection may be either:

  • extraluminal: usually occurs soon after insertion due to contamination during insertion, or less commonly, later via environmental or skin contamination.
  • intraluminal via catheter hub, haematogenous seeding or contaminated infusates.

Clinical features

Extraluminal infections present with:

  • fever, pain and redness +/- discharge from the exit site. If the patient is neutropenic these signs may be masked.

Intraluminal infections may present with:

  • fever only
  • septic shock, often immediately after accessing the CVC but occasionally, hours later.

Investigations

Diagnosis of CVC related infection is based on positive blood cultures taken from the infected CVC compared to peripheral cultures. In paediatrics, peripheral cultures are not usually taken and the diagnosis of a CVC vs blood stream infection is usually based on:

  • clinical suspicion and absence of other focus of infection
  • persistence of an organism in cultures despite treatment with appropriate antimicrobial therapy
  • Blood cultures:(1)
    • Samples to be obtained prior to starting antibiotic therapy
    • Allow adequate drying time after cleaning the CVC hub
    • Put equal amounts of blood into culture bottles from each lumen.

The most common infections are Gram positive (coagulase negative Staph, Staph aureus), but occasionally Gram negative organisms (E Coli, Klebsiella, Pseudomonas) are found. Even less frequently, Candida may be the cause. Out of the more commonly seen infections, Gram negatives and Staph aureus are the most perturbing. Staph aureus infections are quite common shortly after insertion of the CVC ie. wound contamination at the time of insertion.

  • Extraluminal infections present with fever, pain and redness around the site (there may be tracking up/down the line) and discharge from exit sites. Signs may be minimal if patient neutropenic eg. just pain, minimal reddening.
  • Intraluminal infections may present with fever only, or may be quite dramatic with showering of organisms into the bloodstream causing rigors, poor capillary perfusion, lowered oxygen saturation and fever (usually occurs with or shortly after flushing the line, but may also occur a number of hours later). This more dramatic presentation suggests a Gram negative organism.

Port Pocket infection

This is caused by bacterial infection of the tissue around the Port (Port pocket). If the skin over the port breaks down, the port may extrude through the skin (Port erosion). Once Port erosion occurs, the device must be removed.

Clinical features

  • Pain felt in the area of the Port
  • Redness
  • Swelling
  • Purulent discharge.

Diagnosis

  • Do not access the Port. If the port is not accessed take peripheral blood cultures.
  • If the Port is accessed already, take blood culture then remove the needle.
  • Culture any purulent discharge.

Management

  • If non-neutropenic give flucloxacillin and amikacin (Auckland), or vancomycin (Christchurch) through a peripheral cannula whilst awaiting culture results.
  • If neutropenic give first line antibiotics ( see Antibiotic Protocol) whilst awaiting culture results.
  • Consult surgical team as port removal may be required depending on organism and the response to treatment.

Treatment of line infections

Initial management

Non-neutropenic

  • Suspected CVL infection
    • patient generally well:
      • consider single agent flucloxacillin
      • review blood cultures daily and rationalise antibiotics if cultures are positive
      • If cultures are negative and the patient remains febrile at 24 hours consider broadening antibiotic cover
      • Repeat blood cultures daily while the patient remains febrile.
    • patient unwell (high fever; shut down):
      • treat with first line neutropenic fever antibiotic cover (see national antibiotic regimen) plus vancomycin
  • Hickman exit site infection
    • minor infection around exit site (afebrile, non-tender): topical antimicrobial agents based on the culture results (1)e.g., mupirocin
    • purulent discharge: treat with empiric IV flucloxacillin and rationalise according to swab culture results
    • significant tracking along the line, fever or other systemic signs: treat with first line febrile neutropenia antibiotics (see antibiotic protocol) plus vancomycin until swab culture results are available. Line is likely to need removal.

Neutropenic

  • Suspected luminal infection: admit for first line antibiotic cover (see antibiotic protocol) and vancomycin. Antibiotic cover should be discussed with the infectious diseases team if a culture is positive.
  • Hickman exit site infection without systemic symptoms:
    • admit for vancomycin
  • Hickman site infection with systemic symptoms:

Ongoing management

  • If > 1 lumen is positive, give antibiotics either alternating down the lumens (if antibiotic is given more frequently than 24 hourly) or half dose down each line if given once daily.
  • Repeat blood cultures daily until clear for 48 hours. Continue antibiotics for 7 days from culture negativity. Some units (e.g., Christchurch and Sydney) repeat blood cultures 24-48 hours after stopping antibiotics as growth may be inhibited rather than cleared by antibiotics.

Removal of CVC and duration of antibiotics

These are guidelines from the Infectious Diseases Society of America but should be individualised depending on the need for central access for each patient(1). The benefits of catheter removal must outweigh the difficulty of obtaining alternate access. Any patient in septic shock who does not show rapid improvement should have central line removal and alternative temporary access.

Patients and their microbiological results should be discussed with the infectious diseases team.

  • Coagulase negative staph -10-14 days of IV vancomycin with vancomycin CVC locks. May retain CVC.
  • Staph aureus - 14 days of antimicrobial therapy and also perform echocardiogram looking for vegetations. Remove CVC if unable to clear culture.
  • Enteroccocus - 14 days of IV antibiotic therapy plus antibiotic CVC locks.
  • Gram negative bacilli - 14 days IV antibiotics. Remove CVC if unable to clear infection after 72 hours, or earlier if ongoing sepsis clinically.
  • Candida - treat for 14 days after first negative blood culture. Remove CVC as soon as possible.

Alternative strategies to removal of CVC

If removal of CVC is undesirable and the patient is well, then:

  • Consider antibiotic locks. Vancomycin, ceftazidime, cefazolin, ciprofloxacin, gentamicin and ampicillin can be used(1) . This needs to be balanced against possible delays in chemotherapy.
  • 70% ethanol locks(2) for silicon catheters only - will degrade polyurethane (port-a-cath).
  • Staph aureus clearance is <50% without CVC removal and serious consideration to removal should be given with this organism(1). Candidal clearance is also poor.

References

  1. Mermel et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection:2009 update by the Infectious Diseases Society of America. CID 2009;49:1-45.
  2. Onland et al. Ethanol lock technique for persistent bacteremia of long term intravascular devices in pediatric patients. Arch pediatr adolsc med. 2006;160:1049-53)

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Document Control

  • Date last published: 01 December 2010
  • Document type: Clinical Guideline
  • Services responsible: National Child Cancer Network