Replacement Of Central Venous Catheters Research Articles

#3055 Replacement of tunneled cuffed hemodialysis catheters on coated guidewire: a strategic approach to treat CVC-related infections

Abstract Background and Aims Infections of tunneled hemodialysis central venous catheters (CVCs) are a serious problem, and the outcome of dialysis patients strongly depends on their clinical management. Several specialists are involved in choosing the appropriate technical and clinical strategy but often there is no consensus among them on the proper management. We believe that the role of nephrologists must be pivotal in this setting throughout the entire process, from the choice of vascular access to the management of complications. Here, we present our experience using an approach to replace CVCs that was conceived to minimize the rate of infections. Method We propose a CVC replacement technique to minimize the risk of contamination by using a guidewire coating that allow no contact between the old and new CVC. We carried out a retrospective observational study of tunneled CVCs replacement with this technique performed at the Nephrology Unit of the "A. Gemelli Polyclinic" between January 2020 and June 2023. The following parameters were analyzed: age, sex, infection-supporting pathogen, CVC age, and dialysis age. Results During the reporting period, we carried out a total of 87 CVC guidewire replacement procedures for HD tunneled catheters defined “access to be preserved” using our technique. Among the patients (median age 70,6) undergoing this procedure, n=5 (5.75%) presented with endocarditis (n=4 by Staphylococcus aureus, n=1 by Pseudomonas aeruginosa). The follow-up ranged from 6 months to 3 years. During this time only one patient, with endocarditis, had a recurrent infection caused by Pseudomonas aeruginosa after 3 months from the CVC replacement whereas 12 patients presented a de novo CVC infection caused by a different pathogen (n=4 by Staphylococcus aureus, n=1 by Pseudomonas Aeruginosa. Conclusion Overall, our data are encouraging as the lower rate of recurrent infections in our cohort suggests that our CVC replacement technique can be potentially used even in case of dangerous pathogens.

Early Central Venous Catheter Replacement After Candida in Pediatric Intestinal Failure Patients.

Deferred central venous catheter (CVC) replacement places children with intestinal failure (IF) at risk of complications. We hypothesized that early CVC replacement after uncomplicated candidemia is safe and beneficial. We performed a retrospective review of children with IF. Patients were divided into early (<7 days after their first negative culture), and late (≥7 days after their first negative culture) CVC replacement following uncomplicated candidemia. We calculated the median time to CVC removal, clearance of infection, CVC replacement or exchange, and duration of the initial hospitalization. The proportion of patients readmitted within 30 days was also calculated, taking note of the number of candida reinfections. Early replacement occurred in 18 encounters and late replacement in 21 encounters. The median time in both groups to CVC removal was 3 days (P = 0.949), and clearance of infection was 4 days (P = 0.466). The median time to CVC replacement or exchange in the early group was 4 days, compared to 10 days in the late group (P < 0.001). The median duration of the hospitalization in the early group was 12 days compared to 21 days in the late group (P = 0.011). In total 39% of patients from the early group were readmitted within 30 days compared to 57% from the late group (P = 0.359). None of the patients were reinfected with candida within 30 days. Early CVC replacement after uncomplicated candidemia in children with IF decreases hospital stay without increased risk of readmission or reinfection.

Early economic benefits of perioperative nasojejunal tube feeding in non-critical care adult surgical patients with gastric feed intolerance

Background: Fluoroscopy-guided endoscopic placement of nasojejunal tubes (NJT) for perioperative short- or medium-term enteral nutrition (EN) is potentially required for anatomical gastric feed intolerance. Methods: Indication for NJT and successful insertion rates was determined. NJT insertion costs were calculated and compared with central venous catheter (CVC) insertion. Duration of NJT patency in non-critical care surgical patients was determined in days in a local cohort. EN costs were calculated over a hypothetical 28-day period factoring in expected NJT replacements due to blockage and compared with parenteral nutrition (PN) via CVC, which included routine CVC changes every 10 days. Public and private sectors were compared. Results: One hundred and two (93.6%) NJTs were placed successfully, with gastric outlet obstruction the most frequent indication (40.4%) with a median 10 days’ (range 1–68 days, IQR 6–16.75 days) usage. Irrevocable blockage occurred in 33 tubes after a median 9 days (range 3–34 days; IQR 4.75–16 days). Calculated EN costs over 28 days, including NJT replacement every 9 days, reached US$1 676.12 and PN costs with CVC replacement every 10 days, US$3 461.35 (p < 0.001) in the public sector. In the private sector PN costs at 28 days were significantly higher (p < 0.001) at US$5 261.14 compared with EN US$3 780.71. The cost benefit of EN over PN is seen after three days in the public, and four days in the private sector. Conclusion: Exponential cost saving occurs with EN via NJT over time, even when factoring in the likelihood of NJT replacements.

Risk Factors for Mortality in Patients with Stenotrophomonas maltophilia Bloodstream Infections in Immunocompetent Patients.

This study aimed to evaluate bloodstream infections caused by Stenotrophomonas maltophilia in immunocompetent patients with respect to clinical features and risk factors for mortality. We reviewed bloodstream infections detected between January 1, 2012, and July 1, 2021, to identify nosocomial S. maltophilia bacteremia in Koşuyolu Research and Training Hospital. We identified a total of 97 patients with S. maltophilia bloodstream infections. Of these, 17 patients were excluded because of community-acquired infections (n=9), contamination with S. maltophilia (n=3), and insufficient data (n=5), with 80 (57.5% males) patients remaining for analysis. The source of infection was the respiratory tract in 28 (35%) patients. A central venous catheter was used in 60 (75%) patients, which required replacement in 23 patients within five days after detecting S. maltophilia bacteremia. On antimicrobial susceptibility testing, 71 strains were found to be susceptible and 9 (11.3%) resistant to trimethoprim-sulfamethoxazole. Thirty-day mortality was 33.8%. Non-survivors differed significantly from survivors with respect to higher rates of central venous catheters ( p=0.020), mechanical ventilation (p=0.006), urinary catheters (p=0.021), septic shock (p=0.001), hypoalbuminemia (p=0.026) and thrombocytopenia (p =0.039). S. maltophilia bacteremia was independently associated with mortality in patients with hypoalbuminemia, and replacement of central venous catheters had a protective role in reducing mortality. As with other bacterial infections, S. maltophilia bacteremia is associated with a considerably high mortality rate in patients with cardiac conditions. The replacement of the catheter seems to play a beneficial role in 30-day survival.

Impact of central venous catheter repair in pediatric intestinal failure.

Patients with intestinal failure (IF) require long-term parenteral nutrition through central venous catheters (CVCs). When damaged, catheter replacement or repair is considered. Limited literature exists on repair outcomes in this population. We aimed to assess the impact of repair on durability of exiting CVCs and infection rates. This was a retrospective cohort study of pediatric IF patients with tunneled silicone CVCs over 10 years. Outcomes were evaluated by assessing CVC longevity, repair success, replacement, and postrepair infection rates. One hundred thirty-eight repairs and 45 replacements were conducted in 37 patients with repair and replacement rates of 4.7 and 1.5 per 1000 catheter days, respectively. Twenty patients (54%) required ≥1 repair. For CVCs requiring repair, median CVC durability without and with repairs were at 123 and 391 days, respectively (P < .0001). Overall repair success rate was 96% with significantly lower success in the emergency department at 81% (P = .007). The 7-day postrepair infection rate was 2.2% without specific risk factors identified. Most repairs (76%) were performed by the Pediatric Gastroenterology division. Variability in practice was noted among services, including frequency of periprocedural antibiotic use and performance of temporary repairs before permanent repairs. A gradual increase in CVC repair rate was noted over time. Our study showed that CVC repair is effective in prolonging CVC durability in pediatric IF patients without increasing infection rates. Incorporating a temporary repair as a step before permanent repair may offer a route to address potential intraluminal thrombosis before permanent repair.

Pulmonary Embolism in a Critically Ill Infant with Univentricular Parallel Circulation

AbstractA 3-month-old infant patient with hypoplastic left heart syndrome diagnosed in the prenatal period required long-term intensive care for refractory chylothorax and chylous ascites after undergoing bilateral pulmonary artery banding at age 6 days. Weaning from mechanical ventilation was difficult due to massive edema, and a central venous catheter was required because enteral feeding was hampered by the refractory chyle leakage, for which surgery was ineffective. On the evening after central venous catheter replacement was performed, his respiratory condition suddenly deteriorated; cardiac ultrasound revealed that the left pulmonary arterial blood flow had decreased, and enhanced computed tomography demonstrated a left pulmonary embolism (PE), which was identified as the cause of a sudden decrease in the pulmonary blood flow. The patient died due to refractory septic shock at age 5 months. PEs in children, especially patients with cyanotic congenital heart disease, are difficult to diagnose because of their atypical presentation. Current diagnostic criteria are based on adult guidelines, and a few factors in the criteria, such as tachycardia and hypoxia, are difficult to apply for pediatric cyanotic patients with intracardiac or extracardiac right-to-left shunt. In fact, those criteria have lower specificities in children. In conclusion, the present case suggested that a sudden decrease in the pulmonary blood flow can aid the physicians in diagnosing PE in patients with cyanotic congenital heart disease. We need more pediatric cases and evidence of PE in children to make a PE guideline, which is specific to pediatric patients including cyanotic congenital heart disease.

Repair of Central Venous Catheters in Home Parenteral Nutrition Patients.

For patients receiving home parenteral nutrition (HPN), vascular access with a central venous catheter (CVC) is essential to safely administer parenteral nutrition (PN) to meet their nutrition and hydration needs. Unfortunately, despite rigorous training and prevention strategies, CVCs are susceptible to complications such as infection, occlusion, thrombosis, and mechanical failure. Much of the published research on CVC complications focuses on infections; however, catheter occlusions and mechanical failures also contribute significantly to catheter dysfunction and loss. Frequent CVC exchanges put HPN patients at risk of loss of vascular access, making it essential that any strategies that can salvage the CVC be implemented prior to removal. CVC repair is 1 technique that can be utilized to avoid CVC exchanges in certain situations. CVC repairs can be performed in the office or on the ward and are cost effective when compared with CVC replacement. When performed by trained clinical staff, the procedures are highly successful and associated with low risk.

Catheter-free Period Over 2 Days Is Associated with Better Outcome in Catheter-related Bloodstream Infection due to Candida

BackgroundRegardless of active antifungal drugs, mortality of candidemia remains high. Although it is well-known that central venous catheter (CVC) is one of the most important risk factors of candidemia and should be removed immediately, little is known about optimal timing of CVC replacement after removal. Here, we analyzed contributing risk factors associated with 30-day mortality for catheter-related bloodstream infection (CRBSI) due to candida and optimal timing of CVC replacement.MethodsWe conducted a retrospective cohort study at St. Luke#129; fs International Hospital between 2004 and 2015. We compared each clinical component in patients who died within 30 days and were alive at 30 days. Also, catheter-free period (from removal to replacement) was compared between group A and B. Fisher#129; fs exact test and Mann–Whitney U test were used in univariate analysis and multivariate linear regression was used for controlling confoundings.ResultsAmong 228 patients (pts) with candidemia, 166 patients (73%) were on CVC at diagnosis. Of them, 144 patients (65%) removed CVC after the result of candidemia. Seventy-one patients (31%) replaced CVC. Fifteen patients (6%) died within 30 days (group A) and 56 patients (25%) were alive at 30 days (group B). Median age was 74 in group A and 72 in group B (P = 0.331) (Table 1). In univariate analysis, hematological malignancy (OR 6.75, 95% CI 1.01–44.9) and CVC replacement < 2-days after removal (OR 5.63, 95% CI 1.16–27.3) showed statistically significant increase in group A vs group B (Table 2). In multivariate analysis, CVC replacement < 2-days was independently associated with 30-day mortality (Table 3).ConclusionThis is the first study to demonstrate the optimal timing of CVC replacement in CRBSI due to candida. CVC replacement < 2 days was an independent risk factor for 30-day mortality.Disclosures All authors: No reported disclosures.

Management of central venous catheters in intensive care units: Comparative study of guidelines versus practice.

Sir, An observational study was conducted on 100 nurses with minimum 6 months of experience in various intensive care units (trauma, swine flu, medical, and renal) of the hospital to assess their knowledge and clinical practice. A two-part questionnaire [Table 1] was filled by the nurses after every central venous catheter (CVC) insertion for a period of 2 months. Each correct response was scored 1; incorrect 0. Total number of catheter insertions was 148. Mean score for the study was 53%. Table 1 Questionnaire Results from Part A: Standardized equipment set, barrier precaution, filling of the checklist, and an assistant was available in 96%, 95%, 86%, and 98% of the insertions. Two-third were done on monitored beds with head low; only 1% on unmonitored beds. Povidone iodine, 70% alcohol, 2% chlorhexidine-based preparations were preferred in decreasing order for disinfection of skin (60%, 21%, and 19%, respectively). Eighty percent preferred sutures for catheter fixation and transparent bio-occlusive dressing. Results from Part B: Subclavian, internal jugular and femoral vein were preferred by 66.6%, 25%, and 9%. One-fifth were not aware of use of ultrasound. 98% managed unintended arterial puncture by removal of needle/catheter and application of pressure. 90% opined that chest X-ray confirmed placement of CVC. 96% preferred heparin based solution; 4% used normal saline. Two inspections of CVC/day were made by 50%; one/day were made by 40%. One-fifth wiped access ports with antiseptic before drug administration. Removal of infected CVC was considered by 60%; 25% believed in giving an antibiotic and observing. Three-fourth marked 4 h as maximum infusion time for blood products; 24 h for change of intravascular catheters/sets. Tubings for blood products and lipid emulsions were changed by 80% 12 hourly. Three-fourth believed in no fixed duration for changing CVC; one-fourth believed in the weekly change. Half believed in administration of antibiotics for central lines inserted in emergency. Only 25% considered a replacement of the catheter within 48 h. The remaining 25% considered replacement only on signs of infection. Routine prophylactic antibiotics was advocated by 36%. Results show that awareness on the use of chlorhexidine, ultrasound, correct management of arterial punctures and protocol for CVC inserted in emergency departments needs to be increased. Regular training programs with the nursing staff on bundles of care related to insertion and maintenance of CVC are needed.[1,2,3] American Society of Anesthesiologists guidelines[4] are focused on elective insertions of CVC's performed by anesthesiologists, but the Centers for Disease Control and Prevention guidelines[5] also address emergency placements, peripherally inserted central catheters, pulmonary artery catheter and tunneled central lines. Safety or efficacy of chlorhexidine in neonates and infants aged <2 months remains an unresolved issue. Fluid administration sets need to be changed at 96 h intervals and tubings for blood products and lipid emulsions every 24 h. Routine replacement of CVCs on the basis of fever alone and prophylactic administration of systemic antimicrobial agents is discouraged. Mandatory replacement is to be done within 48 h for all catheters inserted in an emergency without aseptic precautions.

Simulation-based training for emergency medicine residents in sterile technique during central venous catheterization: impact on performance, policy, and outcomes.

Central line-associated bloodstream infection (CLABSI) is a preventable nosocomial infection. Simulation-based training in sterile technique during central venous catheter (CVC) placement for emergency medicine (EM) residents, and its effect on changing the medical intensive care unit (MICU) practice of routine replacement of CVCs placed under sterile technique in the emergency department (ED), has not been evaluated. Emergency medicine residents received simulation-based sterile technique training during CVC placement between May 2008 and September 2010. Between June 2008 and January 2011, the authors reviewed records of patients who had CVCs placed in the ED under sterile technique by EM residents and were admitted to the MICU (group 1) and CVCs placed in the MICU under sterile technique by internal medicine (IM) residents (group 2). IM residents completed similar simulation-based training before May 2008. Changes in EM residents' sterile technique performance scores were compared, as well as CLABSI rates in both groups. EM residents' CVC procedural skills were not assessed. Seventy-six EM residents completed simulation-based training with significant improvement in performance (median scores 13 out of 24 before training, 24 out of 24 after training; p < 0.001). CLABSI rates per 1,000 catheter-days were 1.02 in group 1 and 1.02 in group 2 (p = 0.99). Both groups had similar demographics, acuity, and mortality (p > 0.5). Routine replacement of CVCs placed in the ED under sterile technique after simulation-based training would appear to be unnecessary. These findings demonstrate patient-centered outcomes that are comparable for CVCs in ED-admitted MICU patients, regardless of whether the CVC was placed in the ED or MICU.

PICC在SICU控制血管导管相关性感染发病率中的应用研究

目的：探讨中心静脉导管(Central Venous Catheters, CVC)和经外周静脉植入中心静脉导管(Peripherally Inserted Central Catheter, PICC)在长期入住外科重症监护病房(Surgical Intensive Care Units, SICU)的患者中导管相关血流感染(Catheter-Related Blood Stream Infections, CR-BSI)发生率。方法：随机观察并分析长期入住SICU的90例患者更换抗感染中心静脉导管或PICC置管治疗后的导管相关性感染发生情况。按照感染诊断标准，Logistic回归分析CR-BSI确定推测。结果：CVC置管感染8例(感染率8.6/千导管日)，PICC置管感染1例(感染率1.2/千导管日)。CVC置管时间为(19.74 ± 2.14) d，其中发生感染的CVC为置管(13.87 ± 1.56) d；PICC置管时间为(30.41 ± 3.58) d，发生感染的时间为置管第28d。Logistic回归分析表明，置管天数是唯-CVC感染的预测因子(P=0.013)。结论：缩短CVC留置时间，长期入住ICU患者用PICC代替CVC可能降低CR-BSI的发生。 Objective: To study the incidence of CR-BSI (Catheter-Related Blood Stream Infections) of CVC (Central Venous Catheters) and PICC (Peripherally Inserted Central Catheter) in SICU. Methods: Random observation and analysis on the catheter-related infections of the 90 patients’ replacement of CVC or PICC in SICU. According to the diagnostic criteria of infection, CR-BSI Logistic regression analysis is used to determine speculation. Results: 8 cases of infection in CVC (8.6 per thousand) and 1 case of infection in PICC (1.2 per thousand). For CVC the indwelling time was (19.74 ± 2.14) d, in which the infected CVC’s indwelling time was (13.87 ± 1.56) d; For PICC the indwelling time was (30.41 ± 3.58) d and the infection indwelling time was on the 28th. Logistic regression analysis showed that the catheter indwelling time was the only predictor of CVC infection (P = 0.013). Conclusion: Shortening the indwelling time of CVC, using PICC instead of CVC may reduce CRBSI for long-term-stay patients in ICU.

Central Line–associated Bloodstream Infection in Children

Central Line–associated Bloodstream Infection in Children

Enteral versus parenteral nutritional support in allogeneic haematopoietic stem-cell transplantation

Allogeneic haematopoietic stem-cell transplantation (allo-HSCT) is associated with frequent and severe malnutrition, which may contribute to transplant-related morbidity. While both enteral nutrition (EN) via a nasogastric tube and parenteral nutrition (PN) are effective, it remains unclear what is the optimal method of nutritional support. We propose to compare the impact of EN versus PN on early outcome after allo-HSCT. We evaluated the effect of initial nutritional support with EN versus PN on early outcome in 56 patients who required nutritional support after first allo-HSCT for haematological malignancies in our centre. Patients were offered EN but could decline and chose to be treated by PN. Twenty patients received myeloablative conditioning and 36 received reduced-intensity conditioning. Twenty-eight patients received EN and 28 received PN. Compared with PN, EN was associated with a lower median duration of fever (2 versus 5 days; p < 0.01), a reduced need for empirical antifungal therapy (7 versus 17 patients; p < 0.01), a lower rate of central venous catheter replacement (9 versus 3 patients; p = 0.051) and a lower rate of transfer to intensive care (2 versus 8 patients; p = 0.036). The early death rate (<100 days) was the same in both groups (14%). Compared with PN, EN was associated with a lower risk of infection in allo-HSCT, without an increase in the incidence of graft-versus-host disease.

Cutaneous Rhizopus infection at a central venous catheter site in a critically ill renal transplant patient

Invasive fungal infections are increasing in incidence, along with the use of immunosuppressive medications for the prevention of organ transplant rejection, graft versus host disease and treatment of auto-immune disorders. Additionally, the incidence of invasive fungal infections is increasing with the use of new antineoplastic therapies for malignancy, increasing incidence of diabetes mellitus, expanded use of broad-spectrum antimicrobial therapy and with an aging population with chronic medical problems such as chronic renal failure, chronic obstructive pulmonary disease and HIV. We present a case of primary cutaneous zygomycosis at the insertion site of a central venous catheter in a 45-year-old renal transplant patient admitted for acute pancreatitis. In the critical care setting, clinicians must retain a high index of suspicion for invasive fungal infections in immunocompromised individuals to ensure early diagnosis and provide aggressive medical and surgical intervention. Liposomal amphoterin B is the first line antimicrobial therapy, and reduction or discontinuation of immunosuppressive therapy should be considered. Currently there are no consensus opinions or recommendations for routine, scheduled replacement of central venous catheters to prevent infections, even in immunosuppressed patients.

PMO-065 Repair of fractured central venous catheters for parenteral nutrition: techniques and risk of infection

IntroductionTunnelled central venous catheters (CVCs) are the best method of vascular access for long-term parenteral nutrition. Failure of intravenous access can necessitate emergeny admission. Removing and replacing CVCs is painful,...

A Survey of Invasive Catheter Practices in U.S. Burn Centers

Burn-specific guidelines for optimal catheter rotation, catheter type, insertion methods, and catheter site care do not exist, and practices vary widely from one burn unit to another. The purpose of this study was to define current practices and identify areas of practice variation for future clinical investigation. An online survey was sent to the directors of 123 U.S. burn centers. The survey consisted of 23 questions related to specific practices in placement and maintenance of central venous catheters (CVCs), arterial catheters, and peripherally inserted central catheters (PICCs). The overall response rate was 36%; response rate from verified centers was 52%. Geographic representation was wide. CVC and arterial catheter replacement varied from every 3 days (24% of sites) to only for overt infection (24% of sites); 23% of sites did not use the femoral position for CVC placement. Nearly 60% of units used some kind of antiseptic catheter. Physicians inserted the majority of catheters, and 22% of sites used nonphysicians for at least some insertions. Ultrasound was routinely used by less than 50% of units. A wide variety of post-insertion dressing protocols were followed. PICCs were used in some critically injured patients in 37% of units; the majority of these users did not rotate PICCs. Thus, it can be surmised that wide practice variation exists among burn centers with regard to insertion and maintenance of invasive catheters. Areas with particular variability that would be appropriate targets of clinical investigation are line rotation protocols, catheter site care protocols, and use of PICCs in acute burns.

Consistency between guidelines and reported practice for reducing the risk of catheter-related infection in British paediatric intensive care units

Optimal strategies for reducing catheter-related blood stream infection (CR-BSI) differ for adults and children. National guidelines do not make child-specific recommendations. We determined whether evidence explained the inconsistencies between guidelines and reported practice in paediatric intensive care units (PICUs). We conducted a survey of eight interventions for reducing CR-BSI in all 25 British PICUs in 2009. Interventions were categorised as requiring child-specific evidence, generalisable to adults and children, or organisational recommendations. Twenty-four of the 25 PICUs responded. For child-specific interventions, practice diverged from guidelines for "Insert into subclavian/jugular veins" (18 PICUs frequently used femoral veins, supported by observational evidence for increased safety in children). Practice reflected guidelines for "Use standard but consider antimicrobial-impregnated central venous catheters (CVCs) for high-risk patients" (14 used standard only, 3 used standard and antimicrobial-impregnated despite no randomised controlled trial (RCT) evidence for antimicrobial-impregnated CVCs in children, 7 used heparin-bonded for some or all children); "Use 2% chlorhexidine for skin preparation" (20 PICUs); "Avoid routine CVC replacement" (20 PICUs). For generalisable interventions, practice was consistent with guidelines for "Administration set replacement" (21 PICUs) but deviated for "Maintenance of CVC asepsis" (11 PICUs used alcohol due to inconclusive evidence for chlorhexidine). Practice diverged from guidelines for organisational interventions: "Train healthcare workers in CVC care" (9 PICUs); "Monitor blood stream infection (BSI) rates" (8 PICUs). Guidelines should explicitly address paediatric practice and report the quality of evidence and strength of recommendations. Organisations should ensure doctors are trained in CVC insertion and invest in BSI monitoring, especially in PICUs. The type of CVC and insertion site are important gaps in evidence for children.

Endoluminal Brushing of Occluded Long Term Parenteral Nutrition Catheters is Associated With a Reduced Need for Catheter Replacemet

Introduction Maintaining venous access is paramount to survival in patients on home parenteral nutrition(HPN),but central venous catheter(CVC) occlusion is a significant reason for CVC removal; this occurs largely due to lipid or fibrin precipitate, so a standard clearance protocol using ethanol, hydrochloric acid (HCl) and urokinase is well established.1 Endoluminal brushing has been used to diagnose CVC sepsis and resolve occluded haemodialysis CVCs.2 We aimed to evaluate the efficacy of endoluminal brushing of occluded HPN CVCs and whether the technique is associated with reduced need for CVC replacement. Methods Data on patient with occluded HPN CVCs (median duration of HPN 29 months) presenting to a National IFU over 7 years were collected prospectively. Endoluminal brushes were withdrawn in March 2006 in the UK due to manufacturing issues so patients were divided into 2 groups: Brushing Group (patients presenting from Dec 2003 to March 2006,all of whom underwent CVC brushing with ‘fibrin analysis system’ (FAS) endoluminal brushes) and Standard Group (patients presenting from April 2006-Sept 2010,who were managed with a standard protocol of urokinase & ethanol flushing; 70% ethanol ± 5000 units urokinase was used in patients predominantly on a lipid regimen; HCl±urokinase was used for glucose/electrolyte regimens). Statistical analysis was performed with chi-squared. Results 68 episodes of line occlusion occurred in 44 patients (48% male; mean age 47) in the Brushing Group; of these,20 patients had undergone failed treatment with the standard occlusion protocol before brushing. Successful clearance was achieved in 36 patients after a median of 1 brushing (range 1–4); line replacement was required in the other 8 patients (18%) after a median of 1.5 brushing attempts(range 1–4).In patients in whom brushing had been successful, 15 patients9 lines reblocked after a median of 10 months(range 1–65). No complication related to brushing was recorded. 69 episodes of line occlusion occurred in 45 patients (52% male; mean age 50) in the Standard Group, with successful clearance achieved in 16 patients; line replacement was required in the other 29 patients (64%; p Conclusion This is the first study to demonstrate that FAS endoluminal brushing is safe and effective in clearing occlusions in HPN CVCs & is associated with a significant reduction in the need for line replacement compared to standard techniques. If endoluminal brushes become available again in the UK, the technique should be evaluated in a prospective controlled study.

Do Prolonged Peripherally Inserted Central Venous Catheter Dwell Times Increase the Risk of Bloodstream Infection?

From the Department of Pediatrics, Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland (all authors). Received April 6, 2010; accepted May 17, 2010; electronically published October 1, 2010. Infect Control Hosp Epidemiol 2010; 31(11):1184-1187 2010 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2010/3111-0013$15.00. DOI: 10.1086/656589 Peripherally inserted central venous catheters (PICCs) have become increasingly popular as a result of the ease of their placement at the bedside and their long-term viability with relatively minimal mechanical complications. Although PICCs were initially intended for short-term vascular access, these catheters often remain in place for weeks to months. No prospective trials have evaluated whether replacement of central venous catheters (CVCs) beyond 7 days after insertion can reduce rates of central line–associated bloodstream infection (CLABSI). Similarly, no prospective trials have evaluated whether scheduled replacement of PICCs can reduce incidence of CLABSI. In this commentary, we discuss why longer catheter dwell times may increase the risk of CLABSI at an accelerated pace in patients with PICCs and why, in some instances, PICC replacement or an alternative intervention may prevent CLABSI.

Infectious risk associated with arterial catheters compared with central venous catheters*

Scheduled replacement of central venous catheters and, by extension, arterial catheters, is not recommended because the daily risk of catheter-related infection is considered constant over time after the first catheter days. Arterial catheters are considered at lower risk for catheter-related infection than central venous catheters in the absence of conclusive evidence. To compare the daily risk and risk factors for colonization and catheter-related infection between arterial catheters and central venous catheters. We used data from a trial of seven intensive care units evaluating different dressing change intervals and a chlorhexidine-impregnated sponge. We determined the daily hazard rate and identified risk factors for colonization using a marginal Cox model for clustered data. We included 3532 catheters and 27,541 catheter-days. Colonization rates did not differ between arterial catheters and central venous catheters (7.9% [11.4/1000 catheter-days] and 9.6% [11.1/1000 catheter-days], respectively). Arterial catheter and central venous catheter catheter-related infection rates were 0.68% (1.0/1000 catheter-days) and 0.94% (1.09/1000 catheter-days), respectively. The daily hazard rate for colonization increased steadily over time for arterial catheters (p = .008) but remained stable for central venous catheters. Independent risk factors for arterial catheter colonization were respiratory failure and femoral insertion. Independent risk factors for central venous catheter colonization were trauma or absence of septic shock at intensive care unit admission, femoral or jugular insertion, and absence of antibiotic treatment at central venous catheter insertion. The risks of colonization and catheter-related infection did not differ between arterial catheters and central venous catheters, indicating that arterial catheter use should receive the same precautions as central venous catheter use. The daily risk was constant over time for central venous catheter after the fifth catheter day but increased significantly over time after the seventh day for arterial catheters. Randomized studies are needed to investigate the impact of scheduled arterial catheter replacement.