versão impressa ISSN 1677-5449
J. vasc. bras. vol.9 no.1 Porto Alegre 2010
Milton Alves das Neves Junior; Rafael Couto Melo; Adenauer Marinho de Oliveira Goes Junior; Tatiana Rocha Protta; Catarina Coelho de Almeida; Allison Roxo Fernandes; Alexandre Petnys; Edgar Raboni
Cirurgiões vasculares, Serviço de Cirurgia Vascular, Hospital do Servidor Público Municipal de São Paulo (HSPM), São Paulo, SP, Brazil
Long-term venous catheters are widely used in patients needing venous access for prolonged periods. The infection related to these catheters remains a challenge in clinical practice. We reviewed the literature about infection epidemiology and treatment related to catheters. Staphylococcus aureus is the most common isolated bacteria. Tunneled catheters present higher infection rates than implanted ports. Treatment may consist of the use of locks, systemic antibiotics, and even catheter removal, depending on the kind of infection, the isolated microorganism, and the patient's clinical conditions. Catheter salvation should be tried whenever possible.
Keywords: Indwelling catheters, renal dialysis, drug therapy.
Long-term central venous catheters are used when there is the need of prolonged or definitive access to vascular system, frequently employed in hemodyalisis, hemotherpay, chemotherapy and prolonged parenteral nutrition (PPN). They are manufactured in silicone or polyurethane, constituted of single or multiple lumen, being semi or totally implantable.1
They present various complications related to implant, manipulation and maintenance. Infection in long-term catheters is a complication which presents high morbidity and mortality, with additional risks and aggravations in patients often weakened or immune-suppressed, such as those submitted to chemotherapy. In patients undergoing hemodyalisis, the infection referred is a frequent cause of rehospitalization and the second more frequent cause of death.2 A vigilance and aggressive approach program is justified in case of patients carrying these catheters with diagnostic suspicion or in case of infection. There are controversies related to the form of treatment; so the type of infection, the microorganism responsible, the patient's clinical conditions, the need of venous access and the type of catheter involved should be taken into account. In case of long-term catheters, attempts to catheters salvation are valid whenever possible, avoiding multiple punctures and the depletion of accesses in patients with frequent history of difficult venous access.
This review article aims at sketching a protocol for recognition, treatment and prevention of long-term venous catheters infection. Articles presented in the data bases PubMed and BIREME related to this infection were reviewed, whether they address hemodyalisis, chemotherapy or PPN, as well as text-books chapters and guidelines on the subject. The following data were collected: infection index, isolated microorganism, forms of treatment, success rates.
Infection is the most severe complication associated to catheters. In a general manner, it occurs in approximately 19% of patients using this device, 7% local infections and 12% cases of bacteremia associated to the catheter.3
The long-term semi-implantable catheters have a subcutaneous pathway associated to a dacron cuff capable of creating pericatheter fibrosis, reducing the chance of infection in relation to short-term catheters, such as double lumen. The totally implantable catheters, due to the absence of external portion, have even lower rates of contamination.
In long-term semi-implantable catheters use in hemodyalisis, infection is the most frequent late complication, and the Staphylococcus aureus the most isolated agent,4,5 followed by gram-negative bacilli and by negative Staphylococcus coagulase.6
The Broviac® (semi-implantable, single-lumen) and Hickman® (semi-implantable, double lumen) catheters are widely used in PPN patients. Marcondes et al.4 have reported that these catheters have the highest infection rates.
The totally implantable catheters (port-o-cath), used for chemotherapy do not have an external portion and, therefore, present lower infection rates. Groeger et al.7 show infection in 43% of semi-implantable catheters versus 8% of the totally implantable in patients with cancer. For D'Angelo et al.,8 the bacteremia related to catheter occurred in 4.34% of the totally implantable ones. Staphylococcus aureus is the most prevalent bacterium (50% of cases). Biffi et al.9 reported only 0.3% of infection at the port and 2.4% bacteremia related to the catheter.
To characterize the type of infection of the catheter is the first step for a correct therapeutic conduct. Infections are divided into: 1) ostium infection, 2) tunnel or pouch infection, and 3) catheter-related bacteremia.10-12
Ostium infection is characterized by hyperemia and/or purulent secretion extending up to 2 cm from the hole of the catheter exit.
Catheter's tunnel infection presents hyperemia and/or secretion for more than 2 cm of the catheter hole; in totally implantable catheters, hyperemia from the port characterizes the port's infection.
Catheter-related bacteremia is the presence of fever and/or shivering in patients presenting central venous catheter with no other apparent infectious focus. In these cases, the patient must be investigated with hemoculture collections both peripheral and from the catheter itself. Some ways of interpreting the results of these collections are suggested in literature, helping in diagnostic confirmation. These ways are: a) Maki's semiquantitative technique, positive when there are more than 15 colony forming units (CFU) per plaque; b) growth of 5-10 time CFU/mL of blood in the samples collected by catheter and peripheral; c) growth of 1,000 CFU/mL of blood collected by the catheter.10,13-15
The treatment of infections related to the catheters depends upon the type of microorganism present, the type of catheter, systemic symptoms, and type of infection.
Ostium infection presents lower severity and responds well to local care with dressings and topic treatment, with no need of retrieving the catheter.10,11
Tunnel or pouch infection do not respond well to isolated systemic antibiotic therapy, in which case the catheter has to be retrieved.10,11
The treatment of catheter-related bacteremia may be performed with locks, antibiotic therapy and catheter removal.13 Because it is a long-term access, catheter salvation should be attempted, but without posing risk to the patient's health. Indication and moment of retrieval remain controversial in literature.
Poole et al.16 report that, in hemodyalisis catheter, the success of the treatment for patients carrying bacteremia related to catheter with vancomycin locks or heparin-associated ceftazidime depends on the microorganism growing in the culture, reaching success rates of 87% for gram-negative bacteria, 75% for negative Staphylococcus coagulase and only 40% for Staphylococcus aureus. For Maya et al.,17 the use of systemic antibiotics and in locks was capable of saving Staphylococcus aureus-infected catheters in only 41% of cases. For Lentino et al.,6 89% of vascular accesses in infected patients were removed, but there was no improvement in mortality for these patients. Dugdale & Ramsey 18 recommend the early retrieval of Staphylococcus aureus-infected catheters, unless there is another possible focus for infections or that the quantitative culture shows less than 1 CFU/mL. Raad & Sabbagh19 report that patients with catheter-related Staphylococcus aureus bacteremia should be treated with the removal of the catheter and endovenous antibiotic therapy for 10-14 days and that the maintenance of fever or positive culture after 3 days from the treatment onset may indicate complications such as endocarditis or osteomyelitis. Regardless of the isolated microorganism, in case the patient presents complicated bacteremia (fever/shivering associated to hypotension or cyanosis), catheter removal is indicated.10
Fungal infections are found in 10-30% of cultures.10 Candida is the most commonly isolated fungus,10 but Rhodotorula spp20 and Malassezia spp can also be found,21,22 generally in weakened patients. Agarwal et al.23 recommended retrieving the catheter associated with the use of endovenous amphotericin B. However, some authors have shown success in catheter salvation using lock with amphotericin B for complicated infections.24,25
Prevention and care with the catheter
Care for long-term venous catheter infection prevention begins in the moment of its implantation. The entire procedure should be performed in a surgical center, and the whole team should be equipped. The patient should be prepared with previous trichotomy, if needed. In the operation room, asepsis of the implantation site is performed by means of using a degerming solution followed by the aplication of alcoholic solution. The patient is then covered with sterile fields.
Each manipulation must be preceded by adequate antisepsis. After manipulation, the catheter should receive heparin solution with the exact volume indicated in the catheter. This prevents the formation of thrombi in the lumen and pericatheter, reducing the possibility of bacterial fixation and posterior infection. There are bacteriostatic solutions in the market that may replace heparin. Both solutions should be aspired before using the catheter again.
Semi-implantable catheters require dressings in their exposed segments after each use. The totally implantable catheters, on their turn, need dressings until adequate cicatrization of the incision and absence of secretions in the operative wound. Afterwards, habitual care of asepsis and manipulation are required.26
Having in mind the literature findings, we present the following algorithm (Figure 1) for long-term catheter infection patients.
In it we highlight the importance of characterizing the type of catheter infection, since in the cases of ostium or port/tunnel infection the treatment is well established. The most controversial point is catheter-related bacteremia, whose treatment depends upon the patient's conditions and the microorganism present in the culture. It is worth highlighting that, since patients with multiple punctures and possible scarcity of venous access are being dealt with, catheter maintenance should be attempted, but without posing risk to the patients' health.
Aggressive treatment and vigilance on these patients are justified, since morbidity and mortality caused by this type of infection are high.
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Correspondence: Manuscript received Apr 25 2009, accepted for
publication December 16 2009. No conflicts of interests declared concerning
the publication of this article.
Milton Alves das Neves Junior
Serviço de Cirurgia Vascular, HSPM
Rua Castro Alves, 60 Aclimação
CEP 01532-400 São Paulo, SP Brazil
Tel: +55 11 3208.2211, Ramal 223
Manuscript received Apr 25 2009, accepted for publication December 16 2009.
No conflicts of interests declared concerning the publication of this article.