Bacteremia, Central Catheters, and Neonates Treatment

Bacteremia, Central Catheters, and Neonates Treatment 

Objective: Catheter-related sepsis is not uncommon in neonatal ICUs; whether prompt catheter removel affects outcomes in neonetes with bacteremia, however, is unknown. The consequences of central catheter retention in infants with bacteremia and whether organisms isolated from the blood warrant catheter removal were retrospectively investigated at Duke University. A rational approach to central catheter management was also developed on the basis of the relative risks of infectious complications.

Methods: A review of charts for positive blood cultures in neonatal intensive care patients treated between July 1995 and August 1999 yielded 160 episodes of bacteremia in 122 neonates with central venous catheters. Treatments were categorized as "catheter promptly removed," if the catheter was removed within 24 hours, or "attempted catheter sterilization," if the neonate was treated with antibiotics through the catheter. Outcomes were analyzed as a function of attempted sterilization.

Results: Seven neonates had their catheters removed before the physician was notified of the infection and were excluded from the study. Catheter sterilization was attempted in 128 episodes. Seven of these infants died. Complicated bacteremia developed in 59 (46%) of 128 neonates with in place catheters and in 2 of 25 neonates (8%) whose catheters were removed (odds ratio [OR], 9.8; 95% CI 2.2-43.5). No comlications occurred in 54 negative staphylococcal infections. Attempted sterilization was successful in only 1 of 10 patients with Staphylococcus aureus infections, in 10 of 29 patients with entric gram-negative rods, and in 5 of 11 patients with enterococcal infections. Patients with more than 1 positive blood culture were significantly more likely to have end-organ damage than were patients with fewer positive cultures (OR, 1.5; 95% CI, 1.2-1.8). All neonates with noneteric gram-negative rod infections and in-place catheters experienced complications. Logistic regression analysis revealed that attempted sterilization of the central catheter increased the risk of complicated bacteremia (OR, 17.3; 95% CI, 2.2-139.4). Low birth weight and age at infection did not increase the risk of complicated bacteremia, nor did catheter type. Abnormalities seen on chest or abdominal radiographs and mechanical ventilation status were unrelated to complicated bacteremia.

Conclusion: Neonates whose central venous catheters are removed within 24 hours of catheter-related sepsis have significantly improved outcomes compared with neonates treated by central catheter sterilization. Prospective clinical trials are needed to investigate the risk of complicated bacteremia versus the risk of placing a new catheter.