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Spectrum of External Catheter-Related Infections in Children with Acute Leukemia—Single-Center Experience

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Spectrum of External Catheter-Related Infections in Children with Acute Leukemia—Single-Center Experience Journal of Infection and Public Health (2014) 7, 38—43 Spectrum of external catheter-related infections in children with acute leukemia—–Single-center experience a,∗ a a a M. Zachariah , L. Al-Yazidi , W. Bashir , A.H. Al Rawas , a b Y. Wali , A.V. Pathare a Department of Pediatric Hematology (Child Health), Sultan Qaboos University Hospital, Muscat, Oman b Department of Hematology, Sultan Qaboos University Hospital, Muscat, Oman Received 16 February 2013; received in revised form 24 April 2013; accepted 10 June 2013 KEYWORDS Abstract Acute leukemia; Background: External catheters (ECs) are commonly used in children who are receiv- Infection; ing treatment for acute leukemia. Culture; Aims: To study the spectrum of microorganisms and to compare the rates of infec- Catheter; tion. Methods: A total of 42 ECs were inserted, including 28 Port-A-Caths, 11 CVC lines Port-A-Cath; and 3 Hickman lines. Single ECs were required for 19 patients (45.2%), whereas 2, 3 Hickman and 4 ECs were required in 8, 1 and 1 patients, respectively. Results: Overall, 37 culture-documented infections were present in 18 (62%) patients who had ECs. Gram-positive microorganisms were identified in 20 cases, Gram- negative microorganisms in 14 cases and fungal infections in 3 cases. Of the 42 devices implanted, 10 out of 28 Port-A-Caths (35.7%), 2 out of 3 Hickman catheters (66.7%) and 9 out of 11 central venous catheters (81.8%) required removal due to infection. The average length of working life for the ports was 330.6 days (range: 40—1043 days). The median rate of complications due to infection was 2.84 infec- tions per 1000 catheter days (interquartile range: −1.55 to 5.8), and the number of infections was correlated with the number of ports (Pearson’s r = 0.51; p < 0.05). © 2013 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved. Introduction ∗ Corresponding author at: Sultan Qaboos University Hospital, External catheters (ECs) are widely used in the P.O. Box 38, PC 123, Muscat, Oman. Tel.: +968 99734795; management of acute leukemia, although the fax: +968 24413951. need, optimal timing of insertion and type of ECs E-mail addresses: [email protected], [email protected] (M. Zachariah). used are variable [1—4]. Individual circumstances 1876-0341/$ — see front matter © 2013 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jiph.2013.06.005 Spectrum of external catheter-related infections in children with acute leukemia 39 may vary, but early placement is often desirable, All ALL patients were treated using a standard as these patients become neutropenic soon after protocol [MRC-UKALL 2003], whereas AML patients therapy is begun. received AML-15 chemotherapy according to the Several types of ECs can be differentiated either current departmental treatment policy for acute by the type of vessel they occupy (i.e. peripheral leukemia at our institution. Data were collected venous, central venous (CVC), or arterial), their from patient-specific leukemia protocol flow sheets site of insertion (i.e. subclavian, femoral, internal regarding demographics and blood counts (white jugular, peripheral, and peripherally inserted cen- blood cells (WBCs), absolute neutrophil count tral catheter) or their pathway from skin to vessel (ANC), hemoglobin and platelets) at the time of (i.e. tunneled (Hickman) versus non-tunneled (Port- diagnosis. Additionally, EC type and the date of EC A-Cath)). The use of ECs and their relationship to placement were noted. All devices were inserted blood stream infection rates are influenced by sev- in the operating room using a full aseptic tech- eral factors, some of which are patient-related, nique under fluoroscopic guidance. A chest X-ray such as severity of illness and type of illness, was taken to confirm the correct position of the or catheter-related, including the condition under tip of the catheter. Nurses trained in the care of which the catheter was placed and the catheter ECs performed dressing changes, which involved type. Other factors could be institutional, such as skin preparation at the insertion site with an iodine bed size, local hygiene and cleanliness, and medical solution and a sterile dressing. Patients suspected personnel care, among other considerations [5]. of having an EC-related infection had blood cul- This study was undertaken to compare the rates tures taken from both the device and a peripheral of infection with ECs (Port-A-Cath, central venous vein. Patients were considered to have an EC- ◦ catheters, Hickman lines) in children with culture- related infection if they had a fever of 38 C or proven infections receiving treatment for acute more without any obvious cause or had fever and leukemia and to study the spectrum of microor- rigors associated with flushing of the ECs. Line flush- ganisms cultured in these patients. Although these ing with a dilute heparin solution was undertaken devices are extremely necessary, they pose a seri- whenever CVC and Hickman lines were accessed. ous risk of increased morbidity and mortality [6]. The increased risk is due to higher incidences of Statistical analysis infection, thrombosis, mechanical occlusions and other complications [6—8]. Normally distributed continuous variables were expressed as means ± standard deviations. How- ever, continuous variables that were not normally Materials and methods distributed were expressed as medians with interquartile ranges. Categorical variables were After obtaining ethical review approval, a ret- expressed as percentages. Port complications were rospective study of the medical records was correlated using Pearson’s correlation coefficient. conducted. The hospital medical record database Differences were considered to be significant when was searched for all admissions with ICD-10 codes p < 0.05, and all analyses were performed using SPSS related to acute leukemia. All such records were version 15.0 for Windows. individually reviewed to identify patients with CVCs, Hickman lines and Port-A-Cath insertions. All inserted Port-A-Cath devices were the lightweight and durable titanium/polyurethane portal reservoir Results type that were kink-resistant, biocompatible, MRI- compatible, latex-free, PVC-free and radiopaque ECs ® (Celsite , Aesculap, Inc., Center Valley, PA, USA). Table 1 summarizes the patient demographic char- Infections were defined using the Centers for Dis- acteristics. A total of 42 ECs were placed in ease Control (CDC) criteria for catheter-related 29/50 (58%) patients with a total period of 12,271 blood stream infections [9]. catheter days. The average length of working life This retrospective study covered a two-year for the ports was 330.6 days (range: 40—1043 days) period (2009—2010). Incidentally, there were 50 (Table 2). In 28, 11 and 3 patients, single or mul- patients with acute leukemia that were enrolled tiple Port-A-Caths, CVCs or Hickman lines were consecutively during the study period. The median inserted, respectively. Single ECs were required for age (±SD) was 5 ± 3.3 years. There were 43 patients 19 patients (45.2%), whereas 2, 3 and 4 ECs were with acute lymphoblastic leukemia (ALL), whereas required in 8, 1 and 1 patients, respectively. 7 cases had acute myelogenous leukemia (AML). 40 M. Zachariah et al. Outcomes Table 1 Demographic and clinical characteristics of patients with external devices (n = 29). Risk stratification in acute leukemia is important Age (years) for selecting the appropriate therapy and predict- Mean ± SD 5.5 ± 4.0 ing outcomes. Patients are generally classified as Range 1.0—13 low (standard) risk, intermediate and high risk Male sex, n (%) 14 (48) based on demographics, laboratory markers of Female sex, n (%) 15 (52) tumor burden and cytogenetic features. Low-risk Type of disease (standard) cases have favorable demographics and ALL Pre-B ALL, n (%) 18 (62) laboratory features with no cytogenetic abnormal- T-cell ALL, n (%) 2 (7) ities. Intermediate-risk patients have unfavorable Relapsed ALL, n (%) 2 (7) Infant ALL, n (%) 1 (3) demographics and laboratory features but have no AML, n (%) 6 (21) abnormal cytogenetic features. High-risk patients Type of port have unfavorable demographics and laboratory fea- Port-A-Cath (%) 28 (67) tures, present cytogenetic abnormalities and have CVC (%) 11 (26) poor responses to initial therapy. Hickman (%) 3 (7) Of the 42 devices implanted, 10 out of 28 (35.7%) No. of ports (%) 42 (100) Port-A-Caths, 2 out of 3 (66.7%) Hickman catheters, One port, n (%) 19 (45.2) and 9 out of 11 (81.8%) CVCs required removal due Tw o ports, n (%) 8 (38.1) to infection. Twenty-four children were stratified Three ports, n (%) 1 (7.1) as standard risk. In this group, 6 patients had ECs Four ports, n (%) 1 (9.5) (all Port-A-Caths), but only 4 became infected; only Duration of port, days (range) 331 (40—1043) No. of organisms 1 EC had to be removed. Twenty-six children were All cases, n (%) 37 (100) stratified as intermediate- and high-risk patients, Gram-positive, n (%) 19 (51.4) with a total of 36 EC insertions. In this group, Gram-negative, n (%) 15 (40.5) 22 Port-A-Caths were inserted, 14 of which devel- Fungal, n (%) 3 (08.1) oped infections, with 10 ports needing removal due to infection. Because of infection, 9 out of 11 CVC lines and 2 out of the 3 Hickman lines had to be removed. Thus, patients with high- and intermediate-risk disease had more EC insertions Infections and more infections than patients with standard- risk disease. Overall, 37 culture-documented infections were found in 18 (62%) patients who had ECs. There were no organisms identified in 11 (38%) cases, whereas Discussion 12 (41%) patients grew 1 organism, 1 (3.5%) case each grew 2 and 3 organisms, 2 (7%) cases each grew ECs such as Port-A-Caths, CVCs and Hickman 4 organisms and 2 (7%) cases each grew 6 organisms.
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