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A 10 day old neonate (corrected gestation 29 weeks, birth weight 960 g) has been slow to establish feeds. Intravenous access is difficult and he is receiving parenteral nutrition through a central venous catheter (CVC). He develops temperature instability and hyperglycaemia. You decide to start empirical intravenous antibiotics but keep the CVC in situ as the infant is relatively stable. Peripherally taken blood cultures grow coagulase negative staphylococci (CoNS). Should the CVC be removed, knowing that a future replacement may be very difficult?
Structured clinical question
In a preterm neonate, with a central venous catheter in situ, who is bacteraemic with coagulase negative staphylococcus [patient], can catheter sterilisation [intervention] be achieved without increased morbidity or mortality [outcome]?
Search strategy and outcome
Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, Database of Abstracts of Reviews of Effectiveness: none relevant.
“Catheterization, Central Venous”[MESH] AND “Staphylococcus”[MESH], limit (newborn: birth–1 month). There were 22 hits—one relevant study found.5
“Central venous catheter” AND “neonate” and “CONS” [all textwords]. There were seven hits—two relevant studies, one previously found above.
See table 4.
Catheter related sepsis in preterm infants is a common neonatal problem (up to 15.3 infections per 1000 catheter days1). Inspite of this there is no good quality data informing the decision to remove central catheters in bacteraemic neonates. Both papers cited are retrospective case notes reviews. As a result the criteria for removal of catheters was not standardised and the management and follow up of the two groups (catheter retained versus removed) may have differed.
Benjamin et al did not distinguish between contaminated blood cultures, catheters colonised with CoNS and true catheter related CoNS sepsis. This is a practical problem for clinicians and researchers alike and has been recently reviewed2. Karlowicz et al4 used two positive peripheral cultures of the same organism within three days as their definition of CoNS bacteraemia consistent with US Center for Disease Control guidelines.3
Karlowicz et al found that attempting CVC sterilisation did increase the risk of prolonged bacteraemia, but the numbers were too small to detect a difference in end organ infection and mortality. The concern that bacteraemia may ultimately seed to end organs appears to be supported by Benjamin et al. If the CVC was not removed after four positive cultures there was a significant increase in end organ damage. As the number of positive cultures or the duration of bacteraemia increased, CVCs were less likely to be successfully salvaged.4 5 These studies suggest that catheters should be removed in infants who remain bacteraemic on treatment as the morbidity increases and the chances of line salvage diminishes with time. It is still unclear exactly how long clinicians should wait before abandoning sterilisation attempts and actually removing the catheter.
CLINICAL BOTTOM LINE
CVCs infected with coagulase negative staphylococcus can be successfully salvaged in ∼50% of cases.
Attempting sterilisation of infected lines increases the risk of persistent bacteraemia, NNH = 3. End organ damage may be increased if the CVC is retained despite repeated positive cultures.
Prospective randomised studies are required to convincingly address the risks versus benefits of treating infected CVCs in situ.