Central venous catheter infection for infants and children receiving parenteral nutrition ( excluding neonates on the NICU ) - Guidelines for the management of suspected

Publication: 31/12/2010  
Last review: 06/04/2016  
Next review: 26/07/2019  
Clinical Guideline
UNDER REVIEW 
ID: 2165 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2016  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guidelines for the management of suspected central venous catheter infection for infants (excluding neonates on the Neonatal Intensive Care Unit (NICU)) and children receiving parenteral nutrition

Please also refer to the Vascular Access Device Selection Guide

Background

The central venous catheter (CVC) is essential for the management of children requiring long term parenteral nutrition. Catheter types in use are peripherally inserted central catheters (PICC), tunnelled surgical lines (e.g. Broviac/Hickman) and implanted venous access devices (e.g. Port-a-Cath).

There are often a limited number of sites for CVC placement, therefore treatment of the infection without removal of the CVC is often necessary. When the infection is life threatening or there is a confirmed fungal infection or when conservative management of a bacterial catheter related blood stream infections (CRBSI) has failed (i.e. if the same organism is grown again, post-treatment) the CVC must be removed. The microbiologist and paediatric gastroenterology consultant /surgeon and medical staff must discuss the nature of the organism, the clinical condition and venous access limitations of the patient to ensure that line removal is warranted.

Infection is the major complication associated with long-term CVCs and can have serious consequences such as bloodstream infection, metastatic infection (osteomyelitis, endocarditis) and death.
CRBSI can be divided clinically into local (exit site) and bloodstream infections, but these entities may coexist.
CRBSI begins with colonisation of the:

  • internal lumen of the CVC - micro-organisms can gain access to the lumen of a catheter via a contaminated hub or infusate. This more common in long-term CVC.
  • external surface of a CVC - may become colonized as a result of contamination during insertion, via exit site colonisation or secondary to a bacteraemia from a distant source (Elliott et al. , 1997).

A CVC must be colonized before invasion of tissues or bloodstream can occur. The longer a catheter remains in place, the more likely it is to become colonised (Sandoe et al. , 2003).
The most common causative organisms of significance are:

  • Gram negative bacilli
  • Staphylococcus aureus
  • Enterococcus species
  • Coagulase negative Staphylococcus
  • Candida species

Definition

  1. Exit site infection - purulent exudate or erythema surrounding the exit site
  2. CVC related bloodstream infection (CRBSI), meaning
    • A positive blood culture taken through the CVC
    • A positive peripheral blood culture taken before CVC removal
    • The same micro organism isolated from both sites.

However, in many cases the only information will be a positive blood culture in a sick patient with a CVC and no other focus for infection.

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Clinical Diagnosis

Assess the child's general clinical condition

1. An infant or child developing CRBSI may present with

  • Temperature above 38.5°C
  • Tachycardia
  • Tachypnoea and / or grunting respiration
  • A fall in blood pressure
  • Peripheral shut down, may feel cold and clammy
  • Irritability and lethargy
  • Enteral feed intolerance e.g. increased diarrhoea/stoma output and/or vomiting
  • Apnoeic episodes
  • Unstable blood sugars (particularly in neonates)
  • Take note of parent’s concerns – they know their child best; be worried if they are worried.

2. Exit site infection is diagnosed on clinical grounds (exudate and erythema) and may or may not be associated with CRBSI.

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Investigation
  • Peripheral and central Blood Cultures – and the take same volume i.e. 1mL(culture both lumens of double lumen central venous lines)
  • FBC, CRP
  • U & E’s, LFT, calcium, magnesium & phosphate
  • Urine for culture and sensitivity

[Evidence level D]

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Treatment
Non-Antimicrobial Treatment
  • CVC removal
    The definitive treatment for CVC infection is removal of the CVC and thus the source of infection. However, in this patient group there are a limited number of sites for CVC placement. After discussion with microbiology treatment of bacterial infection must be given, rather than removal of the CVC, because a lack of venous access can become life limiting in children who are PN dependant. Salvaging the CVC is recommended in preference to removing the CVC in consultation with the children’s nutrition team and microbiology.
    Only when the CVC infection becomes life threatening or in confirmed fungal infections or when conservative management of a bacterial CRBSI has failed, should the CVC be removed.
  • Administer plasma expanders if required (20ml/kg of 0.9% Sodium Chloride over 30 minutes).
  • Administer antipyretic (i.e. Paracetamol/Ibuprofen) when temperature 38.5°C or above.
  • Discuss fluid and electrolyte requirements with Specialist Registrar for Paediatric Medicine or the Paediatric Consultant of the week.
  • For further advice on fluid and electrolyte management contact the PN pharmacist during normal working hours.
  • Consult parent/carer held information for current nutrition management plans and guidelines.

[Evidence level D]

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Empirical Antimicrobial Treatment

Recommendation: First line (empirical) intravenous (IV) antibiotics are Vancomycin electronic Medicines Compendium information on Vancomycin (if allergic use Teicoplanin electronic Medicines Compendium information on Teicoplanin) and Ceftazidime electronic Medicines Compendium information on Ceftazidime (if allergic use Aztreonam electronic Medicines Compendium information on Aztreonam) via the CVC . See table 1 detailing administration and monitoring of antibiotic therapy.
[Evidence level D]

Recommendation: If attempting to salvage a CVC administer systemic antimicrobials via the infected line.
[Evidence level B]

Recommendation: For double lumen CVCs, alternate lumens for administration of antimicrobials every 24 hours at PN/maintenance fluid line changes.

Recommendation: Review the antibiotic treatment when culture sensitivities are obtained

Recommendation: If CVC salvage is being attempted, antimicrobial line locks should be used together with systemic antimicrobials, where possible. If the patient was receiving line locks for prophylaxis then a different line lock agent should be chosen. Discuss with microbiology.
[Evidence level B/D]

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Directed Antimicrobial Treatment (when microbiology results are known)

Recommendation: If only Gram positive bacteria are cultured, Ceftazidime electronic Medicines Compendium information on Ceftazidime/Aztreonam electronic Medicines Compendium information on Aztreonam can be stopped and gram positive therapy modified according to susceptibilities.

Recommendation: If only Gram negative bacteria are cultured, Vancomycin electronic Medicines Compendium information on Vancomycin can be stopped and gram negative therapy modified according to susceptibilities.

Recommendation: If cultures are negative consider alternative diagnoses because negative cultures have a high negative predictive value.
[Evidence level C]

Prophylactic use of Antimicrobial line locks

Recommendation: Prophylaxis with antimicrobial line locks should be used in PN dependant children with recurrent CRBSI (2 episodes in a 6 month period), as a lack of venous access becomes life limiting.
[Evidence level D]

Recommendation: If a patient has 2 bacterial CRBSIs in a 6 month period, initial prophylaxis should be Tauolock™,
[Evidence level D]

  • Prophylaxis with Taurolock™ should be used in ‘high risk’ PN dependent infants on the neonatal unit after their first episode of CRBSI, as lack of venous access becomes life limiting.
  • PN dependency, in this instance, includes all infants who have undergone surgery resulting in a short bowel, intestinal failure and an inability to survive without PN. This also includes infants who are born with a congenital abnormality, resulting in dysmotility and enteral feed intolerance which prevents their survival without PN.
  • This ‘high risk‘ group includes infants with short bowel, predominantly following surgery for gastroschisis or necrotising enterocolitis (NEC), those with intestinal failure associated liver disease (IFALD) and those in whom long term PN dependence is predicted.

Guidelines for use of Taurolock in infants on the neonatal unit

  • Taurolock™ should be commenced when a course of antimicrobial treatment is completed and the clinical decision for prophylactic line lock has been made. Patients should remain on Taurolock™ until PN is no longer required and the CVC is removed or they require a change of prophylactic agent
  • Taurolock™ may be used in infants under 3 months of age, following a risk assessment by the responsible Consultant.
  • Taurolock™ should only be used when infants are having their PN ‘cycled’ i.e. PN infusing over less than 24 hours
  • 1-2mL* of Taurolock™ should be instilled into the line slowly (max 1mL per 5 seconds) after PN finishes and locked in the line until PN is due to recommence
  • Taurolock™ may cause mild hypocalcaemic symptoms if instillation is not done slowly as directed.
  • Taurolock™ should be aspirated prior to accessing the CVC i.e before restarting PN.

* see Appendix for ‘Prime, flush and line lock volume table

Recommendation: Taurolock™ should be commenced when a course of antimicrobial treatment is completed and the clinical decision for prophylactic line locks has been made. Patients should remain on Taurolock™ until PN is no longer required and the CVC is removed or they require a change of prophylactic agent.
[Evidence level D]

The LTHT Children’s Nutrition Team have over 7 years experience of using prophylactic Gentamicin line locks and 3 years experience of using TauroLock™ and seen a marked decrease in CRBSI in this patient group on long term PN. This experience is currently being audited by the children’s nutrition team in conjunction with Dr J Sandoe. [abstract reporting anecdotal benefit presented to RCPCH 2010 meeting] Also a poster was accepted at ESPGHAN 2012 entitled 'Taurolidine- citrate lock solution (Taurolock) is effective in reducing central venous catheter related blood stream infection during long term parenteral nutrition.

See table of antimicrobials below for details of the presentation and administration of line locks and refer to the Department of Microbiology Restricted Antimicrobial Prescribing Guidelines: - Taurolidine - based catheter lock solutions (TauroLock™) for further information.

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Duration of Treatment

Recommendation: If CVC salvage is planned give the appropriate IV antibiotic/s for 10-14 days.
[Evidence level B]

Recommendation: in the infected CVC is removed 5-14 days treatment is recommended depending on the pathogen and clinical response.
[Evidence level B]

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Treatment Failure
See CVC removal and discuss with microbiology

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Provenance

Record: 2165
Objective:

Aims

  • To improve the diagnosis and management of suspected CVC infection in infants and children receiving parenteral nutrition.

Objectives

  • To provide evidence-based recommendations for appropriate investigation of suspected CVC infection.
  • To provide evidence-based recommendations for appropriate empirical or directed antimicrobial therapy of suspected CVC infection
  • To ensure rapid assessment and treatment of suspected CVC infection and prevent metabolic acidosis and septic shock
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To set-out criteria for referral to specialists.
Clinical condition:
  • Infants and children receiving parenteral nutrition (PN) in hospital or at home with a suspected central venous catheter (CVC) infection
  • Infants and children post PN with CVC in situ with a suspected central venous catheter infection, in hospital or at home
Target patient group: Infants (excluding neonates on the NICU) and children with intestinal failure requiring parenteral nutrition with a CVC in situ
Target professional group(s): Secondary Care Doctors
Pharmacists
Allied Health Professionals
Secondary Care Nurses
Adapted from:

GUIDELINES FOR THE MANAGEMENT OF SUSPECTED CENTRAL VENOUS CATHETER INFECTION FOR CHILDREN RECEIVING PARENTERAL NUTRITION October 2006


Evidence base

  1. BNF for children (2009) bnfc.org.
  2. Medicines for Children (2003) RCPCH.
  3. Guidelines for preventing infections associated with insertion and maintenance of CVC. Journal of Hospital Infection (2001) 47 (supplement) S47-S67.
  4. Bishop et al (2007) Guidelines on the insertion and management of central venous access devices in adults. International Journal of Lab Hem. 29; 261-278.
  5. Elliott et al. , 1997 Elliott TSJ. Can antimicrobial central venous catheters prevent associated infection? Br J Haematol 1997;107:235-241
  6. LTHT Department of Microbiology Restricted Antimicrobial Prescribing Guidelines: - Taurolidine - based catheter lock solutions (TauroLock™)
  7. Malassezia Furfur (1991) Catheter infection cured with antibiotic lock therapy. The American Journal of Medicine 90:128 – 129.
  8. NICE (2007) CG47 Feverish illness in children. www.nice.org.uk/CG047quickrefguide
  9. NICE (2009) CG84 Diarrhoea and vomiting in children under 5. www.nice.org.uk/CG084quickrefguide
  10. Sandoe JAT, Ian R. Witherden IR , Cove JH, Heritage J, Wilcox MH. Correlation between enterococcal biofilm formation in vitro and medical-device-related infection potential in vivo. J Med Microbiol 2003;52:547-550
  11. Mermel, L et al. Clinical practise guidelines for the diagnosis and management of intravascular catheter-related infection:2009 update by the infectious diseases society of America. Clin Infect Dis . 2009;49:1-45.

Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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Table 1. First Line Antibiotics

Antibiotics

Dose

Presentation

Administration

Monitoring

Vancomycin electronic Medicines Compendium information on Vancomycin 
Vancomycin should be prescribed at the same time as Ceftazidime to prevent excessive accessing of the line.

15mg/kg FOUR times daily
(Max 2 gram daily) for paediatric patients only.

Please refer to local vancomycin prescribing guidelines for infants on the neonatal unit.

Made in aseptics* 5mg/mL in Sodium Chloride 0.9% (for peripheral administration) or 10mg/mL for central administration (also compatible with 5% glucose)

IV infusion over at least 60 minutes (it can run along side PN If necessary)

Pre Vancomycin electronic Medicines Compendium information on Vancomycin levels taken before the third dose. Pre dose (trough) level 10 - 20mg/L - adjust dose as necessary

Ceftazidime electronic Medicines Compendium information on Ceftazidime
Ceftazidime should be prescribed at the same time as Vancomycin to prevent excessive accessing of the line

25mg/kg THREE times daily
(TWICE daily in mild renal impairment)
(Max 6 gram daily)  

Made in aseptics*
100mg/mL
in water for injection (WFI)  

Slow IV bolus given over 3-5 minutes. (Doses over 2g should be given as an infusion over 30 minutes in 50mL/100ml Sodium Chloride 0.9% or glucose 5%)

Ceftazidime electronic Medicines Compendium information on Ceftazidime and aminoglycosides should not be mixed in the same giving sets or syringe. Precipitation has been reported with Vancomycin electronic Medicines Compendium information on Vancomycin, therefore giving sets and lines should be flushed between administration of these two agents.  

Teicoplanin electronic Medicines Compendium information on Teicoplanin(IN VANCOMYCIN ALLERGY ONLY)

10mg/kg (max 400mg) every 12 hours for 3 doses, then 6mg/kg (max 200mg) DAILY

Made in aseptics*
200mg or 400mg vial in 3mL in sodium chloride 0.9% (also compatible with glucose 5%

Slow IV bolus over 3-5 minutes
In neonates IV infusion over 30 minutes preferred

 

Plasma Teicoplanin electronic Medicines Compendium information on Teicoplanin concentration is not measured routinely

Aztreonam electronic Medicines Compendium information on Aztreonam (IN CEFTAZIDIME ALLERGY ONLY)

Child 1 month-12 years
30mg/kg every 4-6 hours
Child 12-18 years
1g every 8 hours of 2g every 12 hours

Made in aseptics* as 100mg/mL in water for injection. It can be further diluted with glucose 5% or sodium chloride 0.9% to a concentration of less than 20mg/mL and given as an intermittent IV infusion.

Slow IV bolus over 3-5 minutes


Can be given as an intermittent IV infusion over 20-60 minutes (if further diluted)

None

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Table 2. Alternative antibiotics based on sensitivities

Antibiotics

Dose

Presentation

Administration

Monitoring

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin  

12.5–25mg/kg FOUR times daily.
(Max 1 gram every 6 hours)

Made in aseptics*
50mg/mL in sodium chloride 0.9% (also compatible with glucose 5%)  

Slow IV bolus given over 3-5 minutes

None

Gentamicin 

2.5 mg/kg every 8 hours
(1 month-12 years)
2mg/kg every 8 hours
(12 -18 years)

Ready diluted
10mg/Ml

Slow bolus given over 3 minutes. For infusion, add to 50mL sodium chloride 0.9% or glucose 5% bag and give over 30 minutes.

Gentamicin levels taken before (trough) and 1 hour after (peak) third dose. Trough less than 2 mg/L
Peak 5–10 mg/L, adjust dose if necessary

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Table 3. First Line Antifungals

ANTIFUNGAL

Dose

Presentation

Administration

Monitoring

Fluconazole electronic Medicines Compendium information on Fluconazole 

12mg/kg DAILY (max 400mg)

Ready diluted
(2mg/mL)

Infuse over 10-30 minutes (max infusion rate of 5-10mL/minute)

None

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Table 4. Line Locks

LINE LOCK

Dose

Presentation

Administration

Monitoring

TauroLock™
(Taurolidine)

1-2mL *

Ready diluted
or
Pre-filled syringe in Home PN patients

Instil 1-2mL * into each lumen of line and leave for as long as possible. Aspirate before connecting PN or using the line e.g. to give next dose of antibiotics

None

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Appendix - Prime, flush and line lock volumes for Central Venous Catheters (CVC)

Type of Centeral Venous Ccatheter (CVC)

Size Fr

Maximum prime volume

Prime volume with Smartsite

Minimum 0.9% Sodium Chloride flush volume

Line lock volume

PICC (Cook)

3 Fr

0.5mL

0.6mL

1.0mL

0.6mL

PICC (Cook)

4 Fr

0.6mL

0.7mL

1.0mL

0.7mL

Broviac - Single
(Vygon Lifecath)

2.7 Fr

0.3mL

0.4mL

1.0mL

0.4mL

Broviac
(Vygon Lifecath)

4.2 Fr

0.4mL

0.5mL

1.0mL

0.5mL

Broviac
(Vygon Lifecath)

5.0 Fr

0.75mL

0.85mL

2.0mL

1.0mL

Broviac
(Vygon Lifecath)

6.6 Fr

1.2mL

1.3mL

2.0mL

1.5mL

Hickman
(Vygon Lifecath)

9.6 Fr

1.7mL

1.8mL

5.0mL

2.0mL

Broviac - Double
(Vygon Lifecath)

7 Fr

White 0.75mL
Red 1.1mL

0.85mL
1.2mL

2.0mL
3.0mL

1.0mL
1.5mL

Broviac - Double
(Vygon Lifecath)

9 Fr

White 0.75mL
Red 1.6mL

0.85mL
1.7mL

2.0mL
3.0mL

1.0mL
2.0mL

Broviac - Triple
(Vygon Lifecath)

12.5 Fr

White 0.9mL
Blue 0.9mL
Red 1.9mL

1.0mL
1.0mL
2.0mL

2.0mL
2.0mL
5.0mL

1.0mL
1.0mL
2.0mL

If Fr size of CVC not known use age as a guide

Type of CVC

Age of patient

Minimum 0.9% Sodium Chloride flush volume

Line lock volume

PICC

under 2 years old

1.0mL

1.0mL

Broviac or Hickman line

2 years old & over

2.0mL

2.0mL


Links to:-

  1. British National Formulae for Children www.bnfc.org
  2. Empirical antimicrobial treatment of catheter related infection in long-term catheter in adults.
    For infants and children dosages, refer to BNF for Children.
  3. NICE 2007 Feverish illness in children. www.nice.org.uk/CG047quickrefguide
  4. NICE 2009 Diarrhoea and vomiting in children under
  5. www.nice.org.uk/CG084quickrefguide

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