Long Line Sepsis - Neonatal

Publication: 01/09/2005  --
Last review: 23/11/2018  
Next review: 23/11/2021  
Clinical Guideline
CURRENT 
ID: 654 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

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.

Guideline for the management of Neonatal Long Line Sepsis

Summary
Long Line Sepsis - Neonatal

Long Line Sepsis - Neonatal
Definition
Episodes of catheter related bloodstream infection (CRBSI) are defined as the

  • > 72 hours old
  • the presence of a central venous catheter in babies
  • pure growth of a recognised pathogen or
  • a mixed growth of skin commensals PLUS 3 or more out of 10 pre-defined clinical signs

Where there is no other definite source for the infection.
Clinical signs are

  1. Tachypnoea or significant increase in oxygen or respiratory support
  2. Clinically significant increase in apnoeas and bradycardias
  3. Hypotension
  4. Hypo or hyperglycamia
  5. Lethargy, irritability or poor handling
  6. Poor perfusion (capillary refill time significantly prolonged)
  7. Temperature instability
  8. Ileus or feed intolerance
  9. Decreased urine output
  10. Metabolic acidosis

Suspected intravascular catheter-related infection (CRI)

  • Exit site infection (purulent exudate and/or erythema at exit site).

Investigations

  • Full blood count (FBC) with white cell differential
  • C reactive protein (CRP)
  • Peripheral blood culture (labelled peripheral)
  • Central line blood culture (clearly labelled with the site)

Treatment
Non-Antimicrobial

  • Resuscitate as indicated
  • Discuss with consultant if considering line removal

Antimicrobial

See full guideline for organism-specific recommendations and duration of therapy.

Duration of treatment
See full guideline

Switch to oral agent(s)
Not recommended

Referral criteria
If CVC removal is being considered discuss with consultant on call.

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Background

Central venous catheters are required for a variety of uses during management of babies on the neonatal units such as parenteral nutrition, long term venous access etc.

Catheter types in use are percutaneous intravascular catheters (e.g. Nutriline, Premicath) and tunnelled surgical lines (e.g. Broviac).

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

Infection of long-term vascular access devices begins with colonisation of either the external surface or lumen of the catheter, the latter being more common in a long-term device. Micro-organisms can gain access to the lumen of a catheter via a contaminated hub or infusate. The external surface of a catheter may become colonised as a result of contamination during insertion, via exit site colonisation or secondary to a bacteraemia from a distant source (Elliott et al., 1997). It is axiomatic that a catheter 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 colonized (Sandoe et al., 2003).

The most commonly grown organism of significance is

  • Coagulase negative Staphylococcus

Other organisms causing catheter-related infection in our units include

  • Gram negative bacilli
  • Staphylococcus aureus (MSSA)
  • Enterococcus species
  • Candida species

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Clinical Diagnosis
  1. Exit site infection is diagnosed on clinical grounds (exudate and erythema and may or may not be associated with CRBSI
  2. An infant developing CRBSI may present with
    • Tachypnoea or significant increase in oxygen or respiratory support
    • Clinically significant increase in apnoeas and bradycardias
    • Hypotension
    • Hypo or hyperglycamia
    • Lethargy, irritability or poor handling
    • Poor perfusion (capillary refill time significantly prolonged)
    • Temperature instability
    • Ileus or feed intolerance
    • Decreased urine output
    • Metabolic acidosis

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Investigation
  • Exit site infection affecting any type of vascular access device is a clinical diagnosis. The pathogen responsible can be determined by sending ideally a pus sample or (second best) an exit site swab to the microbiology laboratory for culture.
  • A peripheral and “through-line” blood culture should be sent. At least 1ml of blood should be sent when possible. Positivity of the blood culture increases with the blood volume sent.
  • Intravascular catheter tips should only be sent for culture to confirm a clinical suspicion of a catheter related infection, not as a matter of routine.
  • Full blood count (FBC) with white cell differential
  • C reactive protein (CRP)
  • Peripheral blood culture (labelled peripheral)
  • Central line blood culture (clearly labelled with the site)

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Treatment

The definitive treatment for infection arising from a CVC is removal of the CVC and thus the source of infection. However, CVC are frequently precious assets and should be removed if the risk of leaving the catheter in situ outweighs the risk of removal and when other venous access is available. Removal of a line should always be discussed with the consultant.

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Non-Antimicrobial Treatment
  • Resuscitation/supportive treatment as indicated
  • Investigate as above
  • If the line remains in situ repeat Blood cultures 48 hours after stopping antibiotics
  • Should the line have to be removed there should ideally be a central line free interval of 48 hours.

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Empirical Antimicrobial Treatment
  • Begin  Vancomycin electronic Medicines Compendium information on Vancomycin and  Ceftazidime electronic Medicines Compendium information on Ceftazidime
  • Remove CVC after 48 hours if there is deterioration despite apparently appropriate antimicrobial therapy. Always discuss with consultant before removing line.
  • Give the antibiotics through the line
  • Rationalise the antibiotics when sensitivities are known.

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Duration of Treatment

Treatment Duration1


Organism

Central Venous Catheter
(PICC, Broviac etc)

In situ

Removed

Coagulase-negative Staphylococcus

14 days

Stop on removal

Staphylococcus aureus

Line removal recommended

14 days after removal

Gram negative bacilli (e.g. coliforms, E. coli, Klebsiella spp.)

Line removal strongly recommended
If not possible to remove line
14 days

7 days

Enterococcus spp.

14 days

5 days after removal

Candida spp.

Line removal unless absolute indication not to

Treat until 14 days after last positive culture

Table 1. Length of treatment of central venous catheter related sepsis.

  1. In all cases the recommended duration of treatment assumes complete resolution of clinical and laboratory signs of infection. In other situations specific microbiological advice should be sought.
  2. The specified duration starts from the date of the last positive blood culture or line removal, whichever is later

When to Remove the Line

  • Where recommended, the line should be removed unless the risk of removal is considered greater than the risk of leaving it in situ
  • Central venous catheters are frequently precious assets and should be removed only
    • after discussion with a with a consultant and
    • when other venous access is available.
  • If Blood cultures positive for the same organism after ceasing antibiotic treatment removal is recommended.
  • The CVC should be removed after 48 hours if there is deterioration in the clinical condition.

Line removal strongly recommended

  • Infection with Staphylococcus aureus or Gram‑negative bacilli in a CVC.
  • Candida infection

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Treatment Failure

Please contact Microbiology if the patient is not responding to the recommended antimicrobial regimens.

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Provenance

Record: 654
Objective:
  • To provide evidence-based recommendations for appropriate investigation of neonatal long line sepsis
  • To provide evidence-based recommendations for appropriate antimicrobial therapy of neonatal long line sepsis
  • 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 for surgery or specialist input.
Clinical condition:

Suspected long line sepsis

Target patient group: Infants with percutaneous and tunnelled central venous catheters
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Evidence base

  1. Klien MD, Rood K, Graham P. Central Venous Catheter sepsis in surgical newborns. Pediatric surgery international. 2003;19(7):529-32
  2. Trotter Percutaneous Central venous catheter-related sepsis in the neonate: an analysis of the literature from 1990 to 1994 . Neonatal Network: Journal of Neonatal Nursing. 1996;15(3):15-28
  3. Mahieu LM et al. Catheter manipulations and the risk of catheter-associated bloodstream infection in neonatal intensive care unit patients. J Hosp inf 2001;48(1):20-26
  4. Wagle S et al. C-reactive protein as a diagnostic tool of sepsis in very immature babies. J Paediatr Child Health 1994;30(1):40-44
  5. Berger C, Uehlinger J, Ghelfi D, Blau N, Fanconi S. Comparison of C-reactive protein and white blood cell count with differential in neonates at risk for septicaemia. Eur J Pediatr 1995;154(2):138-44
  6. Elliott TSJ. Can antimicrobial central venous catheters prevent associated infectio? Br J Haematol 1997;107:235-241
  7. 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

Evidence levels:
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

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