Cure of Implantable Venous PortAssociated Bloodstream Infections in Pediatric Hematology-Oncology Patients without Catheter Removal

Lorry G. Rubin, San Shih, Ashok Shende, Gungor Karayalcin, and Philip Lanzkowsky
From the Department of Pediatrics, Schneider Childrens Hospital of Long Island Jewish Medical Center, Long Island Campus for the Albert Einstein College of Medicine, New Hyde Park, New York

The efficacy of antibiotic treatment of port-associated bloodstream infection without device removal has not been systematically studied. We analyzed the outcome of 43 consecutive portassociated bloodstream infections in pediatric hematology-oncology patients. Etiologies included Staphylococcus epidermidis (30) and Staphylococcus aureus (6). Antibiotics were given through the port for a median of 11 days. Four ports were removed within 72 hours. In 36 (92%) of the remaining 39 episodes, there was a response to antibiotic therapy (defervescence and negative blood culture). In 78% of episodes in which there was a response (excluding two in which the catheters were removed because of mechanical problems), the infections were cured without port removal. Two of the four relapses were cured with a second course of antibiotics. The cure rate was 92% for S. epidermidis infections and 67% for S. aureus infections. Thus, the majority of portassociated bloodstream infections in pediatric hematology-oncology patients can be cured without device removal.

There are two types of surgically placed, subcutaneously tunneled Silastic (Dow Corning, Midland, MI) central venous catheters designed for long-term use. Broviac- or Hickmantype catheters exit through the skin after being passed through a subcutaneous tunnel, and totally implantable venous access ports (ports) end in a subcutaneous reservoir after being passed through a subcutaneous tunnel (as, for example, with Mediport [Norfolk, Medina, NY] and Port-A-Cath [Pharmacia Deltec, St. Paul] ports). Ports are accessed by means of a special needle through intact skin. In pediatric oncology patients, ports are associated with a lower rate of catheterrelated bloodstream infection than are Broviac/Hickman catheters [1 4]. Although cure of bloodstream infections related to nontunneled vascular catheters generally requires catheter removal, we and others have found that ;75% of Broviac/Hickman catheterrelated bloodstream infections are cured without catheter removal [3 6]. In contrast, there are limited data concerning the efficacy of antibiotic treatment of port-associated bloodstream infection without port removal. To determine the advisability of initial antibiotic therapy without device removal, we studied the outcome of consecutive catheter-related bloodstream infections occurring in pediatric hematologyoncology patients with totally implantable venous access ports. Methods Patient population. All pediatric hematology-oncology patients cared for at the Schneider Childrens Hospital (New Hyde Park, NY) between 1 January 1991 and 31 December

1993 were identified through a log book of all patients seen by the division of pediatric hematology/oncology. Patients with a port were identified by review of the comprehensive flow sheets maintained for each patient by that division, on which data on all surgically placed vascular catheters, hospital admissions, infections, courses of antibiotic therapy, and vascular catheter removal are tabulated prospectively. To ensure that all episodes of port-related bloodstream infection were identified, episodes of possible catheter-related bloodstream infection were also identified by review of all positive blood culture results for these patients, from a database maintained by the hospital epidemiologist. The inpatient records of all enrolled patients with possible port-related infections were reviewed. Ports. Ports were used primarily for administration of chemotherapy, hydration, antibiotic therapy, and blood products. Ports were accessed by means of a noncoring right-angle needle after cleansing of the skin site with povidone-iodine. When in continuous use, disposable noncoring right-angle needles were replaced every 7 days. Blood culture technique. Blood for culture was inoculated into Isolator 1.5 Microbial Tubes (Wampole Laboratories, Cranbury, NJ). Approximately 0.25-mL aliquots of the contents were plated on solidified agar media as previously described [7], allowing semiquantitation. Definitions of catheter-related bloodstream infection. Portrelated bloodstream infection was defined as previously described [8], with minor modifications. A port-related bloodReceived 9 November 1998; revised 4 February 1999. Presented in part at the annual meeting of the Infectious Diseases Society of America (abstract no 156), held in Orlando in 1994. Reprints or correspondence: Dr. Lorry G. Rubin, Schneider Childrens Hospital, 269-01 76th Avenue, New Hyde Park, New York 11040 (lrubin@lij.edu).
Clinical Infectious Diseases 1999;29:1025 1999 by the Infectious Diseases Society of America. All rights reserved. 10584838/99/2901 0016$03.00

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