39 / 68
J.A. Capdevila et al. / Cir Cardiov. 2016;
23(4)
:192–198
195
Registry
It is mandatory to keep daily record of characteristics and condi-
tions of the catheter. In this registry the type of catheter, insertion
date, anatomic location, daily inspection of dressing, removal date
and cause of removal (malfunction, infection, not required,
. . .
)
must be recorded (
III-A
). The lack of a registry is synonymous of
lack of knowledge on how to use catheters, their complications and
the inability to establish corrective measurements should an event
occur.
40
These registries should ideally be electronically supported
to facilitated data collection and analysis.
Removal
When?
As there is a causal relationship between the duration of PVC
and the risk of phlebitis, the need for systematic replacement of
PVC at a given time interval to avoid local and systemic complica-
tions has been proposed.
18,41,42
However, this strategy may render
expensive the provision of care by increasing in over 25% the cost
and number of catheters to use and make the catheter resite more
difficult.
42,43
This, on the other side, has not avoided the complica-
tions of the use of the newcatheter regardless of the inconveniences
of replacing a line for the patient and caregiver.
More recently, prospective and randomized studies comparing
systematic replacement at 72 h
versus
clinically indicated replace-
ment of PVC did not found statistically significant differences in
the incidence of phlebitis/local infection/bacteremia and the num-
ber of malfunctioning catheters both in hospitalized patients and in
patients on home therapy.
18,41–51
These observations support the
replacement of PVC only when indicated (
I-A
).
Systematic removal of PVC after 3–4 days is not supported,
although it is not advised to keep PVC in place beyond 5 days (
III-B
).
Although keeping in place an unused catheter increases the risk
of phlebitis,
51
it is not clear if theymust be rinsedwithnormal saline
or heparin. It seems that the risk of phlebitis is reducedwith heparin
but it continues to be at 45%,
52
thus being removal advisable if
unused. Therefore, unused catheters should not be kept in place as
the risk of inflammation and infection increases
10,53–55
(
I-A
).
PVC must be removed if the following circumstances apply: end
of therapy, signs of chemical phlebitis, malfunction, suspicion of
infection or suspicion of inappropriate insertion or manipulation
as in cases of vital emergency
56,57
(
II-A
).
How?
Simple removal will be performed with single-use clean gloves
and gauze dressing applied thereafter. Removal for suspected infec-
tion implies sending the tip of the catheter (2–3mm of distal end)
in a sterile container for Microbiology. In the latter case, single-use
sterile gloves and sterile instrument to cut the tip of the PVC must
be used. Only catheters with suspected infection must be sent for
Microbiology (
III-A
). There will be suspected infection if fever or
signs of sepsis without evident focus and/or suppurated phlebitis
appeared. Chemical phlebitis alone is not enough to submit the
catheter for Microbiology. It has to be reminded that catheter-
related bacteremia may develop without any suspicion that the
catheter may be the cause.
8,58
Diagnosis
PVC infection shall be suspected when a patient with one or
more PVC develops fever and/or signs of sepsis without additional
clinical focus. Under this circumstance, past history of inappropri-
ate manipulation and prolonged duration support a PVC-suspected
origin of infection. Septic phlebitis or suppuration at the inser-
tion site support this hypothesis
58,59
; however simple chemical
phlebitis may cause low-grade fever.
If infection is suspected, 2–3 samples for blood culture must
be collected. Sampling from PVC must be performed under aseptic
conditions. A cotton swab should be used to take samples from
purulent exudate if present. As PVCs should be of short duration
and of easy replacement it is not justified to keep a catheter
in situ
while awaiting results from Microbiology if infection is suspected
(
III-B
). We then believe that conservative diagnostic techniques for
diagnosis of infection are not applicable
60,61
(
III-A
). Gram stain of
a PVC segment may quickly draw the attention on the possibility
of infection.
62
Treatment
In the treatment of PVC infection, the first step is removal of the
PVC as it has been mentioned above. Once the PVC is removed and
blood samples taken for culture, the need for empirical antibiotic
treatment will be related to the clinical condition of the patient
(including fever and elevation of biomarkers). Treatment should
be directed to PVC bacteremia. Isolated positive tips cultures do
not need antibiotic treatment.
If empirical antibiotic treatment is initiated, Gram-positive
cocci (including methicillin-resistant
S. aureus
) and Gram-negative
bacilli (including
P. aeruginosa
) must be addressed according to
individual patient risk factors and the institutional flora. Other pos-
sible etiologies, albeit infrequent, have to be considered in special
subsets of patients as those previously treatedwith antibiotics, with
multiple comorbidities, immune depressed or hospitalized for long
periods of time.
63
S. aureus
has become an increasingly impactful
etiologic pathogen for bacteremia as it has been shown in several
studies.
3,4,64–66
For bacteremia related to central venous catheters,
the etiology is well diversified.
A reasonable empirical regimen is a combination of daptomycin
and a -lactam active against
P. aeruginosa
. In patients with -
lactam allergies, aztreonam, an aminoglycoside or a quinolone
could be an alternative. In any case, treatment should follow sen-
sitivity patterns at 24–72 h after cultures are taken
67,68
(
I-A
).
The duration of antibiotic treatment will be related to the iso-
lated pathogen.
S. epidermidis
can be treated with removal of PVC
if no other inert material that can be colonized and/or infected
exists; duration of treatment should not be longer than 7 days. If
no antibiotic treatment is given, the patient must be symptom-free
and cultures must be negative upon removal of PVC.
A different situation is
S. aureus
or
C. albicans
infection as those
require a minimum of 14 days of treatment
69
and follow-up cul-
tures at 72 h. Secondary infectious foci like endocarditis and/or
osteomyelitis must be ruled out.
70
This is even more important
if bacteremia persists after removal of the PVC thus indicating a
more prolonged presence of bacteria in the blood stream.
70–73
This
Consensus Document does not pretend reviewing the treatment of
S. aureus
or other bacteremias and the reader is referred to specific
guidelines.
70,71
Gram-negative bacilli infections usually need 7–14
days of treatment after removal of PVC and after the first negative
blood culture is confirmed.
7
Continuous education
Continuous education of healthcare caregivers on the indica-
tions for PVC insertion and the convenience of having PVC inserted
is necessary. It is necessary to periodically remind the nursing staff
inserting PVC the guidelines for insertion and maintenance
74–81
(
I-A
). Table 3 summarizes the recommendations and degree of evi-
dence and references as produced in this document. The lack of