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Three Part Question

In [a 6-year-old girl with ALL] does [a Portacath (implantable central venous access device) compared to a Hickman line (tunnelled external (TE) central venous catheter (CVC))] increase [the risk of catheter-related infections during the course of ALL treatment]?

Clinical Scenario

A 6-year-old girl with acute lymphoblastic leukaemia (ALL) presents with another episode of febrile neutropenia with positive blood culture from her Hickman line. On a ward round, her parents suggest that they would like her to have a Portacath device inserted so that she can go swimming and be more comfortable around her friends. However, they are worried that she will be more susceptible to infection as the needle passes through the skin each time the device is accessed and have spoken to a few parents of children who have had to have their ports removed because of infection. They would like to avoid further hospital admissions if possible. They ask whether the Portacath will increase their daughter’s risk of infection during the remainder of her treatment.

Search Strategy

The following databases were searched: TRIP Database, NELH guideline finder, BestBETs, Clinical Evidence, Cochrane Library, PubMed.
MeSH terms used were: central venous catheterisation, indwelling catheter, bacterial infections, neoplasms, leukaemia and pediatrics. Text words were: (implant* OR tunnel*) central venous (line OR access OR device), Portacath, Hickman line, cancer, leukaemia, child*, bacterial colonisation and catheter-associated bloodstream infection (CABSI).

Search Outcome

Two prospective cohort studies were appraised

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Allen et al, 2006	139 Paediatric oncology patients (median age 6 years, 41% female). 149 catheters: 78 pre-existing and 71 newly inserted CVC with TE and TID. 19 patients (13%) had more than one device.	Prospective cohort (level 1b)	CABSIs per 1000 line days	Overall: 1.6 TE: 4.8 TID: 0.7	Well-defined sample Small size CABSI objectively defined by CDC guidelines Short follow-up of 1 year but complete First line antibiotic cefepime Multivariate analysis for prognostic factors supported increase risk of TE
			CABSIs over 1 year TE vs TID	7.1 (CABSI rate ratio) (95% CI 4.1 to 12.2)
Adler et al, 2006	281 Paediatric oncology patients (mean age 9.07 years, 41% female). 419 catheters inserted: 173 Hickman and 246 TID. 86 patients (30%) had more than one device inserted (maximum of 7 catheters/patient).	Prospective cohort (level 1b)	CABSIs per 1000 line days	Overall: 2.26 TE: 4.66 TID: 1.45	Well-designed prospective trial following up new insertions of CVC Follow-up until end of trial or removal of catheter; no mean follow-up time given CABSI defi nition included symptoms plus use of line in previous 48 h and blood culture positive Department policy for younger infants and transplant patients to have Hickman line and others TID
			CABSIs TE vs TID	3.2 (CABSI rate ratio)

Comment(s)

There are no specific guidelines or systematic reviews addressing CVC device types and infection rates in children with cancer. Intravascular catheters may result in local and systemic infections including local site infections, CABSIs and metastatic infections (Grady)The long-term central venous devices used in children with cancer are generally either of tunnelled external (TE) design, for example, Hickman or Broviac catheters, which are tunnelled under the skin and inserted into a large central vein, or totally implantable devices (TID), for example Portacaths, which are subcutaneous port devices implanted into a central vein that can be accessed intermittently with a needle.

The appraised studies were both prospective cohort studies with good follow-up, and included children with haematological and solid malignancies. Coagulase negative staphylococcus (CONS) was the most common organism causing CABSIs in both trials, which is consistent with the microbiological profile of CABSIs in children and adults in other studies (Grady). It is acknowledged that although variations in individual hospital practice may exist, according to choice of catheter devices, antibiotic use and decision to remove catheters, similarities and differences in practice in the appraised studies based in the USA and Israel, are consistent with variations seen in UK practice.

The majority of the research comparing central venous access devices in children and adults (Maki, Allen, Adler, Groeger, Ingram, Quaglia, Rao, Ross, Abbas, McLean) has also supported a lower infection rate for TIDs compared to TE devices, possibly relating to reduced exposure to skin microbes. Other prospective trials (Mueller, Wurzel) which were mainly adults based, have also shown a higher rate of infection in TE devices than TIDs, but results did not reach statistical significance. CABSI rates described in the appraised studies by Allen et al and Adler et al were within the range reported in children and adults at 0.7–12.6 infections per 1000 catheter-days.6 Besides the catheter device used, CABSI rates may vary according to age,(Wurzel, Abbas) treatment protocol(Abbas) and type of cancer (Sotir). Comparison of CABSI rates between studies in this field is complicated by the use of different definitions to describe device-related infections, which may include exit site infections, colonisation and catheter-related bacteraemia, with or without fever (Grady). Pathological diagnostic groups, local devices used, operative procedures, use of prophylactic antibiotics at line insertion and length of follow-up, also differ between studies.

A few studies have looked at risk factors specifically related to early and recurrent catheter-related infections. Penel et al found that catheter-related infections during the first month after device insertion are associated with age <10 years, difficulties during the insertion procedure and parenteral nutrition, but not with catheter design. However, this trial’s cohort was only 5% child based and did not include haematological malignancies. In contrast, Adler et al found TE lines to be associated with significantly shorter time to first infection, shorter duration of catheterisation and higher rate of removal for mechanical complications, compared to implantable ports.

Flynn et al report that in children with CABSIs, catheter type does not influence short-term eradication of bacteraemia, and that recurrent bacteraemia is more likely with TIDs than TE catheters. Cellular and anticoagulant debris accumulating over time in the dead space of the ports was suggested to explain this higher rate of recurrence of bacteraemia in TIDs. This study was limited by its retrospective design, which compared CABSIs, including exit site infections, in 151 TE catheters and 21 TIDs, using patient case notes and microbiological records. In contrast, Adler et al, in a retrospective study, found that recurrent bacteraemia with the same organism was related to previous CONS and older age (adolescents), and that TE catheters, and not TIDs, were associated with a significantly increased risk of re-infection from another microorganism, following initial successful CABSI eradication.

The adult guidelines of the British Committee of Haematology support the use of TID lines in children and state that they confer a lower rate of infection than TE catheters when used in adult populations. A systematic review of this topic would be useful to further evaluate the comparison of CVC devices in children with cancer.

There are no published guidelines to advise which central line device should be used in children undergoing chemotherapy for ALL, and practices vary according to tertiary care centres and patient preference. Apart from the risks of infection, other advantages of TIDs over TE devices in children are that they have a longer failure-free duration (in terms of removal because of infection, obstruction and dislodgement)(Rao)and increased overall patient and parental acceptance, as they allow normal activity and improved body image, and are less expensive and easier to care for at home (Ingram, Ross). Children with needle phobia or requiring haematopoietic stem cell transplant (Adler) and young infants, would be more likely to have a TE device, for example, a Hickman line.

Editor Comment

Key results quoted in CABSI rate over time and events per catheter (not per person). CABSI, catheter-associated bloodstream infection; CVC, central venous catheter; TE, tunnelled external catheter, eg, Hickman line; TID, totally implantable device, eg, Portacath.

Clinical Bottom Line

Tunnelled external central venous catheters (eg, Hickman lines) have a 3–7 times higher rate of catheter-associated bloodstream infections than totally implantable devices (eg, Portacaths) in children with cancer. (Grade A) The choice of central venous catheter may depend on tumour type, age and local clinical practice.

References

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