By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
SYNOPSIS: In patients with bloodstream infection whose central venous catheter is removed, delaying insertion of a new catheter at a different site for > 3 days is not associated with better infection outcomes than is earlier catheter insertion.
SOURCE: Lee YM, Ryu BH, Hong SI, et al. Clinical impact of early reinsertion of a central venous catheter after catheter removal in patients with catheter-related bloodstream infections. Infect Control Hosp Epidemiol 2021;42:162-168.
In patients with a central venous catheter (CVC) who develop a catheter-related bloodstream infection, the catheter is most often removed, especially if the etiologic pathogen is a Gram-negative bacillus or Candida. However, the care of some patients may be compromised in the absence of a CVC, necessitating its replacement. It commonly is recommended that CVC reinsertion be delayed because of fear that the new catheter itself will become infected as the result of being exposed to organisms continuing to circulate in the bloodstream. But the evidence to support the need for such a delay is largely lacking. Lee and colleagues now have addressed the issue.
The investigators retrospectively examined the records of 316 adult patients with bloodstream infection assessed as catheter-related by virtue of a culture of the tip of the removed catheters that yielded the same organism. Of these, 169 had a new catheter placed at another site with early reinsertion (i.e., within three days or fewer of catheter removal) in 39 patients (12.4%), while 130 patients (41.1%) underwent delayed reinsertion. The catheter was not replaced in the remaining 147 patients (46.5%).
The mean age of the patients was 68 years. The most frequent cause of the bloodstream infection was Candida spp., which accounted for 34.5% of cases, followed by Staphylococcus aureus (28.2%), coagulase-negative Staphylococcus (23.1%, mostly methicillin resistant), and Gram-negative bacilli (11.1%). The early and delayed groups were similar at baseline except for greater proportions with non-tunneled catheters, coagulase-negative staphylococci, and septic shock, and a lower proportion with methicillin-susceptible S. aureus in the early reinsertion group. Requirements for total parenteral nutrition and hemodynamic monitoring were the reasons for catheter reinsertion more frequently in the early group, while chemotherapy and hemodialysis were more frequent reasons in the delayed group.
Persistent bloodstream infection, defined as microbemia persisting for more than three days after removal of the central catheter, occurred in 22.3% of the early group and 17.9% (P > 0.99) in the delayed cohort. By contrast, it occurred in only 7.5% in patients whose catheter was removed but not replaced. With controlling for confounders, when compared to delayed insertion, early catheter reinsertion was not significantly associated with persistent bloodstream infection or with 30-day mortality.
The investigators concluded that “replacement of a new CVC should not be delayed in patients who still require a CVC for ongoing management.”
The safest approach in any patient, with or without bloodstream infection, is to not replace a CVC once removed. In patients who have an ongoing need for such a device, a new one must be inserted, and this should be done at a site different from the one that was removed. In patients in whom reinsertion is necessary, an important issue is whether, if at all possible, there should be a period of delay before reinsertion for fear the new catheter will become infected.
The urgency to replace a CVC often is related to issues arising in critical illness and to total parenteral nutrition. However, another issue relates to the ability to discharge patients believed to require ongoing parenteral therapy, including outpatient antimicrobial therapy, in whom routine delay of reinsertion may result in unnecessary delay in hospital discharge for as long as three days. Although this study cannot be considered definitive given a number of shortcomings, it does point out that the frequent practice of delaying CVC reinsertion is not clearly evidence-based.