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Single-Lumen Subcutaneous Ports Inserted by Interventional Radiologists in Patients Undergoing Chemotherapy
Incidence of Infection and Outcome of Attempted Catheter Salvage
Delia Kuizon, MD;
Steven M. Gordon, MD;
Bart L. Dolmatch, MD
Arch Intern Med. 2001;161:406-410.
ABSTRACT
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Background Subcutaneous ports are commonly used for vascular access in patients
with cancer undergoing chemotherapy.
Objectives To determine the incidence of catheter-related infection and to assess
the efficacy of catheter salvage in subcutaneous ports.
Methods We retrospectively reviewed 300 subcutaneous single-lumen chest ports
inserted by interventional radiologists in 294 patients between December 1,
1995, and November 15, 1997, at the Cleveland Clinic Foundation, Cleveland,
Ohio. The number of days that the catheter remained in situ, infection rate,
treatment, and outcome of infection were determined.
Results Two hundred ninety-four patients had a total of 79 748 catheter-days.
Vascular access for chemotherapy was the indication for 95% of the subcutaneous
ports placed. Seventeen catheters (5.7%) developed 20 episodes of noninfectious
complications resulting in the removal of 6 ports. Seventeen patients (5.7%)
developed catheter-related infections (2.1/10 000 catheter-days) including
10 episodes of catheter-related bacteremia (1.2/10 000 catheter-days).
The most common organism isolated was Staphylococcus aureus. A total of 15 of the 17 infected catheters were removed. Salvage
was attempted in 6 patients in whom 4 catheters were eventually removed due
to recurrent bacteremia (2 patients) and persistent local infection (2 patients).
One of the 10 patients with catheter-related bacteremia developed septic arthritis.
There were no complications associated with attempted catheter salvage.
Conclusions Subcutaneous single-lumen ports inserted by interventional radiologists
in patients undergoing chemotherapy have low complication rates but infections
remain the leading cause of catheter loss. Antibiotic therapy without catheter
removal is unlikely to eradicate catheter-related bacteremia.
INTRODUCTION
LONG-TERM indwelling venous access devices are a critical issue in the
management of many patients with cancer, facilitating the administration of
chemotherapy and supportive care such as blood transfusion, intravenous antibiotics,
intravenous fluids, and total parenteral nutrition. Since the introduction
of totally implantable central venous catheters as an alternative to external
catheters in the early 1980s,1 subcutaneous
ports have been widely used in patients with cancer undergoing chemotherapy.2, 3, 4, 5 Aside
from easier maintenance and less physical limitations in daily activities,
studies6, 7, 8, 9
have shown lower rates of catheter-related infections and mechanical complications
with subcutaneous ports compared with external catheters. Recently, these
ports are also increasingly being placed by interventional radiologists with
comparable long-term results or even lower complication rates than traditional
surgical placement.10, 11
Infection remains the leading cause of morbidity and catheter loss in
patients with subcutaneous ports.4, 5, 12, 13
The appropriate management of catheter-related infections, however, has not
been clearly defined. A prospective study of patients undergoing hemodialysis
with tunneled, dual-lumen catheters showed failure of antibiotic therapy without
catheter removal (catheter salvage) to eradicate catheter-related bacteremia.14 Although a few studies5, 7
have suggested that port infections, including bacteremic episodes, can be
treated successfully without catheter removal, the safety and efficacy of
catheter salvage in subcutaneous ports has not been determined.
To determine the incidence of subcutaneous port infection and to assess
the outcome of various methods of managing these infections, especially attempted
catheter salvage, we conducted a retrospective, observational study of all
subcutaneous ports placed by vascular radiologists in our institution during
a 2-year period.
PATIENTS AND METHODS
DATA COLLECTION
We reviewed the medical records of all patients with subcutaneous single-lumen
chest wall ports (CR Bard Inc, Murray Hill, NJ, and Meditech, Westwood, Mass)
placed by the interventional radiology department at the Cleveland Clinic
Foundation, Cleveland, Ohio, between December 1, 1995, and November 15, 1997.
Demographic data, underlying diagnosis, indication for port placement, date
of placement, site of venous access, procedural complications, and outcome
of the port on subsequent follow-up were collected by reviewing the radiology
database and computer records. The medical records of patients with suspected
or confirmed catheter-related infections were reviewed. Clinical presentation,
microbiological data, treatment (catheter removal or attempted catheter salvage),
response to treatment, and complications (ie, infective endocarditis, osteomyelitis,
septic arthritis, and death) were recorded. Patients were followed up through
July 1, 1998, or until death or catheter removal.
CASE DEFINITIONS
We defined suspected catheter-related bacteremia as fever (body temperature
>38°C) or nonspecific systemic symptoms in a patient with a subcutaneous
port for whom no other source of infection was apparent after a complete medical
history was taken and a physical examination was performed. We defined confirmed
catheter-related bacteremia as growth of the same organism in blood cultures
obtained from 2 peripheral locations, or from the catheter and a peripheral
site, or growth of the same organism in 1 blood culture and in a drainage
or catheter tip culture.
Local catheter-related infection was defined if there was an organism
isolated in a drainage culture or a positive catheter tip culture and induration,
tenderness, or erythema at the catheter site. Local infection was further
classified into cutaneous site infection (ie, inflammation limited to tissue
overlying the port) and port pocket infection (ie, subcutaneous abscess in
a port pocket).
Patients with catheter-related bacteremia and/or local infection whose
catheters were still in place 3 days after the initial recognition of infection
were considered to have had attempted catheter salvage. Salvage was considered
successful if the same catheter was still in place at the end of 3 months
or if the catheter had been removed for reasons other than persistent or recurrent
bacteremia caused by the same organism, or persistent signs of local infection.
Catheters removed because of persistent or recurrent bacteremia or persistent
local infection were considered to have had salvage failure.
PROCEDURE FOR PORT PLACEMENT BY INTERVENTIONAL RADIOLOGISTS
A total of 3 staff radiologists (B.L.D. and others) performed almost
all (>95%) of the procedures during the study period. Almost all (96%) venous
procedure were done via the internal jugular vein approach. All venous punctures
were done under direct ultrasound guidance with adherence to aseptic technique
during insertion with the use of maximal barrier precautions (ie, sterile
gloves, large sterile drape, and sterile gown, cap, and mask) in a dedicated
procedure room with more than 20 air exchanges per hour.
All patients were given 1 dose of prophylactic intravenous antibiotic
agents, either cefazolin sodium (1 g) or vancomycin hydrochloride (1 g) if
penicillin-allergic, 30 minutes prior to the procedure. Patients with platelet
counts lower than 30 x 109/L or those with known dysfunctional
platelets were given platelet transfusion during the procedure.
All patients receiving subcutaneous port-a-catheters (a totally implanted
vascular system) got home-going instructions about care of the site, and were
instructed to watch for swelling, redness, fever, or hematoma. All patients
were scheduled for a return visit at 3 to 5 days after insertion for a dressing
change in the department of interventional radiology. A second visit was scheduled
at 10 to 14 days after insertion. At that time, the patient is seen by a physician,
and the site is inspected. If things were fine, then the patient was instructed
to return on an as-needed basis.
DATA ANALYSIS
Data analysis was performed using the Epi Info
software (USD Inc, Stone Mountain, Ga).
RESULTS
During the 2-year study period, 300 subcutaneous ports were placed in
294 patients for a total of 79 748 catheter-days. Six patients had a
second catheter placed after the first was removed because of complications.
Eighty-seven percent of the patients were white, 59% were female, and the
patients' mean age was 55 years. Almost all patients (97%) had an underlying
malignancy (Table 1) and almost
all (95%) of the catheters were placed for administration of chemotherapy.
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Table 1. Primary Diagnosis of 294 Patients With Subcutaneous Ports
Placed During Study Period
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At the time of last follow-up the mean duration of the subcutaneous
ports was 266 catheter-days (range, 1-896 catheter-days). A total of 114 catheters
(38%) were in patients who had died secondary to their malignant neoplasms
with a functioning catheter in situ, 91 catheters (30%) were still in place
and functioning in surviving patients, 73 catheters (24%) had been removed
electively, and 21 catheters (7%) had been removed because of complications.
The status of 1 catheter was lost to follow-up. Therefore, the overall catheter
failure rate was 2.6 per 10 000 catheter-days.
NONINFECTIOUS COMPLICATIONS
There were no intraprocedural complications during port-a-catheter insertion.
Three patients had oozing and 1 patient developed a hematoma during the first
24 hours of placement; none required additional interventions.
Seventeen catheters (5.7%) developed 20 episodes of noninfectious complications
beyond the first 24 hours resulting in removal of 6 ports. The overall noninfectious
complication rate was 2.5 episodes per 10 000 catheter-days. There were
13 episodes of catheter occlusion: 9 catheters had resolution of occlusion
after flushing with plasminogen activator while 4 catheters with persistent
flow problems were found to have a dense fibrin sheath. Three catheters required
removal and 1 catheter was salvaged by fibrin stripping. There were 2 cases
of venous thrombosis: one was symptomatic and required removal after anticoagulation
therapy while the other was diagnosed after a failed salvage attempt for bacteremia.
One patient had 2 episodes of skin erosion involving 2 catheters. Both catheters
were removed. There was 1 episode of malposition that resolved spontaneously,
1 case of catheter migration requiring repositioning, and 1 case of subcutaneous
hematoma after the port was accessed.
INFECTIOUS COMPLICATIONS
Seventeen patients (5.7%) developed catheter-related infections for
a catheter infection rate of 2.1 episodes per 10 000 catheter-days. Ten
patients had catheter-related bacteremia (1.2 episodes/10 000 catheter-days).
Four of these patients had concurrent local catheter infections. Six patients
had a pure local infection that was classified into 4 cutaneous site infections
and 2 port pocket infections. One catheter was removed in a local hospital
for infection and detailed information could not be obtained.
Infection was documented after a median of 64 days (range, 6-530 days)
from catheter placement. Five (30%) of the 17 catheter-related infections
developed within the first 30 days of placement.
Five of the 17 infected catheters had a preceding noninfectious complication:
4 catheters had 1 episode of catheter occlusion that resolved with flushing
of plasminogen activator and 1 catheter had a subcutaneous hematoma.
MICROBIOLOGY
Eleven microorganisms were identified in the 10 episodes of bacteremia
(1 patient had 2 organisms isolated). The most common organism was Gram-positive
cocci that was isolated in 8 episodes (73%). Gram-negative rods were isolated
in 3 episodes (27%) (Table 2).
For pure local infections, Gram-positive cocci were isolated in 8 cases (67%),
Gram-negative rods in 3 cases (25%), and mixed anaerobic flora was documented
in 1 case (Table 3).
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Table 2. Microbiological Isolates From 10 Episodes of Catheter-Related
Bacteremia
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Table 3. Microbiological Isolates From Catheter Tip Culture and Port
Pocket Drainage in Patients With Pure Local Infection*
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Staphylococcus aureus and coagulase-negative
staphylococci were the most common organisms isolated for both catheter-related
bacteremia and local infection (Table 2 and Table 3). No catheter-associated
fungal infection was identified.
TREATMENT AND CLINICAL OUTCOME
Fifteen (88%) of the 17 infected catheters were removed. Eleven catheters
were removed immediately while 4 catheters were removed after a failed salvage
attempt.
Catheter salvage was attempted in 3 of the 4 catheters with cutaneous
site infection. Two catheters were eventually removed because of persistent
symptoms. The first patient had persistent discharge despite treatment with
oral ciprofloxacin hydrochloride and drainage culture later grew methicillin-sensitive S aureus. The second patient had persistent tenderness
and induration despite treatment with oral dicloxacillin sodium; catheter
tip culture done after removal yielded Pseudomonas aeruginosa. The 2 patients with port pocket infection were both treated with
immediate catheter removal, oral antibiotics, and local wound care.
Catheter salvage was attempted in 3 of the 10 patients with bacteremia.
Salvage attempt failed in 2 patients. The first patient had recurrent Klebsiella pneumoniae bacteremia while receiving intravenous
ciprofloxacin therapy. This patient had a right internal jugular vein port
and a concomitant left internal jugular hemodialysis catheter. Further investigation
also revealed a nonocclusive right internal jugular vein thrombus. Both catheters
were removed. Repeated blood cultures yielded no organisms after catheter
removal. The second patient had S aureus isolated
from both central and peripheral blood cultures but also had an abscess surrounding
a subcutaneous morphine pump yielding the same organism. The morphine pump
was removed and the patient was treated with 4 weeks of intravenous cefazolin
through the port with resolution of the abscess. Ten days after completion
of antibiotic treatment, the patient developed fever and chills. Blood cultures
again yielded S aureus and the port was then removed.
Salvage attempt was successful in 1 patient with coagulase-negative staphylococci
bacteremia and the catheter was still functional on last follow-up.
Patients who had attempted catheter salvage did not have complications.
There was 1 patient with catheter-related S aureus
bacteremia who had a septic prosthetic joint. His port was immediately removed.
There were no cases of osteomyelitis, endocarditis, or deaths due to catheter-related
bacteremia.
COMMENT
Our study shows that catheter-related complications (infectious or noninfectious)
occur infrequently in patients with cancer who have subcutaneous ports (tunneled,
central venous catheters) inserted by interventional radiologists for the
administration of chemotherapy. The overall catheter failure rate was low
(2.6/10 000 catheter-days). The incidence of noninfectious complications
(2.5/10 000 catheter-days) was similar to the incidence of infectious
complications (2.1/10 000 catheter-days).
The infections associated with subcutaneous port catheters were almost
evenly distributed between bacteremias (1.2/10 000 catheter-days) and
local (tunnel) infections. Most infectious complications occurred after 30
days of insertion and the pathogens most frequently associated with infections
were skin flora (S aureus and coagulase-negative
staphylococci). This probably reflects adherence to aseptic technique during
insertion with the use of maximal barrier precautions in a dedicated procedure
room, the routine use of antibiotic prophylaxis, and the use of skilled personnel
to inset and maintain these catheters.
A total of 4 of the 17 patients with catheter-associated infections
had an episode of catheter occlusion prior to onset of infection requiring
flushing with plasminogen activator, but there were 5 other cases of catheter
occlusion that were salvaged by flushing with plasminogen activator (without
subsequent infections) and 4 other patients with catheters with persistent
flow problems despite plasminogen activator and who were found subsequently
to have dense fibrin sheaths requiring removal or salvage by stripping but
no infectious complications. There was no clustering by date of receipt of
plasminogen activator or practitioner performing the placement or salvage
for the 5 patients with catheter-related infections who had prior noninfectious
complications (including the 4 with catheter occlusions) to suggest a common-source
outbreak (eg, contaminated plasminogen activator).
Almost all of the patients (88%) with catheter-associated infections
required catheter removal with or without attempts at salvage. There was 1
patient with catheter-associated bacteremia with a metastatic complication.
Our findings are consistent with recently reported low success rates of salvage
in patients with bacteremia and tunneled cuff hemodialysis catheters.14
We were unable to compare the infectious complications of single-lumen
subcutaneous ports used for chemotherapy inserted by surgeons vs interventional
radiologists. However, the incidence of catheter-related bloodstream infections
among 360 patients receiving home parenteral nutrition at our institution
between 1976 and 1994 was 6 bloodstream infections per 10 000 catheter-days
(vs 1.2/10 000 in the current study). The tunneled catheters used for
home parenteral nutrition are usually Hickman catheters and were inserted
in the operating room by general surgeons.
These results are important for clinicians who care for patients receiving
chemotherapy. We have shown the use of an interventional radiologist to insert
subcutaneous ports to provide vascular access for chemotherapy was safe and
effective with low rates of complications.
AUTHOR INFORMATION
Accepted for publication July 20, 2000.
Presented in part at the Fourth Decennial International Conference on
Nosocomial and Healthcare-Associated Infections, Atlanta, Ga, March 5-9, 2000.
From the Departments of Internal Medicine (Dr Kuizon), Infectious Diseases
(Dr Gordon), and Interventional Radiology (Dr Dolmatch), Cleveland Clinic
Foundation, Cleveland, Ohio. Dr Dolmatch is now with the Department of Radiology,
The University of Texas, Southwestern Medical Center, Dallas.
Corresponding author: Steven M. Gordon, MD, Department of Infectious
Diseases, Mailstop S-32, 9500 Euclid Ave, Cleveland, OH 44195.
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