Association between early and late catheter removal and outcome of elderly patients with catheter-related bloodstream infection and persistent bacteremia caused by methicillin-resistant staphylococcus aureus
Journal
Journal of the American Geriatrics Society
Journal Volume
58
Journal Issue
6
Pages
1197-1199
Date Issued
2010
Author(s)
Abstract
To the Editor: Catheter-related bloodstream infection (CRBSI) caused by methicillin-resistant Staphylococcus aureus (MRSA) is a common healthcare-associated infection with a high mortality rate in elderly patients.1,2 This condition is a common clinical dilemma for physicians, who must often decide whether to replace the central line immediately because of new-onset sepsis before the source of the infection has been determined. The decision is especially complex when treating debilitated elderly patients with difficult vascular access in whom invasive procedures increase suffering and complications.3,4 Delayed removal of the catheter was shown to be associated with persistent S. aureus bacteremia.5 The present study investigated the association between timing of catheter removal and the outcome of elderly patients with CRBSI and persistent bacteremia caused by MRSA. All hospitalized patients aged 65 and older at National Taiwan University Hospital with MRSA CRBSI and persistent MRSA bacteremia from 2000 to 2008 were included. Persistent MRSA bacteremia was defined as the isolation of MRSA in blood cultures on 7 or more consecutive days despite glycopeptide (vancomycin or teicoplanin) administration for 5 days or longer. MRSA CRBSI was defined as a positive semiquantitative tip culture (≥15 colony forming units) for MRSA in a patient with MRSA bacteremia. Severity of underlying illness was classified using McCabe–Jackson criteria.6 MRSA bacteremia was considered nosocomial when it appeared more than 48 hours after admission. Thirty-day mortality was defined as death without clearance of bacteremia or within 30 days after clearance of bacteremia. Mortality was defined as MRSA related if there was persistent MRSA infection and no other definite cause of death. Catheter removal was classified as early and late if the catheter was removed within and longer than 24 hours after the onset of MRSA bacteremia, respectively. Clinical characteristics and outcomes of patients with early and late catheter removal were compared. CRBSI and persistent bacteremia due to MRSA was diagnosed in 64 elderly patients, mean age 78.5±7.8, 24 (37.5%) female. The most common underlying diseases were end-stage renal disease (51.6%), diabetes mellitus (43.8%), stroke (25%), heart failure (21.9%), and cancer (18.8%). The most commonly associated catheters were central venous catheter (46.9%) and hemodialysis catheter (non-tunneled double lumen catheter, 32.8%; tunneled double lumen catheter, 12.5%). The most common concomitant pathogens were nonfermenting gram-negative bacilli (n=10), enterococci (n=8), and Candida species (n=5). The association between outcome and clinical characteristics and early and late catheter removal is shown in Table 1. There were no significant differences in the demographic characteristics and comorbidities between the early and late catheter removal groups (all P>.05). In patients who received late catheter removal, the median duration from onset of bacteremia to catheter removal was 6 days (interquartile range 3–8 days). After excluding rapidly fatal cases, early catheter removal did not provide a survival advantage for MRSA-related mortality (P=.96) or 30-day mortality (P=.70). The current study showed that immediate catheter removal did not reduce the mortality of elderly patients with CRBSI and persistent bacteremia due to MRSA. These findings provide a rationale for replacing central lines only after better ascertainment of MRSA CRBSI in elderly patients for whom catheter removal is undesirable because of limited vascular access. These findings are also in accordance with the statement in the current guidelines established by the Infectious Diseases Society of America7 that, for selected patients, a catheter should be removed only when bloodstream infection is documented or when there is hemodynamic instability. This strategy can result in reduction of unnecessary catheter removal.8 A previous study found a higher rate of hematogenous complications in patients receiving delayed catheter removal.9 In contrast, this study found metastatic infections were more frequent in patients who received early catheter removal than in those who received late catheter removal, although this difference was not significant. It is not clear whether this association was related to the physician's discretion in choice of treatment or to the heterogeneity of study populations. In another study, patients with delayed catheter removal had a significantly longer duration of S. aureus bacteremia.5 Similar results were observed in this study but failed to achieve statistical significance. Several limitations of this study hindered the ability to estimate the influence of the timing of catheter removal, including the small case number and retrospective design. In addition, this study focused on patients who already had persistent MRSA bacteremia, and therefore its findings should not be generalized to all patients with CRBSI. Further studies are needed to determine which patients require immediate catheter removal to improve outcomes. In summary, CRBSI and persistent bacteremia caused by MRSA in elderly patients is associated with high rates of morbidity and mortality. This study found no survival advantage associated with early catheter removal. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All the authors contributed to the composition of this letter. Sponsor's Role: None.
SDGs
Other Subjects
teicoplanin; vancomycin; aged; bacteremia; blood culture; bloodstream infection; catheter infection; catheter removal; controlled study; female; hospital patient; human; letter; major clinical study; male; medical decision making; methicillin resistant Staphylococcus aureus; morbidity; mortality; outcome assessment; survival; Taiwan; university hospital; vascular access; bacteremia; cross infection; device removal; epidemiology; indwelling catheter; methicillin resistant Staphylococcus aureus; mortality; risk factor; Staphylococcus infection; time; Aged; Bacteremia; Catheters, Indwelling; Cross Infection; Device Removal; Female; Humans; Inpatients; Male; Methicillin-Resistant Staphylococcus aureus; Risk Factors; Staphylococcal Infections; Taiwan; Time Factors; Aged; Bacteremia; Catheters, Indwelling; Cross Infection; Device Removal; Female; Humans; Inpatients; Male; Methicillin-Resistant Staphylococcus aureus; Risk Factors; Staphylococcal Infections; Taiwan; Time Factors
Type
letter