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Retained Hickman catheter cuff as a source of infection
Journal of Infection (1993) 26, 199-2Ol
CASE REPORT Retained
Hickman
catheter cuff as a source of infection
W. I. AI-Wali,* M. H. Wilcox,* K. J. Thickett,* K. M. S i m m o n s t a n d R. C. S p e n c e r *
Departments of * Bacteriology and t Haematology, Royal Hallamshire Hospital, Glossop Road, Sheffield S I o 2JF, U.K. Accepted for publication 20 May I992 Summary Two cases of Pseudomonas aeruginosa infection complicating retained subcutaneous Hickman catheter cuffs are described. Foreign body-associated Pseudomonas infection is unlikely to respond to treatment with antibiotics alone. We therefore recommend that the cuff is removed at the same time as the Hickman catheter is pulled out so as to prevent future infection.
Introduction T h e H i c k m a n catheter is a right-sided atrial silastic catheter inserted into a large vein in the neck. It is c o m m o n l y used in the treatment of patients with neoplastic blood diseases in order to provide continuous intravenous access. T h e catheter leaves the b o d y through a subcutaneous tunnel in the chest wall. A D a c r o n cuff, attached to the catheter within the subcutaneous tunnel, b e c o m e s incorporated with fibrous tissue a b o u t 2I days after insertion. T h e fibrous tissue forms a mechanical barrier against accidental removal of the catheter and against bacteria tracking along the subcutaneous tunnel. 1 Infection is an important complication of central venous cannulation and arises in 7-16 ~/o patients. 2 T h e incidence of H i c k m a n catheter infection has been f o u n d to be b e t w e e n o-I 3 and 2.0 per Ioo patient days. 3-6 W h e n a H i c k m a n catheter is removed, the cuff is often retained subcutaneously, anchored b y the surrounding fibrous tissue. I f there is infection within the tunnel, however, tissue around the cuff is friable and the cuff usually accompanies the catheter as it is pulled out. W e report here two cases of leukaemic patients w h o developed H i c k m a n catheter-associated infection caused b y Pseudomonas aeruginosa and complicated b y a retained cuff. T h e H i c k m a n catheter used in our haematology unit is the B a r d - D a v o l type (Bard Ltd., Crawley, U . K . ) which is available with a single, double or triple lumen.
Case reports Case I A 54-year-old m a n with acute myeloid leukaemia and neutropenia complained of tenderness and s u b s e q u e n t discharge of pus at the exit site of a single-lumen H i c k m a n catheter b u t was neither febrile nor systemically i11. H e was treated with v a n c o m y c i n (I g b.d. Iv) and gentamicin (80 m g t.i.d. IV). T h e next day ox63-4453/93/o2oi99+o3 $08.00/0
© I993 The British Society for the Study of Infection
200
W.I. AL-WALI
ET AL.
his temperature rose to 38 °C and he felt unwell. A swab taken at the exit site of the catheter the previous day yielded P. aeruginosa, Escherichia coli and Klebsiella pneumoniae. Since the strain of P. aeruginosa (PAI) was resistant to gentamicin ( M I C > 4mg/1), ceftazidime (2 g t.i.d.) was substituted. T h e catheter was removed the same day. Even so, two distinct areas of ecthyma gangrenosum developed around the exit site. Blood cultures were negative but culture of the tip of the Hickman catheter yielded P. aeruginosa. T h e patient eventually recovered after treatment with ceftazidime for a total of Io days, with complete healing of the ecthyma gangrenosum lesions. A swab taken from the original exit site 2 weeks after the patient's discharge from hospital grew P. aeruginosa (PA2), although the exit site did not appear to be infected. After a further period of I8 days, the patient developed a localised abscess over the site where the cuff was presumed to have been retained. T h e cuff was removed under local anaesthesia and sent for microbiological investigation. Pseudomonas aeruginosa (PA3) was again isolated. T h e patient was successfully treated with ceftazidime (I g t.i.d. IV) for 7 days. Antibiograms of strains PAI, PA2 and PA3, with seven antibiotics, differed only in gentamicin susceptibilities. T h e outer membrane protein profiles of these isolates, obtained by SDS P A G E were identical (Plate I). 7 Case 2
A 4I-year-old woman with acute myeloid leukaemia had three episodes of Hickman catheter-associated septicaemia caused by Bacillus sp., a coagulasenegative staphylococcus and Moraxella sp. Her single-lumen Hickman catheter was therefore pulled out but the Dacron cuff was retained. After 3 months, she was readmitted to hospital because of a discharge from the exit site of the Hickman catheter. She was not neutropenic and was initially treated with vancomycin (I g b.d. Iv). T h e retained cuff was visible through the wound at the exit site and was removed. A swab taken of the discharge at the exit site yielded P. aeruginosa although blood cultures were negative. T h e patient was treated successfully with a 7-day course of oral ciprofloxacin 75o mg b.d. Discussion
Discussion with the manufacturers of the Hickman catheters used in these patients did not reveal any clear recommendations for removal of cuffs, this being left to the discretion of individual clinicians. Although cuffs usually come out easily when catheters are removed, they may be retained. These two cases illustrate the pitfalls of failing to remove subcutaneous cuffs in patients with infections related to Hickman catheters. In the first case, despite appropriate antimicrobial therapy, a subcutaneous abscess developed, caused by P. aeruginosa and associated with the retained cuff. In the second patient, P. aeruginosa was not isolated during the time that the Hickman catheter was in use but may have been introduced directly into the wound after its removal. Alternatively, it may have seeded the retained cuff during an episode of bacteraemia. T h e bactericidal activity of both beta-lactams and aminoglycosides against P. aeruginosa is significantly reduced in the presence of a polymer surface
yournal of Infection
Plate I
97 66 45 31
22 14 PAl PA2 PA3 Plate I. Outer membrane protein profiles of the three Pseudomonas aeruginosa isolates in case I. Molecular weight markers (kDa) are indicated in the track on the far right.
W . I. AL-'~rALI ET AL.
(Facing p. 2oo)
Infection f r o m H i c k m a n catheter
201
c o m p a r e d to p l a n k t o n i c b a c t e r i a alone. 8'9 B i o f i l m - a s s o c i a t e d b a c t e r i a m a y p r o v i d e a n i d u s for i n f e c t i o n a n d m a y p r o l i f e r a t e o n c e t h e c o n c e n t r a t i o n o f a n t i b i o t i c s d e c r e a s e s (as in case I). T h e r e l a t i v e l y r e d u c e d m e t a b o l i c a c t i v i t y o f cells a s s o c i a t e d w i t h a b i o f i l m w h i c h m a y act as a b a r r i e r a g a i n s t a n t i b i o t i c s o r e v e n i n a c t i v a t e t h e m m a y e x p l a i n this a p p a r e n t a n t i b i o t i c r e s i s t a n c e . 1°' 1~ W e r e c o m m e n d t h a t t h e s u b c u t a n e o u s c u f f o n a H i c k m a n c a t h e t e r is r e m o v e d at t h e t i m e o f its r e m o v a l . A r e t a i n e d c u f f m a y b e t h e s o u r c e o f i n f e c t i o n in a p a t i e n t p r e s e n t i n g w i t h f e v e r f o l l o w i n g t h e r e m o v a l o f a H i c k m a n catheter. References
i. Prkchard AP, David JA. The Royal Marsden Hospital manual of clinical nursing procedures. 2nd edn. London: Harper and Row, 1988. 2. Kaye CG, Smith DR. Complications of central venous cannulation. Br Med J 1988; 297: 572-573 • 3. Riella M, Scribner B. Five years experience with a right atrial catheter for prolonged parenteral nutrition at home. Surg Gynecol Obstet 1976; 143: 205. 4- Thomas J, MacArthur R, Pierce G, Hermrech A. Hickman-Broviac catheters. Indications and resuhs. Am J Surg 198o; 14o: 791-796. 5. Kappers-Klunne M, Degener J, Stijnen T, Abels J. Complications from long term indwelling central venous catheters in haematologic patients with special reference to infection. Cancer 1989; 64: 1747-1752. 6. Cairo M, Spooner S, Sowden L, et al. Long term use of indwelling multi-purpose silastic catheters in paediatric cancer patients treated with aggressive chemotherapy. 07 Clin Onc 1986; 4: 784-788. 7. Lugtenberg B, Meijers J, Peters R, Van der Hoek P, Van Alphen L. Electrophoretic resolution of the major outer membrane protein of Escherichia coli KI2 into four bands. F E B S Lett 1975; 58: 254--258. 8. Nickel J'C, Ruseka I, Wright JB, Costerton JW. Tobramycin resistance of Pseudomonas aeruginosa cells growing as a biofilm on urinary catheter material. Antimicrob Agents Chemother 1985; 27: 619-624. 9. Brown MRW, Allison DG, Gilbert P. Resistance of bacterial biofilms to antibiotics: a growth related effect? 07 Antimicrob Chemother I988 ; 22:777-783. IO. Craddock CF, Edwards R, Finch RG. Pseudomonas peritonitis in continuous ambulatory peritoneal dialysis: laboratory predictors of treatment failure. 07 Hosp Infect 1987; IO: 179-186. II. Giwercman B, Jensen ET, Hoiby N, Kharazmi A, Costerton JW. Induction of betalactamase production in Pseudomonas aeruginosa biofilm. Antimicrob Agents Chemother I 9 9 I ; 35: 1008-1010.
CASE REPORT Retained
Hickman
catheter cuff as a source of infection
W. I. AI-Wali,* M. H. Wilcox,* K. J. Thickett,* K. M. S i m m o n s t a n d R. C. S p e n c e r *
Departments of * Bacteriology and t Haematology, Royal Hallamshire Hospital, Glossop Road, Sheffield S I o 2JF, U.K. Accepted for publication 20 May I992 Summary Two cases of Pseudomonas aeruginosa infection complicating retained subcutaneous Hickman catheter cuffs are described. Foreign body-associated Pseudomonas infection is unlikely to respond to treatment with antibiotics alone. We therefore recommend that the cuff is removed at the same time as the Hickman catheter is pulled out so as to prevent future infection.
Introduction T h e H i c k m a n catheter is a right-sided atrial silastic catheter inserted into a large vein in the neck. It is c o m m o n l y used in the treatment of patients with neoplastic blood diseases in order to provide continuous intravenous access. T h e catheter leaves the b o d y through a subcutaneous tunnel in the chest wall. A D a c r o n cuff, attached to the catheter within the subcutaneous tunnel, b e c o m e s incorporated with fibrous tissue a b o u t 2I days after insertion. T h e fibrous tissue forms a mechanical barrier against accidental removal of the catheter and against bacteria tracking along the subcutaneous tunnel. 1 Infection is an important complication of central venous cannulation and arises in 7-16 ~/o patients. 2 T h e incidence of H i c k m a n catheter infection has been f o u n d to be b e t w e e n o-I 3 and 2.0 per Ioo patient days. 3-6 W h e n a H i c k m a n catheter is removed, the cuff is often retained subcutaneously, anchored b y the surrounding fibrous tissue. I f there is infection within the tunnel, however, tissue around the cuff is friable and the cuff usually accompanies the catheter as it is pulled out. W e report here two cases of leukaemic patients w h o developed H i c k m a n catheter-associated infection caused b y Pseudomonas aeruginosa and complicated b y a retained cuff. T h e H i c k m a n catheter used in our haematology unit is the B a r d - D a v o l type (Bard Ltd., Crawley, U . K . ) which is available with a single, double or triple lumen.
Case reports Case I A 54-year-old m a n with acute myeloid leukaemia and neutropenia complained of tenderness and s u b s e q u e n t discharge of pus at the exit site of a single-lumen H i c k m a n catheter b u t was neither febrile nor systemically i11. H e was treated with v a n c o m y c i n (I g b.d. Iv) and gentamicin (80 m g t.i.d. IV). T h e next day ox63-4453/93/o2oi99+o3 $08.00/0
© I993 The British Society for the Study of Infection
200
W.I. AL-WALI
ET AL.
his temperature rose to 38 °C and he felt unwell. A swab taken at the exit site of the catheter the previous day yielded P. aeruginosa, Escherichia coli and Klebsiella pneumoniae. Since the strain of P. aeruginosa (PAI) was resistant to gentamicin ( M I C > 4mg/1), ceftazidime (2 g t.i.d.) was substituted. T h e catheter was removed the same day. Even so, two distinct areas of ecthyma gangrenosum developed around the exit site. Blood cultures were negative but culture of the tip of the Hickman catheter yielded P. aeruginosa. T h e patient eventually recovered after treatment with ceftazidime for a total of Io days, with complete healing of the ecthyma gangrenosum lesions. A swab taken from the original exit site 2 weeks after the patient's discharge from hospital grew P. aeruginosa (PA2), although the exit site did not appear to be infected. After a further period of I8 days, the patient developed a localised abscess over the site where the cuff was presumed to have been retained. T h e cuff was removed under local anaesthesia and sent for microbiological investigation. Pseudomonas aeruginosa (PA3) was again isolated. T h e patient was successfully treated with ceftazidime (I g t.i.d. IV) for 7 days. Antibiograms of strains PAI, PA2 and PA3, with seven antibiotics, differed only in gentamicin susceptibilities. T h e outer membrane protein profiles of these isolates, obtained by SDS P A G E were identical (Plate I). 7 Case 2
A 4I-year-old woman with acute myeloid leukaemia had three episodes of Hickman catheter-associated septicaemia caused by Bacillus sp., a coagulasenegative staphylococcus and Moraxella sp. Her single-lumen Hickman catheter was therefore pulled out but the Dacron cuff was retained. After 3 months, she was readmitted to hospital because of a discharge from the exit site of the Hickman catheter. She was not neutropenic and was initially treated with vancomycin (I g b.d. Iv). T h e retained cuff was visible through the wound at the exit site and was removed. A swab taken of the discharge at the exit site yielded P. aeruginosa although blood cultures were negative. T h e patient was treated successfully with a 7-day course of oral ciprofloxacin 75o mg b.d. Discussion
Discussion with the manufacturers of the Hickman catheters used in these patients did not reveal any clear recommendations for removal of cuffs, this being left to the discretion of individual clinicians. Although cuffs usually come out easily when catheters are removed, they may be retained. These two cases illustrate the pitfalls of failing to remove subcutaneous cuffs in patients with infections related to Hickman catheters. In the first case, despite appropriate antimicrobial therapy, a subcutaneous abscess developed, caused by P. aeruginosa and associated with the retained cuff. In the second patient, P. aeruginosa was not isolated during the time that the Hickman catheter was in use but may have been introduced directly into the wound after its removal. Alternatively, it may have seeded the retained cuff during an episode of bacteraemia. T h e bactericidal activity of both beta-lactams and aminoglycosides against P. aeruginosa is significantly reduced in the presence of a polymer surface
yournal of Infection
Plate I
97 66 45 31
22 14 PAl PA2 PA3 Plate I. Outer membrane protein profiles of the three Pseudomonas aeruginosa isolates in case I. Molecular weight markers (kDa) are indicated in the track on the far right.
W . I. AL-'~rALI ET AL.
(Facing p. 2oo)
Infection f r o m H i c k m a n catheter
201
c o m p a r e d to p l a n k t o n i c b a c t e r i a alone. 8'9 B i o f i l m - a s s o c i a t e d b a c t e r i a m a y p r o v i d e a n i d u s for i n f e c t i o n a n d m a y p r o l i f e r a t e o n c e t h e c o n c e n t r a t i o n o f a n t i b i o t i c s d e c r e a s e s (as in case I). T h e r e l a t i v e l y r e d u c e d m e t a b o l i c a c t i v i t y o f cells a s s o c i a t e d w i t h a b i o f i l m w h i c h m a y act as a b a r r i e r a g a i n s t a n t i b i o t i c s o r e v e n i n a c t i v a t e t h e m m a y e x p l a i n this a p p a r e n t a n t i b i o t i c r e s i s t a n c e . 1°' 1~ W e r e c o m m e n d t h a t t h e s u b c u t a n e o u s c u f f o n a H i c k m a n c a t h e t e r is r e m o v e d at t h e t i m e o f its r e m o v a l . A r e t a i n e d c u f f m a y b e t h e s o u r c e o f i n f e c t i o n in a p a t i e n t p r e s e n t i n g w i t h f e v e r f o l l o w i n g t h e r e m o v a l o f a H i c k m a n catheter. References
i. Prkchard AP, David JA. The Royal Marsden Hospital manual of clinical nursing procedures. 2nd edn. London: Harper and Row, 1988. 2. Kaye CG, Smith DR. Complications of central venous cannulation. Br Med J 1988; 297: 572-573 • 3. Riella M, Scribner B. Five years experience with a right atrial catheter for prolonged parenteral nutrition at home. Surg Gynecol Obstet 1976; 143: 205. 4- Thomas J, MacArthur R, Pierce G, Hermrech A. Hickman-Broviac catheters. Indications and resuhs. Am J Surg 198o; 14o: 791-796. 5. Kappers-Klunne M, Degener J, Stijnen T, Abels J. Complications from long term indwelling central venous catheters in haematologic patients with special reference to infection. Cancer 1989; 64: 1747-1752. 6. Cairo M, Spooner S, Sowden L, et al. Long term use of indwelling multi-purpose silastic catheters in paediatric cancer patients treated with aggressive chemotherapy. 07 Clin Onc 1986; 4: 784-788. 7. Lugtenberg B, Meijers J, Peters R, Van der Hoek P, Van Alphen L. Electrophoretic resolution of the major outer membrane protein of Escherichia coli KI2 into four bands. F E B S Lett 1975; 58: 254--258. 8. Nickel J'C, Ruseka I, Wright JB, Costerton JW. Tobramycin resistance of Pseudomonas aeruginosa cells growing as a biofilm on urinary catheter material. Antimicrob Agents Chemother 1985; 27: 619-624. 9. Brown MRW, Allison DG, Gilbert P. Resistance of bacterial biofilms to antibiotics: a growth related effect? 07 Antimicrob Chemother I988 ; 22:777-783. IO. Craddock CF, Edwards R, Finch RG. Pseudomonas peritonitis in continuous ambulatory peritoneal dialysis: laboratory predictors of treatment failure. 07 Hosp Infect 1987; IO: 179-186. II. Giwercman B, Jensen ET, Hoiby N, Kharazmi A, Costerton JW. Induction of betalactamase production in Pseudomonas aeruginosa biofilm. Antimicrob Agents Chemother I 9 9 I ; 35: 1008-1010.