|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
© 1999 American Society for Clinical Oncology Hickman Catheter–Related Infections in Neutropenic Patients: Insertion in the Operating Theater Versus Insertion in the Radiology SuiteFrom the Departments of Medical Microbiology and Infectious Diseases, Hematology, Radiology, and Epidemiology and Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands. Address reprint requests to Jan L. Nouwen, MD, Erasmus University Medical Center Rotterdam, Department of Microbiology and Infectious Diseases, Dr Molewaterplein 40, 3015 GD Rotterdam, the Netherlands; email nouwen{at}bacl.azr.nl
PURPOSE: To determine the influence of microbial air quality during Hickman catheter insertion in the operating theater versus insertion in the radiology suite on the incidence of catheter-related infections (CRIs). PATIENTS AND METHODS: Hemato-oncologic patients with prolonged neutropenia on antimicrobial prophylaxis were entered onto the study. Catheters were inserted by experienced radiologists under sonographic and fluoroscopic guidance. RESULTS: Forty-eight Hickman catheters in 39 patients were inserted (23 in the operating theater, 25 in the radiology suite). CRIs were seen in 16 catheters (33%; six per 1,000 catheter days; eight in each group). Local infections were found in nine catheters (22%; six in the operating theater v three in the radiology suite; not significant [NS]), catheter-related bacteremia was found in 10 (29%; three in the operating theater v seven in the radiology suite; NS). Coagulase-negative staphylococci (CoNS) caused all CRIs. Despite early vancomycin therapy, 11 (69%; four in the operating room group v seven in the radiology suite group; NS) of the catheters with CRIs had to be removed prematurely. At 90 days after insertion, catheter survival was 78% and 60% (NS) for the operating room and radiology suite, respectively. Multivariate analysis showed that neutropenia increased the CRI risk 20-fold (P = .004) and was strongly related to premature catheter removal owing to infection (relative risk = 11.9; P = .009). Neutropenia on the day of insertion was also significantly correlated with CRI (P = .04) and premature catheter removal owing to infection (P = .03). Serial cultures of blood, exit site, and catheter hub did not predict the development of CRI. CONCLUSION: The high incidence of Hickman CRI caused by CoNS was not associated with insertion location (operating theater v radiology suite). Neutropenia, including neutropenia on the day of insertion, was a significant risk factor for CRI and infection-related catheter removal.
CENTRAL VENOUS CATHETERS are increasingly inserted percutaneously by radiologists instead of surgeons, guided by radiologic techniques. These imaging techniques have made it possible to combine a very high success rate (approaching 100%) with a very low rate of insertion-related complications.1-7 However, catheter-related infection (CRI) remains a major problem.8-21 In our institute, Hickman catheters in hemato-oncologic patients have been inserted by radiologists in a radiology suite designed for invasive procedures and under sonographic and fluoroscopic guidance since 1991.3 In a retrospective study, a high rate of Hickman catheter–related infections was found at our hematology department: 40% of Hickman catheters had to be removed prematurely because of infections during the period of 1991 to 1994 (median catheter survival of only 28 days).22 In two earlier studies, performed at our institution in the 1980s, catheter survival was much better (median, 46.5 and 104 days, respectively). However, premature removal rates due to CRI were also high at that time (30% and 38%).11,12 Strict implementation of protocols concerning Hickman catheter insertion procedures, handling, and caring policies was subsequently reinforced. However, these measures did not result in a decrease in the incidence of Hickman CRI. In contrast to the recent technical developments in the field of interventional radiology, the design of most radiology suites has not changed. It has to be questioned whether radiologic interventions can be performed safely in rooms that do not meet the standards of operating theaters with regard to microbiologic air quality. The insertion of Hickman catheters in hemato-oncologic patients is an invasive procedure that carries a high risk of infection. Because contamination of the insertion site may be related to the air quality (ie, the level of microbial contamination) of the room in which the procedure is performed, we conducted a prospective study of insertion of Hickman catheters in the radiology suite versus catheter insertion performed in the operating theater.
Patients From August 1994 to October 1995, all consecutive hemato-oncologic patients scheduled to receive intensive chemotherapy with an expected neutropenic episode (neutrophils < 0.5 x 109/L) of more than 1 week were invited to participate in the study. All patients received selective antimicrobial prophylaxis for aerobic bacterial and fungal pathogens (ciprofloxacin and fluconazole orally and amphotericin B inhalations). Patients were excluded if they had signs of active infection or were treated with vancomycin within 3 days of randomization. Patients were randomly assigned to Hickman catheter insertion in the operating theater or the radiology suite by opening of envelopes containing computer-generated random numbers. Only one Hickman catheter per patient per episode was inserted. If the catheter was lost due to noninfectious complications and the patient was still in need of a long-term central venous access, a new randomization procedure was performed. Patients were followed-up for at least 6 months or until catheter removal.
Insertion Procedure In the operating theater, air quality was assured through the use of high-efficiency particulate air filters, laminar downflow, and a ventilation frequency of more than 15 air changes per hour. In the dedicated radiology suite, the ventilation frequency was 12 to 15 air changes per hour, but neither high-efficiency particulate air filters nor laminar airflow were used.
Hickman Catheter Handling and Culturing In case of fever, the patient was meticulously and repeatedly examined. The Hickman catheter exit site and tunnel were inspected by the attending physician. Extra cultures from the exit site and hub interior, plus at least two blood culture sets via both Hickman catheter channels and peripheral vein each, were taken. As long as fever persisted, these investigations were repeated daily. When a CRI was suspected, vancomycin treatment was initiated immediately (1 g intravenously (IV) tid when the patient weighed more than 70 kg and had a fluid intake of more than 3 L/d; otherwise vancomycin was given 1 g IV bid). Dosage was adjusted if there was renal failure and on the basis of peak (target range, 20 to 40 mg/L) and through (< 15 mg/L) values measured twice weekly, beginning 24 to 48 hours after starting vancomycin. When a Hickman catheter had to be removed (see Criteria for Premature Removal of Hickman Catheters), the reason for removal was documented. The Hickman catheter was removed by a surgeon, and at that time, the tip, tunnel, and hub segments were cultured separately. Three to 7 days after removal, the insertion site and the ipsilateral vena subclavia and vena jugularis were investigated using colorflow Doppler sonography to screen for the presence of intravascular thrombosis. If thrombosis was detected, two blood culture sets were drawn by venepuncture, irrespective of the patient's condition.
Definitions of Hickman Catheter–Related Infections Hickman catheter–related bacteremia was considered probable if one or more blood cultures drawn by venepuncture together with one or more blood cultures from Hickman catheter channels grew coagulase negative staphylococci (CNS) or Corynebacterium species and if fever or local symptoms of CRI were present. The Hickman catheter was considered to be colonized if two blood cultures from Hickman catheter channels were positive and at least two blood cultures drawn from venepuncture were negative within 3 days. In addition, the tip of the removed Hickman catheter should grow the same microorganisms in the absence of a diagnosis of Hickman catheter–related infection. Blood cultures (via Hickman catheter or venepuncture) were considered contaminated if only a single blood culture bottle grew CNS or Corynebacterium species in the absence of signs and symptoms of CRI. In such circumstance, additional blood cultures were taken. Local signs of Hickman CRI were defined as redness plus painful swelling and/or exudation of the exit site only, tunnel only (> 2 cm from the exit site), and combined exit site and tunnel. Thrombosis was diagnosed sonographically. Infection of the intravascular thrombus was considered proven if there were positive blood cultures with the same microorganisms persisting after the removal of the Hickman catheter, despite appropriate antibiotic treatment and in the absence of other possible foci of infection. Infection of the intravascular thrombus was considered to be probable if there was persisting fever after removal of the Hickman catheter, despite appropriate antibiotic treatment and in the absence of other possible foci of infection and after excluding drug fever.
Criteria for Premature Removal of Hickman Catheters
Microbiologic Investigations Tip and tunnel segments of removed Hickman catheters were cultured using the semiquantitative roll-plate technique of Maki et al.26 Tip, tunnel, and hub segments of removed Hickman catheter were cultured quantitatively after flushing according to the method of Linares et al.27 After processing, all three segments were finally cultured in thioglycolate broth (brewer modified). Vancomycin serum concentrations were measured using TdxFLx kits and equipment (Abbott Diagnostics, Amsterdam, the Netherlands).
Statistical Evaluation Percentages and continuous data were compared by Fisher's exact test and Mann-Whitney's test, respectively. Kaplan-Meier curves and the log-rank test were used to compare catheter survival curves. The influence of potential prognostic factors regarding catheter survival and the development of Hickman catheter–related infections were evaluated using Cox regression, with the occurrence of neutropenia as a time-dependent variable.28 Catheter survivals in patients whose catheters were removed for reasons other than CRI were considered as censored in the analysis.
Patient Characteristics and Insertion Procedure Forty-eight Hickman catheters were inserted in 39 patients: 32 patients received one catheter, five patients received two catheters, and two patients received three catheters. The two groups were well balanced with regard to age and sex. However, in the radiology suite group, more patients with acute leukemia were included, and in the operating theater group, more patients with non–Hodgkin's lymphoma were included (Table 1). The duration of the first neutropenic episode after catheter insertion was significantly longer in the operating theater group than it was in the radiology suite group. Total number of days with neutropenia while on study was also longer in the operating theater group, although this difference did not reach statistical significance.
The insertion procedure was successful in all but one case (98% success rate). In one case, the contralateral vena subclavia had to be used subsequently. No major complications (pneumothorax, hematothorax, arterial puncture or bleeding, perforation of the vena subclavia, and so on) were observed. In 41 procedures (85%), three or fewer attempts were needed for successful venous access. The median time needed for insertion was 20 minutes in the operating theater versus 15 minutes in the radiology suite group (P = .002). Thirty catheters were inserted by radiologist A and 18 were inserted by radiologist B. The median level of microbial contamination of the air was three-fold lower in the operating theater group compared with the radiology suite (9.5 v 27.5 colony-forming units [CFU]/m3; P = .001).
Infections and Risk Factors
When the incidence of CRI was considered for the two inserting radiologists separately, no significant differences were found: 11 of 30 catheters for radiologist A (36%); five of 18 catheters for radiologist B (28%). Also, no differences in infection-free survivals between the two radiologists were observed. Furthermore, there was no relation between number of insertion attempts and the risk for subsequently developing CRI. Neutropenia was the only significant risk factor associated with the development of Hickman CRI. During periods of neutropenia, the CRI risk was 20-fold higher (P = .004). Interestingly, the presence of neutropenia on the day of insertion was also significantly correlated with CRI (P = .04; Fig 1B). Twenty-eight catheters only lasted one neutropenic episode or less, whereas 20 survived for two or more neutropenic episodes. In 12 of 48 catheter episodes (25%), CRI developed during the first neutropenic episode, whereas in four of 20 catheter episodes, CRI developed during the following neutropenic episodes (P = .14). Thirty-six patients (15 in the operating theater v 21 in the radiology suite) were not neutropenic on the day of insertion; nine CRIs occurred in these patients (three in the operating theater v six in the radiology suite; odds ratio (OR), 0.63 [95% confidence interval (CI), 0.13 to 3.0; NS]). Twenty-three patients (11 in the operating theater v 12 in the radiology suite) did not become neutropenic in the first week after insertion; seven CRIs occurred in these patients (two v five; OR, 0.31 [95% CI, 0.046 to 2.1; NS]). In both instances, Kaplan-Meier survival analysis again showed no significant difference between both groups with regard to their infection-free survivals (92% v 65% at 90 days [P = .14] and 90% v 64% [P = .22] at 90 days for the operating theater group and the radiology suite group, respectively). In only two of 16 CRIs, hub cultures were positive before or at the onset of infection. More than 4,000 serial screening cultures of exit site, hub, and blood were performed. The positive and negative predictive values (PV+ and PV-, respectively) of these serial screening cultures for the subsequent development of CRI were as follows: hub PV+ = 33%, PV- = 63%; exit site PV+ = 50%, PV-, 74%; and blood cultures via the Hickman catheter, PV+ = 36%, PV- = 81%.
Catheter Survival
Multivariate analysis of the data showed that neutropenia was the only significant factor related to the risk of infection-related removal of the catheter (relative risk [RR] = 11.9 [P = .009, 95% CI, 1.6 to > 100]). No significant effect was found for insertion location (RR [radiology suite v operating theater] = 2.4 [P = .26; 95% CI, 0.7 to 8.7]), age, sex, underlying disease, microbial quality of the air, or inserting radiologist. Again, neutropenia on the day of insertion was significantly correlated with infection-related catheter removal (P = .03; Fig 2B). Kaplan-Meier survival analysis for patients who were not neutropenic on the day of insertion and for those who were not neutropenic within 1 week after insertion did not differ significantly between the operating theater versus the radiology suite group (90% v 66% [P = .12] and 85% v 64% [P = .24] at 90 days for the operating theater and the radiology suite, respectively).
Major Complications of Hickman Catheters
Infectious complications other than CRI were seen in 16 catheters. In nine catheters, blood cultures were considered to be contaminated or the catheter was considered to be colonized: cultures showed CNS in all cases (Table 2). In seven episodes, bacteremia was related to chemotherapy-induced mucositis of the digestive tract: in four cases, alpha-hemolytic streptococci were cultured, in one case, Stomatococcus mucilogenes was encountered, and in two cases, Candida species was encountered. In both latter cases, an extensive esophageal candidiasis was found. Surveillance cultures showed large numbers of the same Candida species; candidemia persisted after catheter removal and catheter tip cultures were negative. One patient died shortly after the evolvement of candidemia, the other patient survived. Three patients died while on study (two in the operating theater v one in the radiology suite; P = .66) (Table 2); Hickman CRI was probably related to the death of one patient. Four patients (two in both groups) died within 30 days after catheter removal from progressive hemato-oncologic disease. None died from CRI.
It could be argued that Hickman-type catheter insertion in a radiology suite carries a higher risk of infection than does insertion in the operating theater, because less stringent aseptic conditions, including microbial air quality, exist in the former.29 However, to date, no evidence to this effect has been published. In one study,7 the incidence of CRI of catheters inserted percutaneously by trained radiologists under imaging guidance in hematologic patients was reported to be higher (3.2 per 1,000 catheter days) than in other previous studies concerning catheters inserted in the operating theater (0.6 to 2.5 per 1,000 catheter days).13,30-33 That air conditions can influence the infection rate has been shown earlier in studies concerning infections after orthopedic procedures in which prosthetic materials were implanted.34,35 Therefore, in the United Kingdom, Switzerland, and the United States, guidelines exist regarding the number of CFUs per m3 of air in operating theaters that are considered acceptable for different surgical procedures: less than 10 CFU/m3 for orthopedic operations when implanting prosthetic materials (United Kingdom and Switzerland) or less than 70 CFU/m3 for infection-prone procedures (United States) and less than 200 CFU/m3 for other types of operations.36 In our study, the microbial air quality was quite acceptable and in all but one occasion was below 100 CFU/m3. Although microbial air counts in the radiology suite (median, 27.5 CFU/m3) were shown to be higher when compared with those from the operating theater (median, 9.5 CFU/m3), no effect on the incidence of CRI nor on the infection-related catheter removal rate could be demonstrated. Also, multivariate analysis demonstrated that air conditions were not an independent risk factor for CRI or infection-related catheter removal rate in this study. However, it should be stressed that, potentially, the microbial air quality level in the two insertion rooms in this study will not and cannot be achieved in other hospitals, countries, and so on. All catheters were inserted by two experienced interventional radiologists using imaging guidance techniques and under strict aseptic conditions. No puncture-related complications were seen, and all catheters but one (98%) were inserted successfully. The median total duration of the insertion procedure was only 17 minutes and was slightly though significantly shorter in the radiologists' own radiology suite. No differences in the rate of either mechanical or infectious complications between the two radiologists could be observed. The incidence of infections, catheter survival, and premature catheter removal rates were comparable. Despite early vancomycin therapy, 11 of 16 (69%) Hickman catheters associated with a CRI had to be removed because of persistence of clinical signs of infection. This is in sharp contrast with other studies reporting catheter salvage rates of 70% or more.13,17,20,21,30,31,37-41 Genotyping and virulence studies are in progress to evaluate the possibility that particularly virulent strains of CNS are a factor in this respect. Persistence of certain strains of CNS within patients in this hematology ward has been demonstrated previously.42 Notably, 75% of CRIs developed in the first neutropenic episode, and all infections occurred within 2 months after Hickman catheter insertion. Other studies have also observed that such infections usually developed early after insertion.43 In our study, the only independent risk factors for the development of CRI and for infection-related removal of the catheter were neutropenia as such and, importantly, neutropenia on the day of catheter insertion. In another study of infections in cancer patients with tunneled central-venous catheters, Howell et al10 also found neutropenia to be the only independent risk factor for catheter-related infections (RR = 15.1) and sepsis of unknown origin (RR = 10.3). However, the incidence of CRI in their study was only 1.0 per 1,000 catheter days. In contrast to others,18,20,32,44,45 neither insertion location nor underlying illness, age, sex, or inserting radiologist were independent risk factors in a multivariate analysis. The incidence of Hickman CRI was higher than that which has been reported overall in the literature.10,18,30-33,37,46 However, recent literature and data concerning long-indwelling central venous catheters in neutropenic patient populations show incidences of CRI up to 8.0 per 1,000 catheter days and premature removal rates for infections in 0% to 21%.9,15,17-21 In contrast to others,21,27 we found screening cultures of exit site, catheter hub, and blood cultures not to be predictive for CRI. A possible explanation could be that, in this study, screening cultures were actually performed prospectively before the onset of CRI, whereas other studies, only performed screening cultures when CRI already had developed. Only eight hub cultures grew CNS, whereas 152 skin and exit site cultures were positive. A reason for this might be that in this specific patient population at our institute, another pathogenic route in the development of CRI occurs. All pathogens isolated in Hickman CRI were methicillin-resistant CNS, but it remained unclear in what way these organisms cause this high rate of infections. In conclusion, this study could not demonstrate a relation between insertion location and infectious complications. However, the power of the study to demonstrate moderate differences is limited by the relatively small sample size. The advantages of Hickman catheter insertion in the radiology suite by interventional radiologists using imaging guidance, when performed under strict aseptic conditions, so far outweigh the potentially higher risk for CRIs caused by the inferior microbial air quality when compared with the operating theater. Because neutropenia as such as well as neutropenia on the day of insertion seem to be major risk factors for the development of Hickman CRI, intervention measures will have to take these aspects into consideration. Hickman catheter insertion while the patient is not yet neutropenic might thus reduce the rate of infectious complications to some extent.
We thank Peter de Man, microbiologist, for his expert advice.
1. Denys BG, Uretsky BF, Reddy PS, et al: An ultrasound method for safe and rapid central venous access. N Engl J Med 324:566, 1991 (letter) [Medline]
2.
Skolnick ML: The role of sonography in the placement and management of jugular and subclavian central venous catheters. AJR Am J Roentgenol 163:291-295, 1994
3.
Lameris JS, Post PJ, Zonderland HM, et al: Percutaneous placement of Hickman catheters: Comparison of sonographically guided and blind techniques. AJR Am J Roentgenol 155:1097-1099, 1990 4. Page AC, Evans RA, Kaczmarski R, et al: The insertion of chronic indwelling central venous catheters (Hickman lines) in interventional radiology suites. Clin Radiol 42:105-109, 1990[Medline]
5.
Selby JB, Tegtmeyer CJ, Amodeo C, et al: Insertion of subclavian hemodialysis catheters in difficult cases: Value of fluoroscopy and angiographic techniques. AJR Am J Roentgenol 152:641-643, 1989
6.
Robertson LJ, Mauro MA, Jaques PF: Radiologic placement of Hickman catheters. Radiology 170:1007-1009, 1989
7.
Cockburn JF, Eynon CA, Virji N, et al: Insertion of Hickman central venous catheters by using angiographic techniques in patients with hematologic disorders. AJR Am J Roentgenol 159:121-124, 1992 8. Press OW, Ramsey PG, Larson EB, et al: Hickman catheter infections in patients with malignancies. Medicine (Baltimore) 63:189-200, 1984[Medline] 9. Blacklock HA, Pillai MV, Hill RS, et al: Use of modified subcutaneous right-atrial catheter for venous access in leukaemic patients. Lancet 1:993-994, 1980[Medline] 10. Howell PB, Walters PE, Donowitz GR, et al: Risk factors for infection of adult patients with cancer who have tunneled central venous catheters. Cancer 75:1367-1375, 1995[Medline] 11. Kappers-Klunne MC, Degener JE, Stijnen T, et al: Complications from long-term indwelling central venous catheters in hematologic patients with special reference to infection. Cancer 64:1747-1752, 1989[Medline] 12. Kappers-Klunne MC, Degener JE: Complications from long-term indwelling central venous catheters, with special reference to infections. Neth J Med 28:192-196, 1985[Medline]
13.
Clarke DE, Raffin TA: Infectious complications of indwelling long-term central venous catheters. Chest 97:966-972, 1990 14. Larson EB, Wooding M, Hickman RO: Infectious complications of right atrial catheters used for venous access in patients receiving intensive chemotherapy. Surg Gynecol Obstet 153:369-373, 1981[Medline] 15. Begala JE, Maher K, Cherry JD: Risk of infection associated with the use of Broviac and Hickman catheters. Am J Infect Control 10:17-23, 1982[Medline] 16. Claessen KA, de Vries JT, Huisman SJ, et al: Long-term venous access with a Hickman catheter: Complications and patient satisfaction. Neth J Surg 42:47-49, 1990[Medline] 17. Darbyshire PJ, Weightman NC, Speller DC: Problems associated with indwelling central venous catheters. Arch Dis Child 60:129-134, 1985[Abstract] 18. Keung YK, Watkins K, Chen SC, et al: Increased incidence of central venous catheter-related infections in bone marrow transplant patients. Am J Clin Oncol 18:469-474, 1995[Medline] 19. Newman KA, Reed WP, Schimpff SC, et al: Hickman catheters in association with intensive cancer chemotherapy. Support Care Cancer 1:92-97, 1993[Medline] 20. Rotstein C, Brock L, Roberts RS: The incidence of first Hickman catheter-related infection and predictors of catheter removal in cancer patients. Infect Control Hosp Epidemiol 16:451-458, 1995[Medline] 21. Weightman NC, Simpson EM, Speller DC, et al: Bacteraemia related to indwelling central venous catheters: Prevention, diagnosis and treatment. Eur J Clin Microbiol Infect Dis 7:125-129, 1988[Medline] 22. Bakker J, van Overhagen H, Wielenga JJ, et al: Infectious complications of radiologically inserted Hickman catheters in patients with hematologic disorders. Cardiovasc Intervent Radiol 21:116-121, 1998[Medline] 23. American Society for Microbiology: Clinical Microbiology Procedures Handbook. Washington, DC, American Society for Microbiology, 1992 24. Raad II, Hohn DC, Gilbreath BJ, et al: Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol 15:231-238, 1994[Medline] 25. Maki DG: Yes, Virginia, aseptic technique is very important: Maximal barrier precautions during insertion reduce the risk of central venous catheter-related bacteremia. Infect Control Hosp Epidemiol 15:227-230, 1994 (editorial)[Medline] 26. Maki DG, Weise CE, Sarafin HW: A semiquantitative culture method for identifying intravenous catheter-related infection. N Engl J Med 296:1305-1309, 1977[Abstract]
27.
Linares J, Sitges-Serra A, Garau J, et al: Pathogenesis of catheter sepsis: A prospective study with quantitative and semiquantitative cultures of catheter hub and segments. J Clin Microbiol 21:357-360, 1985 28. Cox DR: Regression models and life tables. J Roy Stat Soc B34:187-220, 1972
29.
Adam A: Insertion of long term central venous catheters: Time for a new look. BMJ 311:341-342, 1995 (editorial) 30. Abrahm JL, Mullen JL: A prospective study of prolonged central venous access in leukemia. JAMA 248:2868-2873, 1982[Abstract] 31. Dawson S, Pai MK, Smith S, et al: Right atrial catheters in children with cancer: A decade of experience in the use of tunneled, exteriorized devices at a single institution. Am J Pediatr Hematol Oncol 13:126-129, 1991[Medline] 32. Fuchs PC, Gustafson ME, King JT, et al: Assessment of catheter-associated infection risk with the Hickman right atrial catheter. Infect Control 5:226-230, 1984[Medline] 33. Harrington KJ, Kelly SA, Pandha HS, et al: An audit of Hickman catheter use in patients with solid tumors. Clin Oncol (R Coll Radiol) 6:288-293, 1994[Medline] 34. Lidwell OM, Lowbury EJ, Whyte W, et al: Effect of ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee replacement: A randomized study. Br Med J (Clin Res Ed) 285:10-14, 1982 35. Lidwell OM, Elson RA, Lowbury EJ, et al: Ultraclean air and antibiotics for prevention of postoperative infection: A multicenter study of 8,052 joint replacement operations. Acta Orthop Scand 58:4-13, 1987[Medline] 36. Whyte W, Lidwell OM, Lowbury EJ, et al: Suggested bacteriological standards for air in ultraclean operating rooms. J Hosp Infect 4:133-139, 1983[Medline] 37. Hendrick AM, Wilkinson A: Infective complications of prolonged central venous (Hickman) catheterization. South Med J 78:639-642, 1985[Medline] 38. Raad I, Davis S, Khan A, et al: Impact of central venous catheter removal on the recurrence of catheter-related coagulase-negative staphylococcal bacteremia. Infect Control Hosp Epidemiol 13:215-221, 1992[Medline] 39. Riikonen P, Saarinen UM, Lahteenoja KM, et al: Management of indwelling central venous catheters in pediatric cancer patients with fever and neutropenia. Scand J Infect Dis 25:357-364, 1993[Medline] 40. Simon C, Suttorp M: Results of antibiotic treatment of Hickman-catheter-related infections in oncological patients. Support Care Cancer 2:66-70, 1994[Medline] 41. Ulz L, Petersen FB, Ford R, et al: A prospective study of complications in Hickman right-atrial catheters in marrow transplant patients. JPEN J Parenter Enteral Nutr 14:27-30, 1990[Abstract] 42. van Belkum A, Kluytmans JAJW, van Leeuwen W, et al: Monitoring persistence of coagulase-negative staphylococci in a hematology department using phenotypic and genotypic strategies. Infect Control Hosp Epidemiol 17:660-667, 1996[Medline] 43. Raad I, Darouiche R, Hachem R, et al: The broad-spectrum activity and efficacy of catheters coated with minocycline and rifampin. J Infect Dis 173:418-424, 1996[Medline] 44. Raad I, Davis S, Becker M, et al: Low infection rate and long durability of nontunneled silastic catheters: A safe and cost-effective alternative for long-term venous access. Arch Intern Med 153:1791-1796, 1993[Abstract] 45. Keung YK, Watkins K, Chen SC, et al: Comparative study of infectious complications of different types of chronic central venous access devices. Cancer 73:2832-2837, 1994[Medline] 46. Mullan FJ, Hood JM, Barros D 'Sa AA: Use of the Hickman catheter for central venous access in patients with haematological disorders. Br J Clin Pract 46:167-170, 1992[Medline] Submitted July 24, 1998; accepted November 24, 1998. This article has been cited by other articles:
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 1999 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
TOP
ABSTRACT
INTRODUCTION
