Invasive medical devices are commonly used in hospitalized children. They result in more than 250,000 infections each year in the United States.1 A catheter-related bloodstream infection (CRBSI) is defined as bacteremia or fungemia in a patient with an intravascular catheter that is the presumed source of infection. This definition belies the challenges a clinician faces in accurately diagnosing CRBSI in children, including difficulties in diagnostic testing and variability in epidemiology based on age, intravascular device used, infusate being given, and underlying clinical condition.2 Additionally, central venous catheters (CVCs) pose other infectious complications aside from CRBSI, including local infection at exit sites, and they can become secondarily infected through seeding of bacteria due to bacteremia originating from infection at a distant site.
Nationwide approximately 4700 children are hospitalized for initial placement of cerebrospinal fluid (CSF) shunts annually, with more than 2400 children hospitalized for shunt-related infections at a cost of over $250 million.3 The most common CNS shunt placed in children is the ventriculoperitoneal (VP) shunt.4 These devices breach natural barriers to infection and provide access for bacteria to enter and proliferate in a site relatively sequestered from the immune system and rich in nutrients. Diagnosis and management of these infections usually involves invasive procedures and prolonged hospitalization, with marked burdens on children and their families, including prolonged hospital stays, potential morbidity, and significant healthcare costs.
Pediatric hospitalists care for a population of children that is increasingly medically complex,5 often including children in the neonatal intensive care unit (NICU) and/or pediatric intensive care unit (PICU), both sites of care where intravascular and CNS catheters are commonly used. Knowledge of optimal diagnostic and treatment strategies for device-related infections is a vital skill for hospitalists. This chapter will help provide information clinicians can use to help develop expertise in the management of infectious complications from these devices.
CENTRAL VENOUS CATHETER-RELATED INFECTIONS
Pediatric bloodstream infections account for approximately 13.5% of all nosocomial bloodstream infections,6 at per-episode cost of approximately $39,000 per episode in PICU patients.7 The majority of nosocomial bacteremias present in the setting of a central venous catheter.8 Risk of infection is present both for CVCs inserted directly into a central vein as well as peripherally inserted central venous catheters (PICCs), which are more commonly used outside of the intensive care unit.9,10
Multiple factors influence the risk of infection, including patient age, medical comorbidities, site of device placement, types of infusate being administered, frequency of times the device is accessed, duration the CVC is in place, and the device type. Table 107-1 lists the most commonly used CVC types in pediatrics. In general, tunneled catheters are a lower long-term risk for infection than non-tunneled catheters, with implanted venous access devices such as portacaths having the lowest rates of infection.11