Q:

9/13/2012
I am l Looking for evidence based information addressing the statement in the IDF Guide for Nurses that reads "The American Academy of Allergy and Immunology strongly discourages the use of permanent indwelling ports or central venous lines in antibody deficient patients due to the risk of infection and thrombotic events." I am hoping you can provide the research to support this statement as I need to present this position to my patients as well as my nursing manager/institution. Thank you for your time

A:

Thank you for your inquiry.

Obviously, there is strong theoretical rationale to avoid any indwelling catheter or central venous line in immunodeficient patients. And the literature is replete with studies documenting the risk of infection due to indwelling intravascular devices. For your convenience I have copied abstracts from a few of these studies below. In my opinion these references should be sufficient to support you effort, but if you need further documentation the references below will lead you to numerous other articles noting the risk of infection resulting from the use of indwelling intravascular devices. Although these references have not used hypogammaglobulinemic patients specifically, many have studied immunodeficient patients, and there is no reason to believe that the data obtained would not apply to patients with hypogammaglobulinemia

Thank you again for your inquiry and we hope this response is helpful to you.

BMC Microbiol. 2012 Jun 8;12(1):102. [Epub ahead of print]
Staphylococcus epidermidis recovered from indwelling catheters exhibit enhanced biofilm dispersal and "self-renewal" through downregulation of agr.
Dai L, Yang L, Parsons C, Findlay VJ, Molin S, Qin Z.
Abstract
Background: In recent years, Staphylococcus epidermidis (Se) has become a major nosocomial pathogen and the most common cause of infections of implanted prostheses and other indwelling devices. This is due in part to avid biofilm formation by Se on device surfaces. However, it still remains unknown that how the process of Se biofilm development is associated with relapsed infection in such patients.
Results: We have identified clinical Se isolates displaying enhanced biofilm dispersal and self-renewal relative to reference strain. These isolates also exhibit enhanced initial cell attachment, extracellular DNA release, cell autolysis and thicker microcolonies during biofilm development relative to reference strain. Our genetic analyses suggest that these clinical isolates exhibit significant downregulation of RNAIII, the effector molecule of the agr quorum sensing system, and upregulation of the autolysin gene atlE. Isogenic deletion of the agr system in Se 1457 confirmed that agr negatively regulating atlE resulted in enhanced initial cell attachment, extracellular DNA release, cell autolysis and biofilm formation abilities. In contrast, double deletion of agr and atlE significantly abolished these features.
Conclusions: Collectively, these data reveal the role of agr system in long-term biofilm development and pathogenesis during Se caused indwelling devices-related relapsed infection

J Infect Dis. 2004 Oct 15;190(8):1498-505. Epub 2004 Sep 15.
Increased colonization of indwelling medical devices by quorum-sensing mutants of Staphylococcus epidermidis in vivo.
Vuong C, Kocianova S, Yao Y, Carmody AB, Otto M.
Source
Laboratory of Human Bacterial Pathogenesis, Rocky Mountain Laboratories, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Hamilton, Montana, USA.
Abstract
Infections with the leading nosocomial pathogen Staphylococcus epidermidis are characterized by biofilm development on indwelling medical devices. We demonstrate that the quorum-sensing regulator agr affects the biofilm development of S. epidermidis in an unexpected fashion and is likely involved in promoting biofilm detachment. An isogenic agr mutant showed increased biofilm development and colonization in a rabbit model. In addition, nonfunctional agr occurred more frequently among strains isolated from infections of joint prostheses. Lack of functionality was based on mutations, including insertion of an IS256 element. Relative to other bacterial pathogens, quorum sensing in S. epidermidis thus has a different role during biofilm development and biofilm-associated infection. Our results indicate that disabling agr likely enhances the success of S. epidermidis during infection of indwelling medical devices. The permanent elimination of quorum-sensing regulation used by S. epidermidis represents a surprising and unusual means to adapt to a certain environment and type of infection

Eur J Clin Microbiol Infect Dis. 2012 Jun;31(6):1027-33. Epub 2011 Sep 10.
Bacteremic complications of intravascular catheter tip colonization with Gram-negative micro-organisms in patients without preceding bacteremia.
van Eck van der Sluijs A, Oosterheert JJ, Ekkelenkamp MB, Hoepelman IM, Peters EJ.
Source
Department of Internal Medicine and Infectious Diseases, University Medical Center, Utrecht, The Netherlands.
Abstract
Although Gram-negative micro-organisms are frequently associated with catheter-related bloodstream infections, the prognostic value and clinical implication of a positive catheter tip culture with Gram-negative micro-organisms without preceding bacteremia remains unclear. We determined the outcomes of patients with intravascular catheters colonized with these micro-organisms, without preceding positive blood cultures, and identified risk factors for the development of subsequent Gram-negative bacteremia. All patients with positive intravascular catheter tip cultures with Gram-negative micro-organisms at the University Medical Center, Utrecht, The Netherlands, between 2005 and 2009, were retrospectively studied. Patients with Gram-negative bacteremia within 48 h before catheter removal were excluded. The main outcome measure was bacteremia with Gram-negative micro-organisms. Other endpoints were length of the hospital stay, in-hospital mortality, secondary complications of Gram-negative bacteremia, and duration of intensive care admission. A total of 280 catheters from 248 patients were colonized with Gram-negative micro-organisms. Sixty-seven cases were excluded because of preceding positive blood cultures, leaving 213 catheter tips from 181 patients for analysis. In 40 (19%) cases, subsequent Gram-negative bacteremia developed. In multivariate analysis, arterial catheters were independently associated with subsequent Gram-negative bacteremia (odds ratio [OR] = 5.00, 95% confidence interval [CI]: 1.20-20.92), as was selective decontamination of the digestive tract (SDD) (OR = 2.47, 95% CI: 1.07-5.69). Gram-negative bacteremia in patients who received SDD was predominantly caused by cefotaxime (part of the SDD)-resistant organisms. Mortality was significantly higher in the group with subsequent Gram-negative bacteremia (35% versus 20%, OR = 2.12, 95% CI: 1.00-4.49). Patients with a catheter tip colonized with Gram-negative micro-organisms had a high chance of subsequent Gram-negative bacteremia from any cause. This may be clinically relevant, as starting antibiotic treatment pre-emptively in high-risk patients with Gram-negative micro-organisms cultured from arterial intravenous catheters may be beneficial

Clin Microbiol Infect. 2011 Nov;17(11):1711-6. doi: 10.1111/j.1469-0691.2011.03504.x. Epub 2011 May 20.
Predictors of catheter-related gram-negative bacilli bacteraemia among cancer patients.
Cairo J, Hachem R, Rangaraj G, Granwehr B, Raad I.
Source
Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M. D. Anderson Cancer Centre, Houston, TX 77030, USA.
Abstract
Gram-negative bacillary bacteraemia (GNB) is associated with high morbidity and mortality among cancer patients. We conducted this study to determine the risk factors that may predict the catheter as the source of GNB in cancer patients. From July 2005 to December 2006 all 266 cancer patients with GNB and central venous catheters (CVCs) at The University of Texas M. D. Anderson Cancer Centre in Houston, were classified as catheter-related bloodstream infection (CRBSI) according to Infectious Diseases Society of America criteria. We compared clinical and microbiological features of CRBSIs and non-CRBSIs. We identified 78 CRBSIs and 126 non-CRBSIs. On univariate analysis, polymicrobial bacteraemia, Stenotrophomonas maltophilia bacteraemia, and more than 1000 CFUs in CVC blood cultures, were more common among CRBSI cases. Escherichia coli bacteraemia, haematologic cancer, neutropenia and prior antibiotic use were more common among non-CRBSI cases. On multivariate analysis, S. maltophilia bacteraemia (odds ratio (OR), 5.78; 95% confidence interval (CI), 1.47-22.78; p 0.045), polymicrobial bacteraemia (OR, 4.04; 95% CI, 1.56-10.44; p 0.042), and more than 1000 CFUs from CVC blood cultures (OR, 4.39; 95% CI, 2.02-9.27; p <0.01), were associated with CRBSI. Neutropenia was associated with non-CRBSI (OR, 0.26; 95% CI, 0.13-0.53; p <0.01). Several factors such as S. maltophilia bacteraemia, polymicrobial bacteraemia and more than 1000 CFUs from a blood culture drawn through the CVC may assist the clinicians in assessing whether an indwelling catheter is the source of a GNB and hence CVC removal may be considered.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology