title: Bacteremia, central catheters, and neonates: when to pull the line.
abstract: OBJECTIVE
  Physicians who treat neonates who become bacteremic while dependent on central venous catheters face a serious and common dilemma. We sought 1) to evaluate the relationship between central venous catheter removal and outcome in bacteremic neonates, 2) to determine species of bacteria that are associated with an increased risk of infectious complications if the central catheter is not removed promptly, and 3) to provide evidence-based recommendations for central catheter management.
  
  
  METHODS
  A retrospective cohort study of all neonates who had central venous access and developed bacteremia between July 1, 1995, and July 31, 1999, was conducted in the Duke University neonatal intensive care unit.
  
  
  RESULTS
  The outcome for patients in whom the central catheter was not removed within 24 hours of organism identification was significantly worse (odds ratio = 9.8) than it was for those whose catheters were removed promptly. For patients who were infected with Staphylococcus aureus or with nonenteric Gram-negative rods, delayed removal of the central catheter was associated with complicated bacteremia. Catheter sterilization was attempted in 27 neonates who were infected with enteric Gram-negative rods; only 10 of these infants retained their catheters without infection-related complications. Infants who had 4 consecutive blood cultures that were positive for coagulase-negative staphylococcus (CoNS) were at significantly increased risk for end-organ damage and death, compared with infants who had 3 or fewer positive blood culture for CoNS (odds ratio = 29.58).
  
  
  CONCLUSIONS
  Bacteremic infants experienced fewer infection-related complications when the central catheter was removed promptly. One positive blood culture for S aureus or a Gram-negative rod warrants central line removal in a neonate. Clinicians who are faced with a neonate who has 1 positive culture for CoNS may attempt medical management without central catheter removal, but documentation of subsequent negative blood cultures is crucial. Once a neonate has 3 positive blood cultures for CoNS, the central catheter should be removed.central line, neonate, bacteremia, bacteria, umbilical catheter, Broviac, percutaneous.
authors.affiliation: Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA.
authors.forename: D K
authors.initials: DK
authors.lastname: Benjamin
authors.forename: W
authors.initials: W
authors.lastname: Miller
authors.forename: H
authors.initials: H
authors.lastname: Garges
authors.forename: D K
authors.initials: DK
authors.lastname: Benjamin
authors.forename: R E
authors.initials: RE
authors.lastname: McKinney
authors.forename: M
authors.initials: M
authors.lastname: Cotton
authors.forename: R G
authors.initials: RG
authors.lastname: Fisher
authors.forename: K A
authors.initials: KA
authors.lastname: Alexander
mesh_terms: D016470:Bacteremia / Q000453:epidemiology / Q000382:microbiology* / Q000628:therapy*; D001419:Bacteria / Q000302:isolation & purification; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000379:methods*; D016983:Enterococcus / Q000302:isolation & purification; D004866:Equipment Contamination; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D015931:Intensive Care, Neonatal / Q000379:methods*; D009359:Neonatology / Q000379:methods*; D017410:Practice Guidelines as Topic; D013211:Staphylococcus aureus / Q000302:isolation & purification; D013997:Time Factors