title: Central venous catheter removal versus in situ treatment in neonates with enterobacteriaceae bacteremia.
abstract: OBJECTIVE
  To determine how often neonates with Enterobacteriaceae (ENTB) bacteremia can be treated successfully without removing central venous catheters (CVCs).
  
  
  METHODS
  A retrospective cohort study was conducted of ENTB bacteremia and CVCs in infants in a neonatal intensive care unit during a 7-year period (1994-2000). Cases of ENTB bacteremia were identified from a microbiology database and limited to late-onset cases occurring after 3 days of age.
  
  
  RESULTS
  There were 53 cases of ENTB bacteremia in infants with CVCs. Blood cultures were positive for ENTB within a median of 10 hours (range: 5-43). Timing of CVC removal was at the discretion of attending neonatologists. Fifteen cases had early-removal CVC (ER-CVC) within 2 days, and 38 cases had late-removal CVC (LR-CVC) >2 days after the first positive blood culture for ENTB. There were no significant differences between infants in the ER-CVC and LR-CVC groups for case fatality, recurrence, or duration of ENTB bacteremia. Although 16 (42%) of 38 (95% confidence interval [CI]: 26%-59%) LR-CVC cases required CVC removal to resolve ENTB bacteremia, 17 (45%) of 38 (95% CI: 29%-62%) LR-CVC cases were treated successfully without removal of CVCs. ENTB bacteremia was successfully treated without CVC removal in 85% of 13 LR-CVC cases with 1 day of bacteremia in contrast to 24% of 25 LR-CVC cases with >1 day of bacteremia (relative risk: 3.5; 95% CI: 1.7-7.4). CVC removal was required to resolve ENTB bacteremia in 9 (82%) of 11 LR-CVC cases with severe thrombocytopenia compared with 7 (32%) of 22 LR-CVC cases without severe thrombocytopenia (relative risk: 2.6; 95% CI: 1.3-5.0).
  
  
  CONCLUSIONS
  Retention of CVCs was successful in 45% of cases of ENTB bacteremia in which it was attempted, but success was unlikely when bacteremia lasted >1 day. ENTB bacteremia cases associated with severe thrombocytopenia rarely resolved unless CVCs were removed.
authors.affiliation: Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of The King's Daughters, Norfolk, Virginia, USA.
authors.forename: Kellie J
authors.initials: KJ
authors.lastname: Nazemi
authors.forename: E Stephen
authors.initials: ES
authors.lastname: Buescher
authors.forename: Robert E
authors.initials: RE
authors.lastname: Kelly
authors.forename: M Gary
authors.initials: MG
authors.lastname: Karlowicz
mesh_terms: D000617:Aminoglycosides / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016470:Bacteremia / Q000097:blood / Q000188:drug therapy*; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000379:methods; D015331:Cohort Studies; D020878:Device Removal; D004755:Enterobacteriaceae / Q000302:isolation & purification; D004756:Enterobacteriaceae Infections / Q000097:blood / Q000188:drug therapy*; D005104:Expert Testimony; D005839:Gentamicins / Q000627:therapeutic use*; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D012189:Retrospective Studies; D014031:Tobramycin / Q000627:therapeutic use*; D016896:Treatment Outcome
chemical_list: D000617:Aminoglycosides; D000900:Anti-Bacterial Agents; D005839:Gentamicins; D014031:Tobramycin