Bacteremia, central catheters, and neonates: When to pull the line

Objectives. Physicians who treat neonates who become bacteremic while depen dent on central venous catheters face a serious and common dilemma. We soug ht 1) to evaluate the relationship between central venous catheter removal and outcome in bacteremic neonates, 2) to determine species of bacteria tha t 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. Method. A retrospective cohort study of all neonates who had central venous access and developed bacteremia between July 1, 1995, and July 31, 1999, w as conducted in the Duke University neonatal intensive care unit. Results. The outcome for patients in whom the central catheter was not remo ved within 24 hours of organism identification was significantly worse (odd s ratio = 9.8) than it was for those whose catheters were removed promptly. For patients who were infected with Staphylococcus aureus or with nonenter ic Gram-negative rods, delayed removal of the central catheter was associat ed with complicated bacteremia. Catheter sterilization was attempted in 27 neonates who were infected with enteric Gram-negative rods; only 10 of thes e infants retained their catheters without infection-related complications. Infants who had 4 consecutive blood cultures that were positive for coagul ase-negative staphylococcus (CoNS) were at significantly increased risk for end-organ damage and death, compared with infants who had 3 or fewer posit ive blood culture for CoNS (odds ratio = 29.58). Conclusions. Bacteremic infants experienced fewer infection-related complic ations when the central catheter was removed promptly. One positive blood c ulture 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 cult ure for CoNS may attempt medical management without central catheter remova l, but documentation of subsequent negative blood cultures is crucial. Once a neonate has 3 positive blood cultures for CoNS, the central catheter sho uld be removed.