Central-Venous Catheter-Related Bloodstream Infections in Pediatric Patients With Fever: CRBSI, Sepsis | EB Medicine
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Management Of Fever And Suspected Infection In Pediatric Patients With Central Venous Catheters

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Table of Contents
 
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology And Pathophysiology
  6. Differential Diagnosis
    1. Local Infections
    2. Systemic Infections
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
  9. Diagnostic Studies
    1. Blood Culture
    2. Complete Blood Count
    3. C-Reactive Protein
    4. Polymerase Chain Reaction
    5. Other Laboratory Testing
    6. Imaging Studies
  10. Treatment
    1. Initial Resuscitation
  11. Special Circumstances
  12. Controversies And Cutting Edge
    1. Procalcitonin And Other Serum Biomarkers
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls For Pediatric Patients With A Central Venous Catheter Presenting With Fever Or Suspected Infection
  16. Time- And Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway For Management Of Fever Or Suspected Infection In Pediatric Patients With A Central Venous Catheter
  19. Tables
    1. Table 1. Types Of Central Venous Catheters
    2. Table 2. Common Organisms Causing Infection In Patients With Central Venous Catheters
    3. Table 3. Types Of Systemic Infections
    4. Table 4. Differential Diagnosis For Fever In Patients With A Central Venous Catheter
  20. References

Abstract

The use of indwelling central venous catheters is essential for pediatric patients who require hemodialysis, parenteral nutrition, chemotherapy, or other medications. Fever is a common chief complaint in the emergency department, and fever in a patient with a central venous catheter may be related to a common cause of fever, or it may be due to a catheter-associated bloodstream infection. Catheter-associated bloodstream infections may also lead to additional complications such as sepsis, septic shock, or septic complications including suppurative thrombophlebitis, endocarditis, osteomyelitis, septic emboli, and abscesses. Early resuscitation as well as timely and appropriate antibiotic therapy have been shown to improve outcomes. This issue focuses on the approach to fever in pediatric patients with central venous catheters and the management and disposition of patients with possible catheter-associated bloodstream infections.

Case Presentations

An 8-year-old boy with a history of standard-risk acute lymphoblastic leukemia presents to the ED with a fever. He has a port central line and is currently undergoing the delayed intensification phase of chemotherapy. He last received chemotherapy 1 day prior to presentation. He also reports a headache and a cough. Upon examination, he is febrile to 39.2ºC, with a heart rate of 120 beats/min and blood pressure of 108/60 mm Hg. He is breathing comfortably and has an oxygen saturation of 99% on room air. You consider what initial laboratory workup you might need…

A 4-year-old girl with a history of gastroschisis requiring intestinal resection that resulted in short gut syndrome presents with a history of fever, vomiting, and diarrhea. She is dependent upon total parenteral nutrition, which is delivered through a Broviac® catheter. She has a history of multiple previous line infections, including a recent MRSA line infection. On examination, her temperature is 38.2°C, and she has a heart rate of 105 beats/min and blood pressure of 100/55 mm Hg. You wonder what initial laboratory testing and imaging you should consider, and what the appropriate disposition for this patient should be…

Introduction

Fever is a common chief complaint of pediatric patients presenting to the emergency department (ED), and patients with a central venous catheter (CVC) may also have common causes of fever similar to children without pre-existing medical conditions. While these common causes of fever may occur in patients with CVCs, it is imperative that emergency clinicians investigate all episodes of fever for catheter-associated bloodstream infections (CA-BSI), and initiate prompt and appropriate antibiotic therapy if catheter-associated infection is suspected.

The use of an indwelling CVC is essential in pediatric patients who require hemodialysis, parenteral nutrition, frequent blood draws, frequent blood product transfusions, or long-term intravenous medications (such as antibiotics or chemotherapeutics). Although essential to the treatment of these patients, there are several complications that may arise with the ongoing use of CVCs. In addition to catheter dysfunction, thrombosis, and embolization, patients with a CVC may also experience infection at the insertion site, the tunneled portion of the catheter, the subcutaneous pocket of a totally implanted intravascular device (a pocket infection), or within the catheter itself. The indwelling catheter provides a portal of entry for bacteria (and other organisms), and renders these patients susceptible to the development of a CA-BSI and the potential for progression to overwhelming infection and sepsis.

The rapid recognition and triage of these patients, with subsequent initiation of antibiotics and resuscitative measures, has been studied extensively and has been shown to improve outcomes in febrile neutropenic patients with indwelling central catheters.1 The time to antibiotic therapy has been consistently used as a quality-of-care measure in this patient population.1,2 Although less-studied in other pediatric populations relying on CVCs, a regular complication in these patients remains the occurrence of CA-BSI. Sepsis syndrome remains a leading cause of morbidity and mortality in pediatric patients, and the Surviving Sepsis Campaign (www.survivingsepsis.org) recommends initiation of empiric antibiotic therapy within 1 hour of the recognition of severe sepsis or septic shock in both adult and pediatric patients.

Critical Appraisal Of The Literature

An online search for literature from 1980 to the present was performed using the Pubmed and MEDLINE® databases. Search terms included fever, central venous catheter, and infection. More than 6000 articles were found using the search terms and included case reports, review articles, and prospective and retrospective studies. This was narrowed by limiting the results to studies involving children aged 0 to 18 years, and articles published in English. A search on Ovid® produced 662 articles, which were analyzed and further refined to 73 relevant articles. Two clinical practice guidelines were also included in the results. A search of the Cochrane Database of Systematic Reviews was also conducted. There is a significant amount of literature on fever or infection with a CVC in the pediatric hematology-oncology population; however, there is a relative paucity of literature specific to other patient populations, such as pediatric patients on dialysis, patients with intestinal failure, patients dependent upon parenteral nutrition, and other subsets commonly requiring long-term central venous access. Very little information is available on the evaluation and acute management of fever in patients with a CVC in the ED.

Risk Management Pitfalls For Pediatric Patients With A Central Venous Catheter Presenting With Fever Or Suspected Infection

  1. “The patient was well-appearing in triage, so she didn’t need to be seen immediately.”
    All patients with a CVC presenting with fever should be evaluated upon arrival. In the setting of a CR-BSI, a patient’s clinical examination can change precipitously. Patients presenting with unstable vital signs should be triaged and evaluated immediately by an emergency clinician.
  2. “The patient was tachycardic with fever, but he had a normal blood pressure, so we didn’t initially provide any fluid resuscitation.”
    In pediatric patients, hypotension is not required for a patient to meet the criteria for septic shock, and this is often a late finding. A patient with evidence of hemodynamic changes without hypotension is considered to be in compensated shock. Fluid resuscitation should be initiated promptly with the goal of reversing hemodynamic abnormalities such as tachycardia and hypotension, and normalizing urine output, mental status, and capillary refill time.
  3. “We were having difficulty accessing the patient’s port, and the parents refused a peripheral blood culture, so the patient didn’t receive antibiotics for almost 2 hours.”
    It is recommended that blood cultures be drawn prior to the patient’s receiving antibiotics. However, since prompt antibiotic therapy has been shown to improve outcomes in neutropenic and critically ill patients, obtaining cultures should not significantly delay antibiotic therapy.
  4. “We started antibiotic therapy within the first hour, but didn’t realize that the patient had a history of a previous infection with a multidrug-resistant organism.”
    Timely and appropriate antibiotic therapy has been shown to improve outcomes in pediatric sepsis patients. It is important to consider each patient’s infection history and cover for resistant organisms if the patient has a history of a previous drug-resistant infection.
  5. “The patient had a CVC and presented with fever, so blood cultures were drawn from 1 of 2 catheter lumens and empiric antibiotics were started 2 days ago. Even though the patient was still febrile after 48 hours, the culture results were negative, so we discontinued antibiotics.”
    A single culture from 1 lumen of the CVC has been shown in several studies to fail to diagnose bacteremia in some patients. Cultures should be drawn from the catheter and a peripheral vein or from all catheter lumens if a peripheral culture cannot be obtained. In the setting of a negative initial culture, repeat cultures should be obtained, and antibiotics should not be discontinued if clinical suspicion for bacteremia remains high.
  6. “All patients with evidence of local catheter site infections should receive systemic antibiotic therapy.”
    When there is evidence of local catheter site infection, topical antibiotics may be sufficient if blood culture results are negative and there is no clinical concern for systemic infection.
  7. “The patient has a CVC and is febrile. He is also complaining of abdominal discomfort. We drew blood cultures and started antibiotics prior to admitting him to the general pediatric service.”
    The presence of a CVC does not mean that the source of the patient’s fever is always the catheter. In this case, a thorough examination would have revealed right lower quadrant tenderness and guarding, and prompted further evaluation for intra-abdominal pathology.
  8. “The patient remained hypotensive after receiving a total of 60 mL/kg of normal saline in the first hour in addition to antibiotics. Dopamine was initiated; however, we had to titrate up on the dose due to persistent hypotension.”
    In patients with fluid refractory shock after appropriate resuscitation, inotropes should be started. If shock persists after the initiation of inotropic support with the appropriate escalation to additional inotropes as needed, hydrocortisone should be considered. Additional considerations include correcting electrolyte abnormalities and administering blood products if anemia or thrombocytopenia are present.
  9. “An oncology patient with a port presented with a reported history of fever. We obtained a blood culture and CBC with differential and determined that the patient was not neutropenic. We gave him a dose of ceftriaxone and told him to follow up with his oncologist as needed.”
    Well-appearing, nonneutropenic patients with a CVC may not require admission to the hospital when presenting with fever. However, proper follow-up is essential. It is necessary to be in communication with the patient’s primary care service (ie, oncology) and ensure that there is timely follow-up of the cultures drawn. Furthermore, it should be confirmed that the patient will be able to return to the hospital in the event of a positive culture or clinical deterioration.
  10. “The patient’s blood culture grew coagulase-negative staphylococci at 20 hours, and he was called back into the ED. He is well-appearing now, so we did not start antibiotics.”
    Coagulase-negative Staphylococcus is a common skin micro-organism that is often a contaminant in blood cultures. However, it can also be pathogenic in these patients, and it cannot be determined to be a contaminant if only 1 blood culture is drawn and found to be positive. Treatment should be continued until an additional blood culture can be drawn and determined to be negative.

Tables

Table 1. Types Of Central Venous Catheters

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

  1. Fletcher M, Hodgkiss H, Zhang S, et al. Prompt administration of antibiotics is associated with improved outcomes in febrile neutropenia in children with cancer. Pediatr Blood Cancer. 2013;60(8):1299-1306. (Retrospective cohort study; 653 patients)
  2. Jobson M, Sandrof M, Valeriote T, et al Decreasing time to antibiotics in febrile patients with central lines in the emergency department. Pediatrics. 2015;135(1):e187-e195. (Quality improvement study)
  3. Pinon M, Bezzio S, Tovo PA, et al. A prospective 7-year survey on central venous catheter-related complications at a single pediatric hospital. Eur J Pediatr. 2009;168(12):1505- 1512. (Prospective observational study; 748 patients)
  4. Barrier A, Williams DJ, Connelly M, et al. Frequency of peripherally inserted central catheter complications in children. Pediatr Infect Dis J. 2012;31(5):519-521. (Retrospective review; 610 patients)
  5. Cesaro S, Corro R, Pelosin A, et al. A prospective survey on incidence and outcome of Broviac/Hickman catheter-related complications in pediatric patients affected by hematological and oncological diseases. Ann Hematol. 2004;83(3):183-188. (Prospective study; 112 patients)
  6. * Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;49(1):1-45. (Clinical practice guidelines)
  7. Eggimann P. Diagnosis of intravascular catheter infection. Curr Opin Infect Dis. 2007;20(4):353-359. (Review)
  8. Flynn PM. Diagnosis and management of central venous catheter-related bloodstream infections in pediatric patients. Pediatr Infect Dis J. 2009;28(11):1016-1017. (Review)
  9. Sihler KC, Chenoweth C, Zalewski C, et al. Catheter-related vs. catheter-associated blood stream infections in the intensive care unit: incidence, microbiology, and implications. Surg Infect (Larchmt). 2010;11(6):529-534. (Retrospective review and prospective collection)
  10. Fratino G, Molinari AC, Parodi S, et al. Central venous catheter-related complications in children with oncological/hematological diseases: an observational study of 418 devices. Ann Oncol. 2005;16(4):648-654. (Prospective study; 368 patients)
  11. Bourgeois FC, Lamagna P, Chiang VW. Peripherally inserted central catheters. Pediatr Emerg Care. 2011;27(6):556-561. (Review)
  12. Dyer BJ, Weiman MG, Ludwig S. Central venous catheters in the emergency department: access, utilization, and problem solving. Pediatr Emerg Care. 1995;11(2):112-117. (Review)
  13. Goede MR, Coopersmith CM. Catheter-related bloodstream infection. Surg Clin North Am. 2009;89(2):463-474. (Review)
  14. Shaul DB, Scheer B, Rokhsar S, et al. Risk factors for early infection of central venous catheters in pediatric patients. J Am Coll Surg. 1998;186(6):654-658. (Case control study; 473 patients)
  15. Yacobovich J, Ben-Ami T, Abdalla T, et al. Patient and central venous catheter related risk factors for blood stream infections in children receiving chemotherapy. Pediatr Blood Cancer. 2015;62(3):471-476. (Prospective study; 252 patients)
  16. Newman N, Issa A, Greenberg D, et al. Central venous catheter-associated bloodstream infections. Pediatr Blood Cancer. 2012;59(2):410-414. (Prospective study; 178 patients)
  17. Adler A, Yaniv I, Steinberg R, et al. Infectious complications of implantable ports and Hickman catheters in paediatric haematology-oncology patients. J Hosp Infect. 2006;62(3):358- 365. (Prospective study; 281 patients)
  18. Kelly MJ, Vivier PM, Panken TM, et al. Bacteremia in febrile nonneutropenic pediatric oncology patients. Pediatr Blood Cancer. 2010;54(1):83-87. (Retrospective cohort study; 167 patients)
  19. Janum S, Zingg W, Classen V, et al. Bench-to-bedside review: Challenges of diagnosis, care and prevention of central catheter-related bloodstream infections in children. Crit Care. 2013;17(4):238. (Review)
  20. * Cecinati V, Brescia L, Tagliaferri L, et al. Catheter-related infections in pediatric patients with cancer. Eur J Clin Microbiol Infect Dis. 2012;31(11):2869-2877. (Review)
  21. Goutail-Flaud MF, Sfez M, Berg A, et al. Central venous catheter-related complications in newborns and infants: a 587-case survey. J Pediatr Surg. 1991;26(6):645-650. (Retrospective review; 587 patients)
  22. Randolph AG, Brun-Buisson C, Goldmann D. Identification of central venous catheter-related infections in infants and children. Pediatr Crit Care Med. 2005;6(Suppl 3):S19-S24. (Review)
  23. Yeung CY, Lee HC, Huang FY, et al. Sepsis during total parenteral nutrition: exploration of risk factors and determination of the effectiveness of peripherally inserted central venous catheters. Pediatr Infect Dis J. 1998;17(2):135-142. (Prospective study; 378 patients)
  24. Ruebner R, Keren R, Coffin S, et al. Complications of central venous catheters used for the treatment of acute hematogenous osteomyelitis. Pediatrics. 2006;117(4):1210-1215. (Retrospective cohort study; 80 patients)
  25. Tarantino MD, Lail A, Donfield SM, et al. Surveillance of infectious complications associated with central venous access devices in children with haemophilia. Haemophilia. 2003;9(5):588-592. (Prospective study; 59 patients)
  26. Wagner M, Bonhoeffer J, Erb TO, et al. Prospective study on central venous line associated bloodstream infections. Arch Dis Child. 2011;96(9):827-831. (Prospective study; 152 patients)
  27. Sumida W, Watanabe Y, Takasu H. Strategies for catheter-related blood stream infection based on medical course in children receiving parenteral nutrition. Pediatr Surg Int. 2012;28(1):21-25. (Prospective study; 9 patients)
  28. Drews BB, Sanghavi R, Siegel JD, et al. Characteristics of catheter-related bloodstream infections in children with intestinal failure: implications for clinical management. Gastroenterol Nurs. 2009;32(6):385-390. (Retrospective review; 101 patients)
  29. Robinson JL, Casey LM, Huynh HQ, et al. Prospective cohort study of the outcome of and risk factors for intravascular catheter-related bloodstream infections in children with intestinal failure. JPEN J Parenter Enteral Nutr. 2014;38(5):625- 630. (Prospective study; 16 patients)
  30. Marra AR, Opilla M, Edmond MB, et al. Epidemiology of bloodstream infections in patients receiving long-term total parenteral nutrition. J Clin Gastroenterol. 2007;41(1):19-28. (Observational study; 47 patients)
  31. Sutter D, Stagliano D, Braun L, et al. Polymicrobial bloodstream infection in pediatric patients: risk factors, microbiology, and antimicrobial management. Pediatr Infect Dis J. 2008;27(5):400-405. (Retrospective review; 18 patients)
  32. Mohammed A, Grant FK, Zhao VM, et al. Characterization of posthospital bloodstream infections in children requiring home parenteral nutrition. JPEN J Parenter Enteral Nutr. 2011;35(5):581-587. (Retrospective chart review; 44 patients)
  33. Silverstein DM, Moylan K. Cause and outcome of central venous catheter infections in paediatric haemodialysis patients. Nephrol Dial Transplant. 2010;25(10):3332-3337. (Retrospective review; 39 patients)
  34. Paglialonga F, Esposito S, Edefonti A, et al. Catheter-related infections in children treated with hemodialysis. Pediatr Nephrol. 2004;19(12):1324-1333. (Review)
  35. Stefanidis CJ. Prevention of catheter-related bacteremia in children on hemodialysis: time for action. Pediatr Nephrol. 2009;24(11):2087-2095. (Editorial commentary)
  36. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011;39(4 Suppl 1):S1-S34. (Practice guidelines)
  37. Bateman SL, Seed PC. Procession to pediatric bacteremia and sepsis: covert operations and failures in diplomacy. Pediatrics. 2010;126(1):137-150. (Review)
  38. Shah SS, Smith MJ, Zaoutis TE. Device-related infections in children. Pediatr Clin North Am. 2005;52(4):1189-1208. (Review)
  39. * Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6(1):2-8. (Consensus statement)
  40. Band RA, Gaieski DF, Hylton JH, et al. Arriving by emergency medical services improves time to treatment endpoints for patients with severe sepsis or septic shock. Acad Emerg Med. 2011;18(9):934-940. (Prospective study; 963 patients)
  41. Seymour CW, Cooke CR, Heckbert SR, et al. Prehospital intravenous access and fluid resuscitation in severe sepsis: an observational cohort study. Crit Care. 2014;18(5):533. (Prospective observational study; 45,394 patients)
  42. White L, Ybarra M. Neutropenic fever. Emerg Med Clin North Am. 2014;32(3):549-561. (Review)
  43. Perrone J, Hollander JE, Datner EM. Emergency department evaluation of patients with fever and chemotherapy-induced neutropenia. J Emerg Med. 2004;27(2):115-119. (Retrospective chart review; 52 patients)
  44. Ammann RA, Hirt A, Luthy AR, et al. Predicting bacteremia in children with fever and chemotherapy-induced neutropenia. Pediatr Infect Dis J. 2004;23(1):61-67. (Retrospective cohort study; 13 patients)
  45. Lucas KG, Brown AE, Armstrong D, et al. The identification of febrile, neutropenic children with neoplastic disease at low risk for bacteremia and complications of sepsis. Cancer. 1996;77(4):791-798. (Retrospective review; 161 patients)
  46. Richardson MW, Grewal SS, Visintainer PF. Emesis predicts bacteremia in immunocompromised children with central venous catheters and fever. Cancer. 2009;115(14):3335-3340. (Retrospective chart review; 48 patients)
  47. Handrup MM, Moller JK, Rutkjaer C, et al. Importance of blood cultures from peripheral veins in pediatric patients with cancer and a central venous line. Pediatr Blood Cancer. 2015;62(1):99-102. (Prospective study; 654 patients)
  48. Scheinemann K, Ethier MC, Dupuis LL, et al. Utility of peripheral blood cultures in bacteremic pediatric cancer patients with a central line. Support Care Cancer. 2010;18(8):913- 919. (Retrospective chart review; 224 patients, 318 episodes of infection)
  49. * Lehrnbecher T, Phillips R, Alexander S, et al. Guideline for the management of fever and neutropenia in children with cancer and/or undergoing hematopoietic stem-cell transplantation. J Clin Oncol. 2012;30(35):4427-4438. (Practice guidelines)
  50. Isaacman DJ, Karasic RB, Reynolds EA, et al. Effect of number of blood cultures and volume of blood on detection of bacteremia in children. J Pediatr. 1996;128(2):190-195. (Prospective study; 300 patients)
  51. Andreola B, Bressan S, Callegaro S, et al. Procalcitonin and C-reactive protein as diagnostic markers of severe bacterial infections in febrile infants and children in the emergency department. Pediatr Infect Dis J. 2007;26(8):672-677. (Prospective study; 408 children)
  52. Pulliam PN, Attia MW, Cronan KM. C-reactive protein in febrile children 1 to 36 months of age with clinically undetectable serious bacterial infection. Pediatrics. 2001;108(6):1275- 127 (Prospective study; 77 patients)
  53. Sanders S, Barnett A, Correa-Velez I, et al. Systematic review of the diagnostic accuracy of C-reactive protein to detect bacterial infection in nonhospitalized infants and children with fever. J Pediatr. 2008;153(4):570-574. (Systematic review; 10 studies)
  54. Shachor-Meyouhas Y, Sprecher H, Moscoviz D, et al. Molecular-based diagnosis of bacteremia in the setting of fever with or without neutropenia in pediatric hematology-oncology patients. J Pediatr Hematol Oncol. 2013;35(7):500- 503. (Prospective study; 70 patients)
  55. Picardi M, Pagliuca S, Chiurazzi F, et al. Early ultrasonographic finding of septic thrombophlebitis is the main indicator of central venous catheter removal to reduce infection-related mortality in neutropenic patients with bloodstream infection. Ann Oncol. 2012;23(8):2122-2128. (Prospective study; 100 patients)
  56. * Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39(2):165-228. (Clinical practice guidelines)
  57. * Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009;37(2):666-688. (Clinical practice guidelines)
  58. Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is as-sociated with improved outcome. Pediatrics. 2003;112(4):793- 799. (Retrospective cohort study; 91 patients)
  59. Weiss SL, Fitzgerald JC, Balamuth F, et al. Delayed antimicrobial therapy increases mortality and organ dysfunction duration in pediatric sepsis. Crit Care Med. 2014;42(11):2409- 2417. (Retrospective observational study; 130 patients)
  60. Wolf J, Curtis N, Worth LJ, et al. Central line-associated bloodstream infection in children: an update on treatment. Pediatr Infect Dis J. 2013;32(8):905-910. (Review)
  61. Simon A, Bode U, Beutel K. Diagnosis and treatment of catheter-related infections in paediatric oncology: an update. Clin Microbiol Infect. 2006;12(7):606-620. (Review)
  62. Leonidou L, Gogos CA. Catheter-related bloodstream infections: catheter management according to pathogen. Int J Antimicrob Agents. 2010;36(Suppl 2):S26-S32. (Review)
  63. West DC, Marcin JP, Mawis R, et al. Children with cancer, fever, and treatment-induced neutropenia: risk factors associated with illness requiring the administration of critical care therapies. Pediatr Emerg Care. 2004;20(2):79-84. (Retrospective chart review; 143 patients)
  64. Secmeer G, Devrim I, Kara A, et al. Role of procalcitonin and CRP in differentiating a stable from a deteriorating clinical course in pediatric febrile neutropenia. J Pediatr Hematol Oncol. 2007;29(2):107-111. (Prospective study; 49 patients)
  65. Phillips RS, Wade R, Lehrnbecher T, et al. Systematic review and meta-analysis of the value of initial biomarkers in predicting adverse outcome in febrile neutropenic episodes in children and young people with cancer. BMC Med. 2012;10:6. (Systematic review and meta-analysis; 25 studies)
  66. Pierce R, Bigham MT, Giuliano JS Jr. Use of procalcitonin for the prediction and treatment of acute bacterial infection in children. Curr Opin Pediatr. 2014;26(3):292-298. (Review)
  67. Gendrel D, Raymond J, Coste J, et al. Comparison of procalcitonin with C-reactive protein, interleukin 6 and interferon-alpha for differentiation of bacterial vs. viral infections. Pediatr Infect Dis J. 1999;18(10):875-881. (Prospective study; 700 patients)
  68. Lin SG, Hou TY, Huang DH, et al. Role of procalcitonin in the diagnosis of severe infection in pediatric patients with fever and neutropenia—a systemic review and meta-analysis. Pediatr Infect Dis J. 2012;31(10):e182-e188. (Systematic review and meta-analysis; 18 studies)
  69. Kasem AJ, Bulloch B, Henry M, et al. Procalcitonin as a marker of bacteremia in children with fever and a central venous catheter presenting to the emergency department. Pediatr Emerg Care. 2012;28(10):1017-1021. (Prospective study; 62 patients)
  70. Haeusler GM, Carlesse F, Phillips RS. An updated systematic review and meta-analysis of the predictive value of serum biomarkers in the assessment of fever during neutropenia in children with cancer. Pediatr Infect Dis J. 2013;32(10):e390- e396. (Systematic review and meta-analysis; 37 studies)
  71. Phillips RS, Lehrnbecher T, Alexander S, et al. Updated systematic review and meta-analysis of the performance of risk prediction rules in children and young people with febrile neutropenia. PLoS One. 2012;7(5):e38300. (Systematic review and meta-analysis; 9 articles)
  72. Bartholomew F, Aftandilian C, Andrews J, et al. Evaluation of febrile, nonneutropenic pediatric oncology patients with central venous catheters who are not given empiric antibiotics. J Pediatr. 2015;166(1):157-162. (Retrospective review; 138 patients)
  73. Chang MI, Carlson SJ, Nandivada P, et al. Challenging the 48-hour rule-out for central line-associated bloodstream infections in the pediatric intestinal failure population: a retrospective pilot study. JPEN J Parenter Enteral Nutr. 2015. Jan 7. [Epub ahead of print] (Retrospective cohort study; 16 patients)
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Authors

Courtney Brennan, MD; Vincent J. Wang, MD, MHA

Publication Date

December 2, 2015

CME Expiration Date

January 2, 2019

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