Central Line and Fever

Central Line and FeverYes. It is indubitable. Children will present for evaluation of fever. Many, if not most, will be well and likely have a self-limited illness (but, do NOT say “it’s just a virus”!). Some, however, will have fevers associated with other conditions that warrant greater concern (ex, Sickle Cell Disease, Leukemia, Neutropenia). Certainly, there are also a number of children that have unique “hardware” that complicates the evaluation of fever (ex, VP shunt, Gastrostomy Tube, Vagal Nerve Stimulator). Recently, one of my stellar PEM Fellows, Simone Lawson, raised an important question: How do you manage a child with a Central Line and Fever? Let’s review:

 

Central Line Basics

  • Central lines are commonly used for pediatric patients who need:
    • Frequent blood draws 
    • Hemodialysis
    • Frequent blood product transfusions
    • Long-term intravenous medications (ex, chemotherapy)
    • Parenteral nutrition
  • Central lines, while useful, can lead to complications [Brennan, 2015]

 

Central Line and Fever

While patients may present with fever due to benign etiologies, the concern is that it is due to an infection associated with the foreign body in the blood vessel.

  • Catheter-Associated Bloodstream Infection = Primary bloodstream infection (not related to another source) or clinical sepsis with the presence of an indwelling vascular access. [Brennan, 2015]
  • Risk factors for catheter-associated bloodstream infection:
    • Younger ages (< 3 years of age)
    • Lower body weight (< 8 kg)
    • Parenteral nutrition
    • Neutropenia
      • VERY HIGH RISK patient!
      • Prompt evaluation and empiric antibiotics are important!
      • May present in subtle fashion, so triage can be misleading.
        • May not mount same response to infection
        • May not demonstrate overt signs of infection
          • Look thoroughly for any possible evidence of a source.
          • Abdominal pain/distension – Typhlitis?
          • Mucositis – great risk for bacterial translocation
    • Specific medical conditions:
      • Cancers
        • Stem cell transplantation
        • Neuroblastoma [Moskalewicz, 2017]
      • Gastroenterology conditions (ex, Short Gut Syndrome) [Alexander, 2016]
  • Other important factors:
    • Prior line infections
    • Prior growth of multidrug resistant organisms
    • Externalized central lines – have increased risk [Moskalewicz, 2017]
    • Implanted ports – have lowest risk of infection

 

Central Line and Fever: Evaluation

Brennan et al offer a useful guideline for pediatric patients with central lines presenting with fever: [Brennan, 2015]

  1. Overt Sepsis
    • YES:
      • Fluid resuscitation, blood cultures, and empiric antibiotics with double gram-negative coverage and vancomycin… perhaps clindamycin for toxic shock as well (essentially, don’t be stingy with the antibiotics!)
      • Consider vasoactive medications if needed.
    • NO:
      • Obtain blood cultures (at least 2 sites – one from central line and one from peripheral site OR second lumen) [Handrup, 2015; Brennan, 2015]
      • Culture any drainage from site
  2. Neutropenic OR Suspected to be Neutropenic?
    •  YES:
      • Administer antispeudomonal beta-lactam or carbapenem
      • Admit
    • NO:
      • Non-Neutropenic patients are still at risk for infection [Moskalewicz, 2017; Gorelick, 1991]
      • History of MRSA or resistant organisms?
        • YES:
          • Administer vancomycin
          • Consider clindamycin for toxic shock
          • Admit
        • NO:
          • Administer ceftriaxone
          • Discuss admission vs close, outpatient follow-up with sub-specialist
          • Some patients may be safely managed as out-patients under the sub-specialist supervision. [Bartholomew, 2015; Averbuch, 2008]

 

Moral of the Morsel

  • Bugs like Foreign Bodies. Central lines can easily harbor bacteria so don’t underestimate the potential for bacterial infection even when only fever is present for patients with central lines.
  • Suspect neutropenia, treat like neutropenic! In patients who at at risk for being neutropenic, don’t wait for the CBC to prove it.
  • Talk to the Sub-specialists! The patient’s sub-specialist will know whether the particular patient has other specific factors that increase or decrease her/his risk.
  • Admission is the default. There may be an occasion when a patient is lower risk that the sub-specialist is comfortable treating as an outpatient, but realize they are not NO risk.

 

References

Moskalewicz RL1, Isenalumhe LL2, Luu C3, Wee CP4, Nager AL5. Bacteremia in nonneutropenic pediatric oncology patients with central venous catheters in the ED. Am J Emerg Med. 2017 Jan;35(1):20-24. PMID: 27765482. [PubMed] [Read by QxMD]

Alexander T1, Blatt J, Skinner AC, Jhaveri R, Jobson M, Freeman K. Outcome of Pediatric Gastroenterology Outpatients With Fever and Central Line. Pediatr Emerg Care. 2016 Nov;32(11):746-750. PMID: 27814324. [PubMed] [Read by QxMD]

Brennan C1, Wang VJ2. Management Of Fever And Suspected Infection In Pediatric Patients With Central Venous Catheters. Pediatr Emerg Med Pract. 2015 Dec;12(12):1-17; quiz 18-9. PMID: 26569627. [PubMed] [Read by QxMD]

Handrup MM1, Møller JK, Rutkjaer C, Schrøder H. Importance of blood cultures from peripheral veins in pediatric patients with cancer and a central venous line. Pediatr Blood Cancer. 2015 Jan;62(1):99-102. PMID: 25213546. [PubMed] [Read by QxMD]

Bartholomew F1, Aftandilian C1, Andrews J2, Gutierrez K1, Luna-Fineman S1, Jeng M3. Evaluation of febrile, nonneutropenic pediatric oncology patients with central venous catheters who are not given empiric antibiotics. J Pediatr. 2015 Jan;166(1):157-62. PMID: 25444524. [PubMed] [Read by QxMD]

Averbuch D1, Makhoul R, Rotshild V, Weintraub M, Engelhard D. Empiric treatment with once-daily cefonicid and gentamicin for febrile non-neutropenic pediatric cancer patients with indwelling central venous catheters. J Pediatr Hematol Oncol. 2008 Jul;30(7):527-32. PMID: 18797200. [PubMed] [Read by QxMD]

Yeung CY1, Lee HC, Huang FY, Wang CS. 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 Feb;17(2):135-42. PMID: 9493810. [PubMed] [Read by QxMD]

Gorelick MH1, Owen WC, Seibel NL, Reaman GH. Lack of association between neutropenia and the incidence of bacteremia associated with indwelling central venous catheters in febrile pediatric cancer patients. Pediatr Infect Dis J. 1991 Jul;10(7):506-10. PMID: 1876466. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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