Yes. 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]
  • Line malfunction 
  • Line fracture / leakage
  • Thrombosis and embolism
  • Infection
    • Local Infection
      • Insertion site infection
      • Tunnel path infection
      • Subcutaneous pocket infection
    • Systemic infection
      • Endocarditis
      • Septic thromboembolism
      • Osteomyelitis
      • Systemic inflammatory response syndrome
      • Sepsis, Severe Sepsis, and Septic Shock

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