Candidal thrombophlebitis of central veins: case report and review.

Although candidemia and central catheter septic thrombosis is quite common, central veins thrombophlebitis caused by Candida spp. is a rarely reported complication in critically ill patients. Here we report a case of thrombophlebitis of the right internal jugular and subclavian veins due to Candida albicans which occurred in a patient admitted in the intensive care unit for major trauma. The individual was eventually cured after prolonged course of antifungal therapy. We also review 24 additional cases of Candida induced central veins thrombophlebitis reported since 1978. A central vein catheter was in place in all 25 patients with 21 (84%) being admitted in an intensive care unit, 22 (88%) were receiving total parenteral nutrition and 23 (92%) undergoing a course of antibiotic therapy. Overall mortality was 16%, including two patients who received no therapy and died. In the group of patients receiving only medical therapy, the mortality rate was 13%, while no deaths were observed among those treated with combined medical and surgical therapy. Literature data suggest that Candida caused central veins thrombophlebitis is a rare and probably underdiagnosed infectious complication of the critically ill patient. Despite the dramatic presentation with persistent candidemia, mortality is low even with a conservative medical approach with prolonged fungicidal therapy through the use of amphotericin B or echinocandins. Thus, the decision for a combined surgical debridement should be assessed for each patient.

Comparison of catheter-related infection and tip colonization between internal jugular and subclavian central venous catheters in surgical neonates.

BACKGROUND: The primary aim of this study was to compare catheter-associated infections and tip contaminations between percutaneously placed central venous catheters in the internal jugular and subclavian veins in surgical neonates undergoing major noncardiac surgery. METHODS: The prospectively computerized protocols of 295 procedures were analyzed retrospectively. RESULTS: One hundred twenty-nine internal jugular venous (group I) and 107 subclavian venous catheters (group S) were included. The median postconceptual age was 37 weeks in group I and 38 in group S. The weight ranged from 580 g to 4.5 kg in group I and from 820 g to 4.5 kg in group S at the time of insertion. Significantly more catheter-associated infections were observed in group I (15.5 vs. 4.7%; chi-square analysis: P < 0.01). The internal jugular venous catheters were also associated with a significantly increased probability of an earlier onset of a catheter-associated infection compared with the subclavian venous catheters (log rank test: P < 0.01; Cox model: P < 0.01). This probability was only slightly increased by a lower weight (Cox model: P = 0.075), and it was not increased by a lower age (Cox model: P = 0.93). Significantly more catheter tips were contaminated by pathogens in group I (55.8 vs. 33.6%; chi-square analysis: P < 0.01). CONCLUSION: The internal jugular venous catheters were associated with a higher infection rate as well as earlier onset of catheter-associated infection compared with the subclavian venous catheters.

The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population.

OBJECTIVE: The objective was to assess the risk of central venous catheter infection with respect to the site of insertion in an intensive care unit population. The subclavian, internal jugular, and femoral sites were studied. DESIGN: An epidemiologic, prospective, observational study. SETTING: The setting is a well-functioning intensive care unit under a unified critical care medicine division in a university teaching hospital. Critical care medicine attendings and fellows covered on site 17 and 24 hrs per day, respectively. PATIENTS: Patients were critically ill. All patients were triaged into the intensive care unit by on-site critical care medicine fellows. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In an intensive care unit population, we prospectively studied the incidence of central venous catheter infection and colonization at the subclavian, internal jugular, and femoral sites. The optimal insertion site for each individual patient was selected by experienced intensive care physicians (critical care medicine attendings and fellows). All of the operators were proficient in inserting catheters at all three sites. Confounding factors were eliminated; there were a limited number of experienced operators inserting the catheters, a uniform protocol stressing strict sterile insertion was enforced, and standardized continuous catheter care was provided by dedicated intensive care nurses proficient in all aspects of central venous catheter care. Two groups of patients were analyzed. Group 1 was patients with one catheter at one site, and group 2 was patients with catheters at multiple sites. Group 1 was the primary analysis, whereas group 2 was supporting.A total of 831 central venous catheters and 4,735 catheter days in 657 patients were studied. The incidence of catheter infection (4.01/1,000 catheter days, 2.29% catheters) and colonization (5.07/1,000 catheter days, 2.89% catheters) was low overall. In group 1, the incidence of infection was subclavian: 0.881 infections/1,000 catheter days (0.45%), internal jugular: 0/1,000 (0%), and femoral: 2.98/1,000 (1.44%; p = .2635). The incidence of colonization was subclavian: 0.881 colonization/1,000 catheter days (0.45%), internal jugular: 2.00/1,000 (1.05%), and femoral: 5.96/1,000 (2.88%, p = .1338). There was no statistically significant difference in the incidence of infection and colonization or duration of catheters (p = .8907) among the insertion sites. In group 2, there was also no statistically significant difference in the incidence of infection and colonization among the three insertion sites. CONCLUSION: In an intensive care unit population, the incidence of central venous catheter infection and colonization is low overall and, clinically and statistically, is not different at all three sites when optimal insertion sites are selected, experienced operators insert the catheters, strict sterile technique is present, and trained intensive care unit nursing staff perform catheter care.

[The subclavian vein catheter related infections (author's transl)]. / Les complications infectieuses du cathétérisme de la veine sous-clavière.

The aim of the present investigation was to study the possible means to prevent the subclavian vein catheter related infections. The tip of the catheter and the part situating at the skin puncture were cultured using the semiquantitative culture method. The growth of the micro-organisms was divided into three groups: classical pathogenic, opportunistic and non pathogenic. We did not find any growth in 64 p. cent of the catheters. The puncture site gave growth in 15 p. cent, the catheter tip in 6,5 p. cent and both of them in 14 p. cent In this study four cases (1,5 p. cent) of septicemias were found. In these cases Streptococcus fecalis was the most common microorganism. The aim of the semiquantitative culture method was to differentiate a real catheter related infection and contamination. The real infection was found only in 32 catheter tips though growth was seen in 54 catheter tips. According to this investigation it seems that the most important factor in preventing catheter related infections was strict sterility during the catheter placement as well as during the maintenance. A small dose of heparin probably reduces the formation of fibrin sleeve around the catheter tip and thus prevents infections. The time the patient is catheterized is also of importance, patients with catheter related septicemia had twice as long duration than cases without growth of catheter tip.