A prospective randomized double-blind trial of bolus urokinase in the treatment of established Hickman catheter sepsis in children
Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, United States Journal of Pediatric Surgery
(Impact Factor: 1.39).
07/1994; 29(6):742-5. DOI: 10.1016/0022-3468(94)90359-X
The incidence of Hickman catheter sepsis is 10% to 40%, with resultant catheter loss in one third of infections. Urokinase causes dissolution of colonized intracatheter fibrin thrombi and may improve salvage.
To evaluate the efficacy of 12-hour-interval slow-push urokinase infusion in addition to standard antibiotic therapy in the treatment of catheter sepsis in a pediatric oncology population.
A two-arm randomized double-blind trial was undertaken, with catheter salvage rate as the end point. Patients with Hickman catheter sepsis were randomized after culture data confirmed the diagnosis. The study drug was administered by a slow intravenous push and given at 12-hour intervals for a total of four doses. The catheters were aspirated after 1 hour.
The trial was stopped after 41 patients were entered into the study; 18 patients received a placebo, and 23 received the urokinase. In the placebo group, six catheters were lost; in the urokinase group, eight were lost. The rate of bacterial clearance was equivalent for both. After administration of the study drug, each group had three episodes of fever and chills; two of these resulted in hypotension (one in each group). The authors conclude that slow-push urokinase infusion during established Hickman catheter sepsis does not result in improved catheter salvage or bacterial clearance. Slow intravenous push infusions in this setting may provoke hemodynamic instability even after initiation of antibiotics.
Available from: Amado Salvador Pena
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ABSTRACT: In children and adolescents from two areas of Costa Rica with contrasting gastric cancer risks, two factors suspected to be linked to the natural history of the disease were tested: serum antibodies to Helicobacter pylori and serum pepsinogen levels. One hundred fifty-five subjects from the high-risk area of Turrubares were compared to 127 from the low-risk area of Hojancha. No significant differences were found in the prevalence of IgG or IgA antibodies to Helicobacter pylori between the two regions. The prevalence of IgG was 65.8% in the high-risk area and 72.4 in the low-risk area, and that of IgA was 43% in both areas. The levels of pepsinogen, especially pepsinogen C, were significantly elevated in subjects with H. pylori antibodies in their serum. The mean levels of pepsinogen C in those negative, positive, and strong positive for H. pylori antibodies were 8.7, 14.3, and 21.1 ng/ml. These findings suggest that H. pylori-associated gastritis, predominantly of antral localization, is very prevalent in Costa Rican children and adolescents. Such gastritis might be associated with a high prevalence of intestinal metaplasia and a high gastric cancer risk in the inland, but not the coastal rural populations. H. pylori may therefore be an insufficient cause whose role in gastric carcinogenesis is contingent upon the presence of other factors.
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ABSTRACT: Urokinase plasminogen activator was used in combination with antibiotic therapy given through the catheter to improve the treatment of right atrial catheter infections.
One hundred fifty-four episodes of bacteremia and candidemia occurring in 97 children with malignant or hematologic conditions were treated. After 24 hours of antibiotic therapy, 1 ml urokinase (5000 units/ml) was instilled, dwelling 1 hour, and then removed; this was repeated within 24 hours. Antibiotic therapy was continued for then removed; this was repeated within 24 hours. Antibiotic therapy was continued for 10 to 35 days. Administration of urokinase was repeated once if infection recurred within 8 weeks of initial treatment.
There were no adverse affects from administration of urokinase. Bacteremia clearance failed after initial administration of urokinase in 12 episodes; this failure was mostly associated with the presence of gram-positive organisms. Blood culture results remained positive in three cases after repeat therapy. Bacteremia recurred in 15 of 125 episodes; in three cases bacteremia did not clear after repeat administration of urokinase or recurred again. Recurrence was lowest for gram-negative organisms and Candida sp. Less than 5% of catheters were removed as a result of treatment failure.
Administration of urokinase combined with antibiotic therapy is safe and may be effective in treating bacteremia and candidemia in patients with right atrial catheters. Use of urokinase may improve treatment of organisms that are otherwise difficult to control and may prevent recurrence of infection.
Available from: John Greene
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ABSTRACT: Although the management of CVC-related infection appears complex and at times the literature seems to be contradictory, simple guidelines can direct the clinician in a stepwise fashion. Knowledge of the pathogenesis of each organism and the immune status of the host is crucial to decide whether catheter removal or retention is indicated. For example, in general, GNB bacteremia does not immediately prompt catheter removal in a neutropenic patient but does in a nonneutropenic host because of the gastrointestinal source of the former and a primary catheter source in the latter. In summary, as more CVCs are inserted in patients undergoing chemotherapeutic, antimicrobial, transfusional, and nutritional supportive care, novel approaches to prevention and treatment of the associated infectious complications inherent with such devices are needed. A multifaceted approach from impregnated catheters to local catheter-site antisepsis was reviewed. We may find, however, that as simple handwashing between patients is crucial to infection control, so too is a trained catheter-care team using total barrier precautions and ensuring proper local catheter maintenance critical to preventing CVC-related infections.
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