ArticlePDF AvailableLiterature Review

Infection of totally implantable venous access devices: A review of the literature

  • Azienda Ospedaliera Universitaria Careggi, Italy, Firenze


Totally implantable venous access devices, or ports, are essential in the therapeutic management of patients who require long-term intermittent intravenous therapy. Totally implantable venous access devices guarantee safe infusion of chemotherapy, blood transfusion, parenteral nutrition, as well as repeated blood samples. Minimizing the need for frequent vascular access, totally implantable venous access devices also improve the patient’s quality of life. Nonetheless, totally implantable venous access devices are not free from complications. Among those, infection is the most relevant, affecting patients’ morbidity and mortality—both in the hospital or outpatient setting—and increasing healthcare costs. Knowledge of pathogenesis and risk factors of totally implantable venous access device–related infections is crucial to prevent this condition by adopting proper insertion bundles and maintenance bundles based on the best available evidence. Early diagnosis and prompt treatment of infection are of paramount importance. As a totally implantable venous access device–related infection occurs, device removal or a conservative approach should be chosen in treating this complication. For both prevention and therapy, antimicrobial lock is a major matter of controversy and a promising field for future clinical studies. This article reviews current evidences in terms of epidemiology, pathogenesis and risk factors, diagnosis, prevention, and treatment of totally implantable venous access device–related infections.
The Journal of Vascular Access
1 –13
© The Author(s) 2018
Reprints and permissions:
DOI: 10.1177/1129729818758999
J VA e Journal of
Vascular Access
Long-term venous access devices (LTVADs) are essential
for reliable and safe administration of repeated intrave-
nous antineoplastic and antimicrobial therapy, total paren-
teral nutrition (PN), blood products, and blood
samplings.1–3 Guidelines strongly recommend their use
for preventing venous toxicity by chemotherapy agents
and for reducing anxiety and discomfort associated to
repeated venous access.4 First introduced in 1982,5 totally
implantable venous access devices (TIVADs) are particu-
lar types of LTVAD, which are constituted by a silicon or
polyurethane central venous catheter (CVC), usually
inserted in a vein of the supra-/infraclavicular area, and
then connected—with or without tunneling—to a reser-
voir implanted subcutaneously in the upper thoracic
region, usually over the pectoral muscle (so-called “chest
port”); as an alternative option, the catheter may be
Infection of totally implantable
venous access devices: A review
of the literature
Fulvio Pinelli1, Elena Cecero2, Dario Degl’Innocenti3,
Valentina Selmi1, Rosa Giua2, Gianluca Villa2, Cosimo Chelazzi1,
Stefano Romagnoli1 and Mauro Pittiruti4
Totally implantable venous access devices, or ports, are essential in the therapeutic management of patients who
require long-term intermittent intravenous therapy. Totally implantable venous access devices guarantee safe infusion
of chemotherapy, blood transfusion, parenteral nutrition, as well as repeated blood samples. Minimizing the need for
frequent vascular access, totally implantable venous access devices also improve the patient’s quality of life. Nonetheless,
totally implantable venous access devices are not free from complications. Among those, infection is the most relevant,
affecting patients’ morbidity and mortality—both in the hospital or outpatient setting—and increasing healthcare costs.
Knowledge of pathogenesis and risk factors of totally implantable venous access device–related infections is crucial
to prevent this condition by adopting proper insertion bundles and maintenance bundles based on the best available
evidence. Early diagnosis and prompt treatment of infection are of paramount importance. As a totally implantable
venous access device–related infection occurs, device removal or a conservative approach should be chosen in treating
this complication. For both prevention and therapy, antimicrobial lock is a major matter of controversy and a promising
field for future clinical studies. This article reviews current evidences in terms of epidemiology, pathogenesis and risk
factors, diagnosis, prevention, and treatment of totally implantable venous access device–related infections.
Totally implantable venous access devices, catheter-related infections, catheter-related bloodstream infections, central
line–associated bloodstream infections, port
Date received: 18 September 2017; accepted: 28 December 2017
Department of Anesthesia and Intensive Care, Azienda Ospedaliero-
Universitaria Careggi, Florence, Italy
2Department of Health Science, University of Florence, Florence, Italy
3 School of Human Health Sciences, University of Florence, Florence,
4Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
Corresponding author:
Fulvio Pinelli, Department of Anesthesia and Intensive Care, Azienda
Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50012 Florence,
758999JVA0010.1177/1129729818758999The Journal of Vascular AccessPinelli et al.
2 The Journal of Vascular Access 00(0)
inserted in a vein of the upper limb and connected to a
reservoir placed in the upper arm over the biceps muscle
(so-called peripherally inserted central catheter (PICC)-
port) or—though quite exceptionally—it may be inserted
in the femoral vein (so-called groin port). TIVADs mini-
mize complication rate related to central venous access if
compared to other LTVAD,6–10 provide a better cosmetic
appearance and let patients perform activities of daily liv-
ing more easily.11 Nonetheless, TIVADs are not free from
early and late complications. Infection is certainly the
most relevant and one of the most common complica-
tions, being a frequent cause of removal,2,3,7,12 thereby
reducing the cost-effectiveness of the TIVAD itself and,
more importantly, determining an increase in morbidity
and mortality.13–16 We reviewed current literature about
TIVAD-related infections, providing insight into preven-
tion and discussing the challenges associated with diagno-
sis and management of this relevant complication.
While certainly being one of the most frequent TIVAD-
related complications, infection has a huge variability in
terms of incidence rate throughout the literature. Recent
papers report infection rates ranging from 0.018
events/1000 catheter days to 0.35 events/1000 catheter
days in adult cancer patients,17–22 while a higher infec-
tion rate (1.21/1000 catheter days) was reported in a
study on pediatric oncology patients.23 These recent data
are not much different from the incidence reported in
less recent studies in cancer patients, that is, a range
from 0.11 to 0.37/1000 catheter days,2,3,24–30 but also in
patients with cystic fibrosis.31–34 Despite this variability,
which could be ascribed to various factors related, for
example, to the type of population studied or to the study
design, there is no doubt that TIVAD-related infection is
the most frequent indication to port removal.26,27,29,35–38
In a recent French study on a cohort of patients with
solid tumors, port-related infections required TIVAD
removal in 81% of the cases, while conservative treat-
ment was feasible only in a minority of patients.37
Moreover, in the same study, 48% of the TIVAD-related
infections were associated with complications, including
25% of septic shock. A high incidence rate of death at
12 weeks (46%) has been reported in patients with
TIVAD-related infection.39 All this considered, it is evi-
dent that TIVAD-related infections have a relevant
impact on morbidity and mortality, both in the hospital
or outpatient setting. Furthermore, the cost associated
with each episode of catheter-related bloodstream infec-
tion (CRBSI) is particularly relevant, being associated
with several expensive interventions (diagnostic proce-
dures, forced hospitalization, antibiotic treatment,
removal and placement of a new device, etc.).
Pathogenesis of TIVAD-related
When dealing with TIVAD-related infection, it is impor-
tant to understand the mechanisms underlying the bacterial
colonization of an implantable intravascular device. First,
extra-luminal contamination (i.e. migration of organisms
along the external surface of the catheter) may occur dur-
ing TIVAD insertion, particularly if appropriate antiseptic
procedures are not adopted.40,41 Extra-luminal colonization
during port maintenance may also occur (inappropriate
disinfection of the skin before insertion of the Huber nee-
dle). Though, in TIVADs, the most frequent route of con-
tamination is intraluminal (i.e. migration of organisms into
the lumen of the catheter after contamination of the cathe-
ter hub or, less frequently, after infusion of contaminated
solutions). Another possible but infrequent route of cathe-
ter colonization is hematogenous (i.e. contamination from
blood-borne bacteria coming from a distant source42–44).
As the microorganisms interact with the catheter, bacte-
rial colonization of the device may occur by different
mechanisms. First, anytime a catheter is placed in the
bloodstream, its external surface is slowly but inevitably
wrapped by a connective tissue—the so-called fibrin sheath
or fibrin sleeve or (more appropriately) fibroblastic
sheath—which is the physiological response of the blood to
the foreign body (the venous catheter) placed into the ves-
sel.45,46 Even if the bare surface of the catheter is inhospita-
ble to colonization, this fibroblastic sheath may theoretically
host a subsequent bacterial or fungal colonization.42,47
Though, there is still no convincing evidence that the fibro-
blastic sheath may actually favor the growth of the micro-
organisms, considering that sheath formation happens in
100% of VADs, while the event of a CRBSI is fortunately
quite uncommon.
However, on the internal surface of the catheter, the
organisms which are constantly present in the lumen attach
to the walls of the catheter, forming colonies and secreting
a sticky polysaccharide matrix that forms the so-called
biofilm, which is an ideal microenvironment for bacterial
survival.42,48 The transition of microbes from the attach-
ment to the walls inside the biofilm to a free-floating form
can lead to injection of bacteria into the bloodstream, with
subsequent bacteremia and sometimes a clinically evident
bloodstream infection. This progression from catheter col-
onization (a phenomenon constantly present in any intra-
vascular device, with no exception) to CRBSI (a relatively
rare occurrence) is probably related to the virulence of the
germs, but it may also be a quantitative phenomenon, as
the number of organism present in the biofilm is propor-
tional to the risk of bacteremia, which in turn increase the
probability of developing a CRBSI.49 In addition, the bio-
film itself may increase the pathogenicity of microbes, act-
ing as a barrier toward host defense mechanisms and
Pinelli et al. 3
potentially making them less susceptible to antimicrobial
The microorganisms responsible for TIVAD-related
infections are various, essentially represented by bacteria
and fungi. As regards bacteria, Coagulase-Negative
Staphylococci (CoNS) are frequently encountered, fol-
lowed by Staphylococcus aureus, while Candida species
are the most common pathogens among fungi.17,18,37,38,55
Some studies have also reported a high frequency of gram-
negative strains as responsible for port infection, like
Klebsiella species and Escherichia coli or Pseudomonas
aeruginosa.19,21,23,27,56,57 This variability is likely related to
different variables as the characteristics of the patient pop-
ulation, the type of intravenous treatment (i.e. PN vs
chemotherapy), and the nature of the environmental micro-
flora. As CoNS are part of the normal flora of the human
skin, their frequent role as pathogens is suggestive of
extra-luminal contamination due to inadequate skin disin-
fection before the insertion of the Huber needle.
Risk factors
The knowledge of the risk factors associated with TIVAD-
related infections is important in order to adopt preventive
measures targeted to lower and ideally reduce to zero early
and late infectious complications. Several studies have
focused on the assessment of patient-related risk factors.
Among cancer patients, those with hematologic malignan-
cies suffer of higher infection rates,12,17,19,28,58–60 and both
young age and a low white blood cell count represent addi-
tional risk factors.12,23,27,28,61 The existence of an underly-
ing hematologic malignancy is more significantly
associated with late infections than with early local infec-
tions, and impaired immunity caused by both the disease
itself and an intensive chemotherapy schedule may also be
responsible of such complications.17,35,58,62 HIV-infected
cancer patients are reported to have a high incidence rate
of TIVAD-related infections, up to 3.20/1000 catheter
days,56,63–65 while diabetes does not seem to increase port
infections rate in cancer patients.66,67 However, diabetes
was found to be a risk factor for port infection in cystic
fibrosis.68 Placement of the port in hospitalized patients
was also associated with higher risk of developing a
TIVAD-related infection if compared to port placement in
outpatients; this may be easily explained by the risk sec-
ondary to a prolonged exposition to nosocomial flora.6,17,20
Indications for TIVAD placement may affect infection
rate: palliative chemotherapy was found to be associated
with a higher risk than adjuvant chemotherapy.12,17,19 The use
of port for PN also increases the risk of TIVAD-related infec-
tions, possibly because of PN itself, since both lipids and
amino-acids favor bacterial colonization and biofilm forma-
tion or also because of the more frequent manipulations of
the line associated with this kind of treatment.25,38,61,67,69 As
regards the site of port placement, insertion at the chest
(chest-port) and in the upper limb (PICC-port) share an iden-
tical risk of infectious complications,70 while ports placed
with a femoral venous access (groin ports) have a higher
infection risk.20,71 The obsolete technique of venous cannula-
tion by venous cut-down is also associated with a very high
risk of infection and is discouraged by the Centers for
Disease Control and Prevention (CDC) guidelines. Technical
difficulties at the time of insertion (for instance, repeated
attempts during “blind” cannulation of the veins with the
landmark technique) may increase bacterial colonization
because of prolonged procedural time and occurrence of
local hematomas.61 In this regard, real-time ultrasound-
guided puncture and cannulation of the vein appear to have a
role not only for the prevention of mechanical complication
but also for the prevention of infection. The most obvious
and relevant risk factor related to the technique of insertion is
nonetheless the omission of those interventions which are
recommended by the international guidelines for a proper
prevention of intra-procedural contamination during inser-
tion: choice of a dedicated ambient for performing the proce-
dure, appropriate hand hygiene before the procedure, skin
antisepsis with 2% chlorhexidine in alcohol, maximal barrier
precautions (sterile gloves, sterile gown, non-sterile mask,
non-sterile cap, and long sterile cover for the ultrasound
probe), and use of an intra-procedural checklist.
Frequent manipulation of the line, typically in hospital-
ized patients and more particularly in immunosuppressed
patients, is known to increase infection rates.63,72 The
appropriate interval between TIVAD placement and its
first use is controversial. The old-fashioned recommenda-
tion was to wait at least 24 h before the first use, but some
authors have reported shorter intervals without any
increased risk of infection;73–75 however, a few other stud-
ies suggest a reduction of infection and removal rate by
adopting longer intervals (>6 days) between placement
and first use.76,77 Finally, to our knowledge, only one study
considered the type of device as a possible risk factor for
TIVAD-related infections; as the interpretation of this
study has many concerns (one above all: the TIVADs were
inserted with the obsolete technique of venous cut-down)
and the two types of ports were different under too many
aspects (size, material and shape of the reservoir; size and
material of the catheter; etc.), it is difficult to understand
which features of the device might have an impact as
TIVAD–CRBSI prevention strategies.21 Other studies are
necessary to confirm or disprove this evidence, since dif-
ferent devices may differ in many structural features.
Signs and symptoms of local and/or systemic infection
may represent a suspicion of catheter-related infection, but
its confirmation requires microbiological methods and
4 The Journal of Vascular Access 00(0)
precise criteria. Samples for culture should be obtained
before the initiation of antibiotic therapy: current Infectious
Diseases Society of America (IDSA) guidelines recom-
mend the simultaneous culture of blood from the device
and blood from a peripheral vein. Since the risk of false
positive due to contamination during peripheral blood cul-
ture is very high, skin preparation before peripheral veni-
puncture for blood culture should be done exclusively with
2% chlorhexidine in alcohol. As defined by the Guidelines
of the IDSA,78 TIVAD-infective complications can be
local, of the bloodstream—CRBSIs—or both. Local infec-
tions include infections of the tract of tunneled catheter
(tenderness, erythema, and/or induration more than 2 cm
along the subcutaneous tract of the catheter) or infections
of the pocket (tenderness, erythema, and/or induration
over the pocket; spontaneous rupture and drainage, puru-
lent collection or skin necrosis). Both can be associated
with concomitant bloodstream infection. As the same
Guidelines strongly recommend, when a local infection is
suspected, it is mandatory to obtain samples for culture
from swab of the drainage; culture of peripheral blood
should be done to rule out systemic infection.78 In case of
local skin infection, blood samples should not be taken
from the port, because of the risk of spreading the infec-
tion. In all other cases, blood cultures should always be
obtained from both the device and a peripheral vein.
The diagnosis of CRBSI is based on one of the follow-
ing: (a) positive blood culture from a peripheral vein, with
either positive semi-quantitative (>15 colony-forming
units (CFUs)/catheter segment) or quantitative (>103
CFU/catheter segment) culture, with concomitant positive
culture of the same organism from a catheter segment; (b)
simultaneous positive cultures of blood samples from the
catheter and from a peripheral vein, as long as the quantita-
tive essay shows a ratio of at least 5:1 (TIVAD vs periph-
eral); and (c) simultaneous positive cultures of blood
samples from the catheter and from a peripheral vein, with
the catheter blood becoming positive at least 2 h before the
positivity of peripheral blood. The latter, known as delayed
time to positivity (DTP), is currently regarded as the most
accurate and most cost-effective diagnostic method.
When the TIVAD is removed, a negative culture of the
catheter tip cannot exclude the diagnosis; culture of the
material inside the reservoir may be more sensitive than
catheter tip culture for the diagnosis of CRBSI;79 there-
fore, the internal lumen of the reservoir should be cul-
tured.79 Nevertheless, simultaneous quantitative blood
cultures and the differential time to positivity of qualitative
blood cultures, which do not require port removal, are the
most frequently used methods for diagnosis.80
In terms of cost-effectiveness, DTP is today the method
to be preferred, since quantitative culture is relatively
expensive and not easily available in all labs. This implies
that in the case of suspected port-related infection, the first
intervention must be a simultaneous culture of blood from
a peripheral vein and blood from the device: (a) the diag-
nosis of port-related infection will be confirmed only if the
same germ is cultured on blood samples, as long as the
culture of the blood from the device becomes positive at
least 2 h before the peripheral culture; (b) the simultaneous
growth of germs in both blood samples at similar times of
positivity (or an early positivity in the peripheral blood) is
diagnostic for a bloodstream infection non-related to the
device; (c) the presence of germs exclusively in the blood
drawn through the device will imply a diagnosis of coloni-
zation, without bloodstream infection; (d) the presence of
germs exclusively in the peripheral blood culture will usu-
ally suggest a false positive due to contamination (typi-
cally because of inadequate skin antisepsis before blood
Strategies to prevent port infections should start from the
insertion. A scrupulous attention and adherence to guide-
lines is required to minimize the risk of incoming complica-
tion. The guidelines we refer to are epic3 2014 guidelines40
and Centers for Disease Control and Prevention (CDC)
2011 guidelines,81 as well as the very recent Infusion Nurses
Society (INS) 2016 guidelines.82
Prevention starts with working in a clean environment
every time a port is placed or handled. An operating room
or a radiological suite recently used for clean-contaminated
or contaminated procedures is not an appropriate environ-
ment. The ideal environment is a procedural suite strictly
dedicated only to TIVAD insertion (or more generally to
LTVAD insertion). Hand hygiene is mandatory because
hand-mediated transmission is a major contributing factor
in the acquisition and spread of infection in hospitals, and
washing hands either with water and soap or with waterless
alcohol-based hand rub is associated with a reduction in
infections.83,84 Alcohol scrub is known to be more effective
than washing with water and soap: the latter is to be pre-
ferred only in specific situations (for instance, when there is
visible dirt on the hands or when there is a risk of contami-
nation by spore-forming bacteria). Using an aseptic surgi-
cal technique during port insertion with maximal sterile
barrier precautions (i.e. cap, mask, sterile gown, sterile
gloves, a sterile full-body drape, and a long sterile cover for
the probe) lowers the rate of infection.85 It is very important
to educate healthcare staff and periodically assess knowl-
edge of and adherence to guidelines.86,87 The use of check-
lists at the time of insertion has been proven to be effective
both as an educational tool and as a tight verification of the
adherence to the guidelines during each maneuver.
Most guidelines also agree that venous cannulation by
real-time ultrasound guidance effectively reduces the risk
of intra-procedural contamination if compared to the
“blind” cannulation by landmark technique or to the
venous cutdown.54,88
Pinelli et al. 5
During insertion and usage of port, appropriate prepara-
tion of the skin also reduces the risk of catheter-related
infection. This is a crucial point. Indeed, microorganisms
that colonize the skin are the cause of most CRBSI.17
Many investigations have been performed to identify the
most effective antiseptic agent for skin preparation.89–91
Chlorhexidine gluconate in alcohol has shown to lower
rates of catheter colonization or CRBSI more than povi-
done-iodine or alcohol alone.90 A recent review and meta-
analysis by Maiwald and Chan92 showed that chlorhexidine
gluconate is more efficient than povidone-iodine, but that
the presence of alcohol provides additional benefit.
According to guidelines,40 skin at the insertion site must be
decontaminated with a single-use application of 2% chlo-
rhexidine gluconate in 70% isopropyl alcohol and it must
be allowed to dry 30 s prior to start the procedure. Povidone
iodine should be used only in patients with known allergy
to chlorhexidine. Application of antimicrobial ointments
to the port wound at the time of insertion is not recom-
mended because the efficacy of this practice for infection
prevention is uncertain and it even might promote fungal
infections and antimicrobial resistance.40 However, the
risk of local wound infection after port implantation may
be reduced by proper choice of the site of the pocket (ide-
ally: just below the clavicle for chest ports; at the upper
arm for PICC ports) and avoidance of transcutaneous
sutures which are inevitably associated with bacterial con-
tamination of the subcutaneous tissue which host the reser-
voir (this implies skin closure of the pocket wound with
intradermal stitches and/or cyanoacrylate glue).
Systemic antibiotic prophylaxis before or during port
insertion is not recommended—and even overtly discour-
aged—by international guidelines.78 A recent meta-analy-
sis from Johnson et al., including four studies and 2154
patients undergoing port placement, demonstrated no sta-
tistically significant effect of antibiotic prophylaxis on
rates of infection. Unnecessary administration of antibiot-
ics results in a higher risk of allergic reactions, may help
the development of multidrug-resistant organisms, and
increases the costs of healthcare.93
There is no convincing evidence that antibiotic lock
solutions should be used routinely to prevent CRBSIs.
Most of the studies available are conducted in hemodialy-
sis patients. Prophylactic antibiotic lock therapy (ALT) has
shown only marginal benefit in oncologic patient.94 In
addition, concerns exist about the potential side effects
(toxicity, allergic reactions, and emergence of bacterial
resistance) associated with the antibiotic drug. Therefore,
the CDC guidelines suggest to consider prophylactic anti-
biotic lock only in patients with long-term catheters who
have a history of multiple CRBSI despite optimal maximal
adherence to aseptic technique.8
A possible prevention of strategies in patients with
LTVAD at high risk of infection may also be represented
not by the prophylactic antibiotic lock but by the
prophylactic lock with non-antibiotic antimicrobial agents
such as taurolidine, citrate, or ethylenediaminetetraacetic
acid (EDTA), possibly in association.82,95 The interest in
testing these agents is high, since they are safe, inexpen-
sive, and effective against all germs and are not associated
with the risk of eliciting allergic reactions or bacterial
Lock prophylaxis
Let us analyze more closely the pros and cons of the pro-
phylactic lock. Antibiotic lock prophylaxis, the periodic
loading of the dead space of the device with a highly con-
centrated antibiotic solution, is a technique proposed for
prevention of CRBSI. The solution of antibiotic is allowed
to dwell—or is “locked”—inside the catheter while the
CVC is not in use, so to reduce the degree of colonization
and decrease the risk of infection. Prophylactic antibacte-
rial lock is expected to reduce the bacterial colonization of
the device, but data available are still not conclusive for
scarcity of strong evidence from high-quality scientific
studies.8 Furthermore, there are concerns about the risk of
non-infective complications96 and the possible emergence
of resistances.97 Clinical practice guidelines recommend to
consider a prophylactic lock not routinely, but just for
patients with a history of multiple CRBSI in spite of adher-
ence to strict aseptic measures and in cases where the event
of infection would be particularly hard to manage, such as
in the case of patient with limited venous resources.8,78,82
Lots of antibiotic lock solutions have also been evaluated,
mostly on hemodialysis catheters, either alone or in com-
bination, including vancomycin, gentamicin, cefazolin,
cefotaxime, minocycline, ciprofloxacin, and linezolid.97
Though, despite their efficacy, antibiotic agents may not
be the best choice for a prophylactic lock.
As a matter of fact, in this setting, non-antibiotic sub-
stances with antimicrobial proprieties are an interesting
area of development. Prophylactic locks with ethanol, tau-
rolidine, citrate, or EDTA have been studied in the last
years. Several studies on the effect of ethanol in preventing
CRBSI, both in children and adults, have been publis
hed98–105 and suggest that prophylactic ethanol lock (EL)
decreases the rates of infection and catheter removal. In
those studies, the most effective ethanol concentration was
70%.106 Despite good results with ethanol prophylaxis,
there are concerns about safety. In fact, the use of ethanol
could be associated with structural changes in catheters
and it may affect catheter integrity (mostly, first-genera-
tion polyurethane, but also silicone and carbothane cathe-
ters).107 Concerns exist also about the possible systemic
toxicity of ethanol, such as tiredness, headaches, dizziness,
nausea, light-headedness, and abnormalities of liver func-
tion test.108,109 Moreover, a placebo randomized controlled
trial (RCT) of daily EL to prevent CRBSI in patients with
tunneled catheters found that the reduction in the incidence
6 The Journal of Vascular Access 00(0)
of infections using preventive EL was non-significant,
although the low incidence of CRBSI due to intraluminal
contamination may preclude definite conclusions; also, the
low incidence of CRBSI in the placebo group suggests that
the study was underpowered.110 Furthermore, ethanol is
known to interact with serum proteins and other proteins,
inducing their precipitation and subsequent lumen occlu-
sion. Finally, no study with EL in ports is currently
A promising non-antibiotic lock solution is taurolidine,
which has a large spectrum of activity against bacteria and
fungi.111 Commonly used taurolidine concentrations111
(1.35%–2%) are at least 10 times higher of the minimal
inhibitory concentration (MIC) 50 of the majority of
Gram-positive and Gram-negative microorganisms.
Several studies on the effect of taurolidine in preventing
CRBSI found that its use was associated with a reduced
CRBSI rate compared to other control lock solutions also
in high-risk patients.17,112–114
A recent report from Liu et al.,115 evaluating three stud-
ies involving 236 patients with a total of 34,984 catheter
day, indicated that catheter locking with taurolidine-citrate
reduced the incidence of CRBSI and Gram-negative bacte-
rial infection, whereas it was associated with an increased
risk of catheter obstruction. Moreover, no adverse effects or
development of resistance have ever been reported with the
use of taurolidine.111 The association with citrate appears to
be particularly promising,95 considering that the two sub-
stances may have a synergic effect against the biofilm.
Indeed, citrate—apart from its anticoagulant properties—
has well-defined antibacterial effects, but not exclusively
due to its capacity of demolishing the biofilm. The antibac-
terial effect of citrate is already present at concentration of
4%, and it increases progressively up to 40%; although
very high concentrations are potentially harmful if acciden-
tally infused into the circulation, they are not generally
Finally, a new promising drug with very high anti-bio-
film and antibacterial effects is tetra-sodium EDTA; in
spite of a lot of experimental evidence, clinical studies are
still insufficient.116
Last but not least, it is noteworthy that no randomized
clinical study has specifically assessed the effectiveness
and safety of such non-antibiotic antimicrobial substances
(ethanol, taurolidine, citrate, and EDTA) in preventing
TIVAD-related infections.
When a port-related BSI is diagnosed, specific therapy with
standard antimicrobial agents should be initiated as soon as
possible. These infections are most commonly caused by
CoNS, S. aureus, and Candida species and less commonly
by Bacillus species, Corynebacterium jeikeium, Enterococci,
rapidly growing Mycobacteria, and Gram-negative bacilli.28
The treatment usually includes the removal of the device
and a systemic antimicrobial therapy.117 Nevertheless, in
some situations (expected risks during the removal of the
device or expected difficulties in placing a new access due
to exploitation of the venous patrimony), the salvage of the
device may be taken into consideration.78
The removal of the device is obviously mandatory in
the presence of a tunnel or of a pocket infection or in the
presence of a complicated BSI (BSI with severe sepsis or
septic shock, endocarditis, septic thrombophlebitis, osteo-
myelitis, or other hematogenous seeding).78 A non-compli-
cated CRBSI due to S. aureus and Candida spp. is also an
indication for port removal.
If a non-conservative strategy is decided, the TIVAD is
promptly removed. The time between the clinician’s decision
to remove the port and its actual removal is a variable signifi-
cantly associated with the occurrence of complications.37
If a conservative strategy is decided, in cases of uncom-
plicated CRBSI not caused by S. aureus or Candida spp., a
therapy with systemic antibiotics in combination with ALT
should be considered.78 The TIVAD should also be
removed if blood cultures are persistently positive 72 h
after antibiotics are started (when no other site of infection
has been identified) or if bacteremia recurs shortly after
completion of a course of antibiotics.118
In case of a tunnel infection or a pocket infection, cul-
tures of local discharge and blood cultures should be
obtained. These infections usually require prompt catheter
removal, incision, and drainage if indicated and 7–10 days
of antibiotic therapy with modification of empiric antibiot-
ics based on cultures and the antibiotic susceptibilities of
the recovered pathogens.78
Once a CRBSI is diagnosed, specific therapy with
standard antibiotic agents should be initiated as soon as
possible. ALT is indicated when catheter salvage is the
goal for patients with uncomplicated CRBSI involving
long-term catheters.78 The duration of antimicrobial ther-
apy depends on several factors including type of microor-
ganism implicated, catheter removal or retention, clinical
response to antimicrobial therapy within the first 48–72 h,
and the possible development of other complications.
According to the IDSA,78 strategies for managing CRBSI
vary by pathogen.
Though there is no data from randomized trials with
adequate sample size to determine the optimal duration for
the treatment, patients with S. aureus CRBSI should have
the infected catheter removed, and they should receive
4–6 weeks of antimicrobial therapy because of the risk of
infective endocarditis.119 There are some exceptions to this
rule: in selected patients with uncomplicated CRBSI (as
long as they are not diabetic, not immunosuppressed, and
not bearer of prosthetic intravascular device), a shorter
duration of antibiotic therapy (i.e. a minimum of 14 days of
therapy) should be considered. If fever and bacteremia
persist for >72 h, the treatment should be extended to
Pinelli et al. 7
4–6 weeks.78 Early removal of the catheter within the first
3 days is associated with better outcome with a more rapid
response to therapy and/or a higher cure rate.120–122 Patients
with S. aureus CRBSI should perform a transesophageal
echocardiography (TEE) to rule out the presence of vege-
tations on the cardiac valves, suggestive for infective
endocarditis. TEE should be done at least 5–7 days after
the onset of bacteremia to minimize the possibility of
false-negative results, and it should be repeated in patients
with persistent fever or positive blood cultures 72 h after
catheter removal and start of the antibiotic therapy.123,124 In
extreme circumstances (e.g. no alternative catheter inser-
tion site), a combination of ALT and systemic therapy can
been used to salvage infected ports with S. aureus CRBSI,
and the patient should receive systemic and ALT for
4 weeks.125,126
CoNS are the most common cause of CRBSI but they
are also the most common contaminant; therefore, the
diagnostic criteria for CRBSI should be carefully respected
before initiating a specific therapy.28,127 Usually, in uncom-
plicated infections, a benign clinical course has to be
expected. After catheter removal, a systemic antibiotic
therapy for 5–7 days is the treatment of choice; otherwise,
if the catheter is retained, systemic antibiotic therapy for
10–14 days in combination with ALT is the most appropri-
ate strategy.78
In case of uncomplicated infections due to Enterococcus
species, a 7–14 day course of therapy is recommended
when the long-term catheter is retained and antibiotic lock
is used. Those infection are associated with a low risk of
endocarditis.128 In cases of CRBSI due to vancomycin-
resistant Enterococci, linezolid or daptomycin may be
The Gram-negative bacilli most commonly involved in
CRBSI are those that form biofilms and include
Enterobacter, Stenotrophomonas, Klebsiella, Pseudomonas,
and Acinetobacter species.129 Those can be multidrug-
resistant (MDR) microorganisms; therefore, in case of per-
sistent bacteremia or severe sepsis, the device should be
removed. Recent studies in which antibiotic lock and sys-
temic antibiotics were used to treat gram-negative rod
CRBSI have found high success rates.126,130,131 Treatment
over a 7-day period appears to resolve the infection. If this
approach fails (i.e. if bacteremia persists or severe sepsis
occurs despite systemic antibiotic therapy and ALT), the
device should be removed, and the duration of antibiotic
treatment should be extended beyond 7–14 days.78
According to guidelines,78 catheters should be removed
in all cases of CRBSI due to Candida species, and systemic
specific therapy should be promptly initiated. In the treat-
ment of candidemia caused by Candida albicans and azole-
susceptible strains, fluconazole should be administered for
14 days after the first negative blood culture. For Candida
species with resistance to azoles (e.g. Candida glabrata
and Candida krusei), echinocandins or lipid formulations
of amphotericin B are highly effective.132,133 Catheter sal-
vage by antifungal lock therapy is still investigational at the
present time and it is still not indicated.134,135
In patients with persistent bacteremia, a thrombophlebi-
tis should be suspected, that is, the concomitant occurrence
of a catheter-related thrombosis (diagnosed by ultrasound)
and catheter-related BSI (documented by DTP). The most
common microorganism implicated in this complication is
S. aureus.136 In thrombophlebitis due to CVCs, the optimal
management in terms of duration of treatment, anticoagu-
lants, thrombolytic agents, and so on is still to be defined.
For the management of endocarditis due to CRBSI, we
remand to specific papers on this issue.
According to guidelines of the IDSA, in cases of uncom-
plicated port-related bloodstream infection not involving
S. aureus or Candida spp., conservative treatment with
systemic antimicrobial and ALT can be considered.78
Being most catheter-related infections (CRI) associated
with intraluminal colonization and biofilm formation,
administration of high concentrations of antimicrobial
solution that dwells in the lumen for an extended period of
time might sterilize the device.
A highly concentrated antibiotic (100–1000 times MIC)
used as lock solution should have a low risk of toxicity and
adverse events, a low potential for resistance, a spectrum
of activity that include common or targeted pathogens, and
the ability to penetrate or disrupt a biofilm.137–139
Many antibiotics have been tested as lock solutions in
both in vitro models and in clinical studies, including
beta-lactams, aminoglycosides, fluoroquinolones, glyco-
peptides, oxazolidinones, polymyxins, lipopeptides, and
CRBSI due to coagulase-negative staphylococci or
Gram-negative rods131 showed high cure rates in many
clinical trials when systemic antibiotic administration is
associated with LT. In fact, the use of vancomycin or teico-
planin locks in the treatment of coagulase-negative staphy-
lococci CRBSI had an effectiveness of 88.6% in the
treatment of port-related BSI.131 Teicoplanin locks seem to
deeply reduce the failure rate compared with vancomycin
locks.141 LT with daptomycin also seems to be very prom-
ising in those patients who had failed standard therapy
with vancomycin or cefazolin.13,142 Despite guidelines
suggest port removal if P. aeruginosa infection is identi-
fied,78 ALT with flouroquinolones and aminoglycosides
has shown good outcomes for Pseudomonas spp., similar
as for Enterobacteriaceae spp.143
As we said earlier, when CRBSI is associated with
S. aureus, the catheter should be removed because of the
high failure rates of ALT (45%–60%) and risk of death,131
but in exceptional circumstances (as, for example, no other
possible site for a VADs), when complications are
8 The Journal of Vascular Access 00(0)
excluded, cefazolin and vancomycin can be used in the
attempt of catheter rescue.78
Regarding LT for Candida infections, propensity of
this fungus to form biofilms on catheters makes these
infections difficult to treat due to multiple factors,
including increased resistance to antifungal agents.144
Thus, the cure of CRBSI due to Candida spp. still
requires catheter removal in addition to systemic anti-
fungal therapy.78 Nevertheless, promising antifungal
lock therapy strategies, including use of amphotericin,
ethanol, or echinocandins, have been tested.145,146
Clinical trials are needed to further define the safety and
efficacy of this therapy.
In addition, non-antibiotic drugs have been proposed
for lock therapy (LT). The most promising is EL therapy in
combination with systemic antibiotics. In a recent review,
Tan et al. showed rates of clinical cure ranged from 67% to
100% across all studies, with an overall clinical cure rate
of 90% and overall line salvage of 84%.106 However, none
of this study was specifically carried out on TIVADs.
Clinicians have to be aware that when using LT, a solu-
tion dwell in a catheter lumen; therefore, the potential for
occlusion exists. This risk is expected to decrease if the
solution also contains an anticoagulant. The most com-
monly used anticoagulant drugs are heparin and citrate.
Flushing of the lock solution may lead to unnecessary sys-
temic concentrations of antibiotics and anticoagulants. The
risk of toxicity is limited if the lock is aspirated instead of
When a CRBSI is suspected, if catheter salvage is
decided, ALT should be initiated within the first 48–72
h. In fact, this is associated with enhanced outcomes and
improved salvage of the catheter.147 Duration of ALT is
often consistent with that of concurrent systemic ther-
apy. Current guideline recommendations of targeting
10–14 days of ALT are based on limited comparative
clinical data.78 Some authors have proposed an abbrevi-
ated courses of therapy of 72 h that may offer a more
convenient, cost-effective option and reduce the risk of
One of the main problems related to the lock therapy is
its cost in terms of time, human resources, and drug
expense. Considering that removal and insertion of
TIVADs is nowadays carried out with minimal risk of
complications (thanks to ultrasound guidance, advanced
aseptic technique, etc.), in many situations, ALT may
prove to be time-consuming and not cost-effective.
In summary, lock therapy (LT) is not yet fully standard-
ized and may not be easy to plan and to carry out in non-
expert hands: due to many concerns related to its safety, its
effectiveness, and its cost—LT is to be considered as a
strategy for port savage only in selected cases. Nevertheless,
some of these concerns may be overcome in the future by
the introduction in clinical practice of antibacterial lock
with non-antibiotic substances.
Infection is one of the most frequent and certainly the most
severe complications associated with the use of TIVADs,
being associated with an increased risk of morbidity and mor-
tality, delay in treatment, prolonged hospitalization, and ele-
vated healthcare costs. Therefore, preventive measures are of
paramount importance. Clinical guidelines strongly support
and recommend the use of specific bundles for infection pre-
vention, both at the time of insertion and during maintenance.
An ideal insertion bundle should include adoption of a dedi-
cated ambient for the procedure, proper hand hygiene, skin
antisepsis with 2% chlorhexidine, maximal barrier precau-
tions, ultrasound-guided venipuncture, appropriate choice of
the site for the reservoir, and skin closure with glue. An ideal
maintenance bundle should include hand hygiene, sterile
gloves, and skin antisepsis with 2% chlorhexidine before
placing the Huber needle; securement of the Huber needle
with transparent semipermeable dressing; aseptic manage-
ment of the infusion line, including a policy of proper scrub-
bing of the hub and/or use of disinfecting caps over the hubs;
and removal/replacement of the Huber needle within 1 week.
The cornerstone for an early, accurate, and cost-effective
diagnosis is the adoption of the method of the DTP. Prompt
treatment of the TIVAD-related infection is also mandatory:
this includes systemic antibiotic treatment and removal of the
TIVAD; early removal of the device is recommended in case
of S. aureus, Gram-Negative, or Candida infections, whereas
in non-complicated infections caused by other microorgan-
isms, a conservative strategy with a systemic antibiotic treat-
ment and ALT may be considered.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
This work was supported by “Philip and Irene Toll Gage
Foundation”. This funder has provided a grant to the Department
of Health Science of the University of Florence to economically
support the feasibility, management, coordination, statistical
analysis and recruitment of investigators for this study. The
funder had no role in study design, data collection and analysis,
decision to publish, or preparation of the manuscript.
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... Port catheters are placed in the upper thoracic region (chest port), usually above the upper pectoral muscle. More rarely, it can also be placed in the upper arm region and femoral region (inguinal port) as alternatives (9,10). Although the cost of port catheters is high, there are significant advantages, such as patients experience less pain and anxiety due to a small number of needle interventions, a lower risk of infection, and do not interfere with the activities of patients due to their complete placement under the skin (bathing, swimming, etc.). ...
... The data collection form was prepared by researchers after a literature review on port catheter care (1,2,5,8,10,17,19,20). The prepared data collection form was submitted for the opinions of ten experts, including five doctors and five academic nurses, and it was edited according to the results of their feedback. ...
... Port catheter-related infection rates are reported to be 0.018 to 0.35 per 1000 catheter days (10). Referring to port catheter-related infections, external-lumen infections are due to the lack of proper antiseptic application on the skin before the placement of Huber needles, and internal-lumen infections are due to infusion of the diluted solution into the catheter and thereby migration of organisms from the center of the catheter to the catheter lumen. ...
... 15 Even with a reduction in the risk of microbial contamination due to total implantation under the skin, 3-10% of TIVAD carriers experience a related infection, which is the most common indication for device removal. 16,17 The infection rates vary among studies because of differences in underlying disease, immunodeficiency level, and definition of device infection. 17 Our study showed an expected infection rate of 0.58, which was similar to previous studies that reported 0.09-2.8 ...
... 16,17 The infection rates vary among studies because of differences in underlying disease, immunodeficiency level, and definition of device infection. 17 Our study showed an expected infection rate of 0.58, which was similar to previous studies that reported 0.09-2.8 infections per 1,000 device-days. ...
Background: Totally implantable venous access devices (TIVADs) are frequently used in pediatric patients with cancer owing to their multiple benefits. Despite occasional infections with TIVADs, knowledge of the incidence and risk factors is limited. Methods: This retrospective study included pediatric patients with cancer who received TIVAD at Chungbuk National University Hospital from 2001 to 2021. We collected data on demographics, diagnosis, duration of TIVAD use, pathogens, and other risk factors. Results: During the study period, 55 TIVADs with 25,954 device-days were applied in 49 patients. There were 15 TIVAD infections (15/55, 27.3%), with an infection rate of 0.21 infections per TIVAD per year (0.58 cases/1,000 device-days). TIVAD infections occurred at a median of 5 months (range, 8 days-30 months) after insertion. The most common causative microorganisms were methicillin-resistant coagulase-negative staphylococci (n = 8, 53.3%) followed by Escherichia coli (n = 3, 20.0%). Infection-free TIVAD survival was higher in the group with normal platelet count at insertion (platelet counts ≥ 150,000/μL) than in the group with thrombocytopenia at insertion (platelet counts < 150,000/μL) (81.3% vs. 32.1%, P = 0.004). Device removal was the mainstay of treatment (11/15, 73.3%). Conclusion: TIVAD infection may be related to thrombocytopenia at the time of device insertion. Further studies are needed to identify preventive factors against TIVAD infections in children with cancer.
... Some complications can be avoided or treated, and the management of catheter-related infections varies according to the type of catheter involved. Still, it is always possible to guarantee the preservation of the device, and the insertion of a new device is necessary, contributing to the delay in oncologic treatment [9][10][11] . ...
... Implantable intravenous ports have been compared with external infusion devices in much literature, and the conclusions reached are that implantable intravenous ports are relatively less risky. Studies [21] have shown that implantable intravenous ports are better than PICCs in reducing the occurrence of infections in patients with hematologic malignancies, not only by greatly reducing the number of punctured veins but also by smoothly delivering drugs directly to the central vein. Also, it can not only greatly reduce the number of punctured veins, but also smoothly deliver drugs to the central vein, greatly reduce the damage of chemotherapy drugs and hypertonic drugs to peripheral veins, and reduce the occurrence of phlebitis. ...
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Background: Totally implantable intravenous ports (TIVAPs) are mostly used for long-term intravenous infusion therapy in cancer patients and can be left in the body for long periods of time for easy management, making them a simple and safe infusion device. Although the risks associated with long-term retention of fully implantable IV ports are less than those associated with other intravenous catheters, various complications may still occur at the time of implantation or during long-term use. Purpose: To provide a scientific basis for clinical reduction of implantable intravenous port-associated infection complications by studying the risk factors for catheter-associated infection complications in patients applying implantable intravenous ports. Methods: A retrospective study was conducted on oncology patients treated with TIVAP at our hospital between January 2017 and November 2021, with a review of patients who were unplanned for extubation. Their demographic data, underlying disease status, and surgery-related data were counted to summarize and analyze the complications and related influencing factors of implantation and postimplantation. Results: A total of 70 individuals with a mean age of 56.49 ± 12.19 years were included in the study. Among them, 39 were male and 64 had the highest percentage of epithelial tumors, followed by tumors of the lymphopoiesis system and mesenchymal tumors with 4 and 2 cases, respectively. Forty-eight of these patients did not have their ports removed as planned due to the occurrence of catheter-related hematogenous infections. In univariate analysis, BMI and neutropenia were risk factors for catheter-associated infections. In the multivariate analysis, BMI (OR = 1.38, 95% CI: 1.07-1.78, p=0.013) was an independent risk factor for catheter-associated infections. Conclusions: The overall complication rate of fully implanted intravenous ports was high, but most complications improved with symptomatic management, and no deaths due to port complications were identified. Infection was the most common complication, with catheter-associated bloodstream infection being the most common cause of unplanned port extraction. Patients with a higher BMI were at high risk of developing implantable IV port-associated infections, which may be an independent risk factor for implantable IV port-associated infections.
... Fortunately, the TIVAP explantation rate described in recent studies is low with a few exceptions [21,22]. Nevertheless, every single explantation means notable consequences for every patient, particularly a delay in ongoing chemotherapy for cancer treatment and difficulties for parenteral nutrition, resulting in increased morbidity, mortality, and costs [23,24]. ...
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Purpose Since their invention 40 years ago, totally implantable venous-access ports (TIVAPs) have become indispensable in cancer treatment. The aim of our study was to analyze complications under standardized operative and perioperative procedures and to identify risk factors for premature port catheter explantation. Methods A total of 1008 consecutive TIVAP implantations were studied for success rate, perioperative, early, and late complications. Surgical, clinical, and demographic factors were analyzed as potential risk factors for emergency port catheter explantation. Results Successful surgical TIVAP implantation was achieved in 1005/1008 (99.7%) cases. No intraoperative or perioperative complications occurred. A total of 32 early complications and 88 late complications were observed leading to explantation in 11/32 (34.4%) and 34/88 (38.6%) cases, respectively. The most common complications were infections in 4.7% followed by thrombosis in 3.6%. Parameters that correlated with unplanned TIVAP explantation were gender (port in situ: female 95% vs. male 91%, p = 0.01), underlying disease (breast cancer 97% vs. gastrointestinal 89%, p = 0.004), indication (chemotherapy 95% vs. combination of chemotherapy and parenteral nutrition 64%, p < 0.0001), and type of complication (infection 13.4% vs. TIVAP-related complication 54% and thrombosis 95%, p < 0.0001). Conclusion Standardized operative and perioperative TIVAP implantation procedures provide excellent results and low explantation rate.
... Totally implantable venous access devices (TIVADs) have been widely used in patients who need long-term chemotherapy or parenteral nutrition [1,2]. Demands for TIVADs in cancer patients, especially in children with cancer, are increasing rapidly in recent years [3]. ...
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Background Accurately positioning totally implantable venous access device (TIVAD) catheters and reducing complications in pediatric patients are important and challenging. A number of studies have shown methods for locating the tip of the TIVAD catheter. We assessed the success and complications of TIVAD implantation guided by transesophageal echocardiography (TEE) via the internal jugular vein (IJV) for 294 patients in this retrospective study. Methods From May 2019 to March 2021, 297 cases of TIVADs in our hospital were analyzed in this observational, non-randomized, single-center study. The position of the catheter tip under TEE and chest radiography and rates of periprocedural, early, and late complications were evaluated. Results The implantation was successful in 242 (82.3%) cases which was in a proper position, and the results were consistent with those of postoperative chest radiography. A total of 72 complications were recorded. Of these, 1 case had a perioperative complication, 66 had early complications, and 5 had late complications after port implantation. The most common complications were local infection and catheter malposition, namely 10 (13.9%) cases of incision infection and 58 (80.6%) cases of catheter malposition. In total, 6 (8.3%) cases of port explantation were required. Conclusion Confirmation of proper TIVAD catheter positioning by TEE through an internal jugular approach in children was accurate and safe.
... According to a random number table, the patients receiving arm infusion port implantation in our hospital from January 2020 to August 2021, were divided into three groups, includng 0.9% sodium chloride solution conduction group (group A), 5.45% sodium chloride solution conduction group (group B) and 10% sodium chloride solution conduction group (group C). Inclusion criteria were (1) no contraindications for arm infusion port implantation, such as hemorrhagic tendency, bacteriemia, and being allergic to silicone, rubber or titanium alloy used in the arm infusion port implantation 7 Materials. Implantable access ports were purchased from B. BRAUN MEDICAL (CHASSENEUIL, France). ...
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Abstract At present, there are few clinical studies on the application of high-concentration sodium chloride solutions in intracavitary ECG-guided catheter tip localization during the arm infusion port implantation. This study observed the effects of sodium chloride solutions with different concentrations on intracavitary ECG-guided arm infusion port implantation in the patients with cancer. The 657 patients receiving arm infusion port implantation in our hospital between January 2020 and August 2021 were randomly divided into 0.9% sodium chloride solution conduction group (group A), 5.45% sodium chloride solution conduction group (group B) and 10% sodium chloride solution conduction group (group C). The derived rate of stable intracavitary ECG, the occurrence rate of characteristic P wave, the time used for catheter tip localization and the optimal position rate of catheter tip were compared between the three groups. The derived rate of stable intracavitary ECG was significantly higher in the group B (97.78%) and group C (98.63%) than in the group A (93.90%) (all P
Introduction: Pediatric port access can be challenging in the emergency department; however, it must be performed promptly and safely. Port education for nurses traditionally includes procedural practice on adult-size, tabletop manikins, which lacks the situational and emotional aspects inherent in pediatrics. The purpose of this foundational study was to describe the knowledge and self-efficacy gain from a simulation curriculum that promotes effective situational dialogue and sterile port access technique, while incorporating a wearable port trainer to enhance simulation fidelity. Methods: An educational intervention impact study was conducted using a curriculum integrating a comprehensive didactic session with simulation. A unique element included a novel port trainer worn by a standardized patient, along with a second actor portraying a distressed parent at the bedside. Participants completed precourse and postcourse surveys on the day of simulation and a 3-month follow-up survey. Sessions were video recorded for review and content analysis. Results: Thirty-four pediatric emergency nurses participated in the program and demonstrated an overall increase in knowledge and self-efficacy with port access that was sustained at the 3-month follow-up. Data revealed positive feedback regarding the participants' simulation experience. Discussion: Effective port access education for nurses requires a comprehensive curriculum integrating procedural aspects and situational techniques to address the components of a true port access experience involving pediatric patients and families. Our curriculum successfully combined skill-based practice with situational management, and promoted nursing self-efficacy and competence with port access in the pediatric population.
Background: Complications after removal of totally implanted vascular access devices. (TIVADs) have not been studied widely. The aim of this study was to assess the prevalence and risk factors of these complications. Methods: This was a single-center retrospective study conducted in Gustave Roussy hospital in Villejuif, Ile-de-France, France. All adult patients scheduled for TIVAD removal between January 2015 and November 2019 were eligible for the study. The record of complications was compiled by noting the reason for a surgical or emergency department consultation during the month following removal, and also by calling the patients during the week of TIVAD removal to assess whether surgical advice was needed. Results: There were 2533 included patients, representing 2583 TIVAD removals. The prevalence of complications was 1.47% (n = 38), of which 0.31% were infectious complications (n = 8). These complications required surgical or interventional radiology management in 50% of cases. In multivariate analysis, two independent risk factors were associated with these complications: the duration of the surgical procedure (p = 0.04) and the active status of the underlying malignant disease (p = 0.07). Conclusions: Complications after TIVAD removal are uncommon (prevalence = 1.47%), but their morbidity appears to be high, with interventional procedures frequently needed. The duration of the removal procedure and the active status of cancer appear to be associated with the occurrence of complications.
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Introduction In this retrospective study, the safety and complication rates of port implantations via the internal jugular vein under ultrasound and fluoroscopy guidance in adult oncology patients were analyzed. Material and methods Eight hundred seven ports implanted in 799 adult oncology patients at a tertiary Oncology-Anticancer Hospital during a 36-month period from January 1, 2017 to December 31, 2019 were retrospectively reviewed. Data acquisition was obtained until December 31, 2020. All procedures were performed by two specialized interventional radiologists under ultrasound and fluoroscopy guidance. The vein access was via the internal jugular vein. Catheter days (the total number of days of maintenance of the port by all of the patients until removal, death, or December 31, 2020), technical success rates, and complication rates were evaluated based on the interventional radiological reports and patient medical records. Multivariate analysis regarding patients such as age, sex, body mass index (BMI), marital status, educational level, cancer type, side of insertion, diameter of internal jugular vein, diabetes, anticoagulants/antiplatelets, purpose of implantation, and catheter material as to the risk of complications was conducted. Results A total of 369,329 catheter maintenance days were observed (457.7±345.0). The technical success rate was 99.9%, and a total of 85 (10.5%) complications occurred, of which 24 (28.2%) occurred early (<30 days) and the remaining 61 (71.8%) were late (>30 days) complications. Specifically, 28 (3.5%) were catheter-related thrombosis (CRT), 27 (3.4%) related to infection, 17 (2.1%) were mechanical complications (16 fibrin sheath formation and one catheter occlusion), six (0.7%) related to catheter migration, four (0.5%) related to incision healing problems, and the remaining three (0.4%) related to ischemic skin necrosis. Forty-seven (5.8%) ports were removed due to complications. On multivariate analysis, cancer type was found as a risk factor for the development of a complication. Additionally, there was an indication that hematologic malignancy is related to infection. Conclusion Placement of ports via the internal jugular vein under ultrasound and fluoroscopy guidance is a safe procedure, with low rates of early and late complications.
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Objective To prospectively evaluate the perioperative safety, early complications and satisfaction of patients who underwent the implantation of central catheters peripherally inserted via basilic vein. Methods Thirty-five consecutive patients with active oncologic disease requiring chemotherapy were prospectively followed up after undergoing peripheral implantation of indwelling venous catheters, between November 2013 and June 2014. The procedures were performed in the operating room by the same team of three vascular surgeons. The primary endpoints assessed were early postoperative complications, occurring within 30 days after implantation. The evaluation of patient satisfaction was based on a specific questionnaire used in previous studies. Results In all cases, ultrasound-guided puncture of the basilic vein was feasible and the procedure successfully completed. Early complications included one case of basilic vein thrombophlebitis and one case of pocket infection that did not require device removal. Out of 35 patients interviewed, 33 (94.3%) would recommend the device to other patients. Conclusion Implanting brachial ports is a feasible option, with low intraoperative risk and similar rates of early postoperative complications when compared to the existing data of the conventional technique. The patients studied were satisfied with the device and would recommend the procedure to others.
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Totally implantable venous access devices (TIVADs) increase the quality of life in children with hematologic and oncologic diseases or organ failures. The aim of this study is to determine the reasons for port removal. The port catheters, implanted and removed in patients between January 2000 and June 2013 were evaluated retrospectively. The patients were divided into two groups, whose port catheters were removed due to completed therapy (completed therapy group, CTG) and whose port catheters were removed because of a port catheter-related complications (complication group, CG). In the CG, the patients whose port catheters are removed for infectious reasons are investigated for whether there is a relationship with age, gender, body mass index (BMI), height and weight at the time of port implantation and removal. In total, 242 patients who underwent port implantation and removal were included in the study. The male to female ratio was 1.32/1 and the mean age of the patients was 9.4±4.9 years (0-24 year). Patients were enrolled in CTG (n=170, 70.2%), and CG (n=72, 29%). There is a positive correlation between BMI and infections (p<0.05). In the CG, patients under steroid treatment had higher incidence of non-infectious causes than infectious causes (p<0.05). Oppositely, non infectious complications were higher in steroid free patients (p<0.05). There was no catheter related mortality in the entire study group. The hematological malignancies and solid tumors are the most common underlying primary disease in patients with port removal because of complications. Infectious complications are most common cause of port removal in children and despite other microorganism, fungi should be considered as a cause of catheter related infections.
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Background: The most appropriate lock solution for central venous access devices is still to be defined. GAVeCeLT - the Italian group for venous access devices - has developed a consensus on the evidence-based criteria for the choice and the clinical use of the most appropriate lock solution for central venous catheters (excluding dialysis catheters). Method: After the constitution of a panel of experts, a systematic collection and review of the literature has been performed, focusing on clinical studies dealing with lock solutions used for prevention of occlusion (heparin, citrate, urokinase, recombinant tissue plasminogen activator [r-TPA], normal saline) or for prevention of infection (citrate, ethanol, taurolidine, ethylene-diamine-tetra-acetic acid [EDTA], vancomycin, linezolid and other antibiotics), in both adults and in pediatric patients. Studies on central lines used for dialysis or pheresis, on peripheral venous lines and on arterial lines were excluded from this analysis. Studies on lock solutions used for treatment of obstruction or infection were not considered. The consensus has been carried out according to the Delphi method. Results: The panel has concluded that: (a) there is no evidence supporting the heparin lock; (b) the prevention of occlusion is based on the proper flushing and locking technique with normal saline; (c) the most appropriate lock solution for infection prevention should include citrate and/or taurolidine, which have both anti-bacterial and anti-biofilm activity, with negligible undesired effects if compared to antibiotics; (d) the patient populations most likely to benefit from citrate/taurolidine lock are yet to be defined. Conclusions: The actual value of heparinization for non-dialysis catheters should be reconsidered. Also, the use of lock with substances with anti-bacterial and anti-biofilm activity (such as citrate or taurolidine) should be taken into consideration in selected populations of patients.
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Purpose: Children with intestinal failure (IF) requiring central venous catheters (CVCs) often experience frequent catheter-related bloodstream infections (CRBSIs), which is a serious and life-threatening complication. To reduce the incidence of CRBSI, prophylactic ethanol lock therapy (ELT) was initiated. Methods: Patients with IF received home parenteral nutrition via a silicone tunneled CVC. All of them had received therapeutic ELT from January 2009 (first period) and prophylactic ELT from December 2012 (second period). Prophylactic ELT refers to ethanol lock for 2 h during the monthly hospital visit. We compared the CRBSI rate and number of CVC replacements between both periods. Results: Four patients received 19 CVCs for a total of 5623 catheter days. In the first period, there were 12 CRBSIs in 1823 catheter days (rate 6.77 per 1000 catheter days). In the second period, there were 9 CRBSIs in 3800 catheter days (rate 3.13 per 1000 catheter days). Overall, the rate of CVC replacement decreased from 4.92 to 1.72 per 1000 catheter days (p = 0.04). No adverse reactions were experienced during ethanol instillation. Conclusion: Monthly prophylactic ELT for IF patients is considered to be a safe and effective modality for reducing the replacement of CVCs due to CRBSIs.
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Candida albicans is a major cause of catheter-related bloodstream infections and is associated with high morbidity and mortality. Due to the propensity of C. albicans to form drug-resistant biofilms, the current standard of care includes catheter removal; however, reinsertion may be technically challenging or risky. Prolonged exposure of an antifungal lock solution within the catheter in conjunction with systemic therapy has been experimentally attempted for catheter salvage. Previously, we demonstrated excellent in vitro activity of micafungin, ethanol, and high-dose doxycycline as single agents for prevention and treatment of C. albicans biofilms. Thus, we sought to investigate optimal combinations of micafungin, ethanol, and/or doxycycline as a lock solution. We performed two- and three-drug checkerboard assays to determine the in vitro activity of pairwise or three agents in combination for prevention or treatment of C. albicans biofilms. Optimal lock solutions were tested for activity against C. albicans clinical isolates, reference strains and polymicrobial C. albicans-S. aureus biofilms. A solution containing 20% (v/v) ethanol, 0.01565 μg/mL micafungin, and 800 μg/mL doxycycline demonstrated a reduction of 98% metabolic activity and no fungal regrowth when used to prevent fungal biofilm formation; however there was no advantage over 20% ethanol alone. This solution was also successful in inhibiting the regrowth of C. albicans from mature polymicrobial biofilms, although it was not fully bactericidal. Solutions containing 5% ethanol with low concentrations of micafungin and doxycycline demonstrated synergistic activity when used to prevent monomicrobial C. albicans biofilm formation. A combined solution of micafungin, ethanol and doxycycline is highly effective for the prevention of C. albicans biofilm formation but did not demonstrate an advantage over 20% ethanol alone in these studies.
Background Central venous catheter (CVC) use is commonplace in cancer patients. Antimicrobial lock therapy (ALT), the instillation of a concentrated antimicrobial solution into the catheter lumen, is one method for preventing infection among CVCs. This systematic review discusses the effectiveness and safety of prophylactic ALT in cancer patients with CVCs. Methods A literature search was performed using the Medline database and Google Scholar from inception until April 2016. The following terms were used: ‘antimicrobial lock solution’, ‘antibiotic lock solution’, ‘oncology’, ‘hematology’, ‘pediatrics’, ‘prevention’, ‘cancer’, ‘catheter related bloodstream infections’, ‘central-line associated bloodstream infection’ (CLABSI) and ‘central venous catheter’. Studies evaluating prophylactic ALT in cancer patients alone were eligible for inclusion. Case reports, case series and in-vitro studies were excluded. Results In total, 78 articles were identified. Following all exclusions, 13 articles (three adult and 10 pediatric) were selected for evaluation. The most common agents utilized were vancomycin with heparin; ethanol; taurolidine; and minocycline with EDTA. Quality of evidence was moderate to high in adult studies and low to moderate in pediatric studies. Use of ALT decreased the incidence of CLABSI in the majority of studies; however, there were significant differences in definitions of CVC-related infection, dwell times and lock solutions. Conclusion Lock therapy may be an adjunct in high-risk cancer patients for the prevention of CLABSI; higher quality evidence is needed for specific ALT recommendations.
Purpose: Few in vivo studies have been reported describing efficacy and duration of antibiotic lock therapy (ALT) with daptomycin (DPT) for long-term catheter-related bloodstream infections (CRBSI) due to coagulase-negative staphylococci (CoNS). We retrospectively analysed the efficacy of short-course ALT with DPT in combination with systemic treatment (ST) for CoNS-associated CRBSI in our hospital. Methods: Patients admitted for CoNS-associated CRBSI and treated with DPT as ALT and ST were retrospectively analysed. Success was defined as preservation of the catheter device 30 days after ending treatment. Catheter removal within 30 days of discontinuing treatment, for either microbiological documentation of CRBSI relapse or re-occurrence of unexplained fever, was considered as failure. Results: Among 7610 patients admitted to the Departments of Internal Medicine/Infectious Diseases and Pneumology in Cannes from January 2013 to November 2015, we identified 28 episodes of CoNS-associated CRBSI. Seven patients died of cancer during follow-up. Thus, 21 episodes were analysed among 20 patients (median age 67 years, 12 males, all treated for neoplasia and carrying a port-a-cath® device). Staphylococcus epidermidis was the main agent responsible for CRBSI. Median duration of systemic and ALT DPT was 3 days, in combination with rifampin for 4 days and then generally followed by a switch to oral drugs, most frequently cotrimoxazole or linezolid, to achieve 14 median days of treatment. Clinical success and failure rates were 76% and 24%, respectively. Conclusions: Short-course DPT as ALT, combined with 14 days of ST, allowed conservative management of CoNS-associated CRBSI in surgically implanted-catheters in three-fourth of cases.
Approximately every 5 years, the Infusion Nurses Society publishes evidence-based practice standards. This article provides an overview of the process used in standards development, describes the format of the standards, and provides a short summary of selected standards as applied to home care. The Standards are an important document that should be available to every home care organization that provides home infusion therapy.
Background: Totally implantable venous access ports (TIVAPs) are used for prolonged central venous access, allowing the infusion of chemotherapy and other fluids and improving the quality of life of children with cancer. TIVAPs were developed to reduce the infection rates associated with central venous catheters; however, infectious events remain common and have not been fully investigated in pediatric oncology patients. Procedure: A retrospective cohort was formed to investigate risk factors for central line-associated bloodstream infection (CLABSI) in pediatric cancer patients. Sociodemographic, clinical, and TIVAP insertion-related variables were evaluated, with the endpoint being the first CLABSI. A Kaplan-Meier analysis was performed to determine CLABSI-free catheter survival. Results: Overall, 188 children were evaluated over 77,541 catheter days, with 94 being diagnosed with CLABSI (50%). Although coagulase-negative staphylococci were the pathogens most commonly isolated, Gram-negative microorganisms (46.8%) were also prevalent. In the multivariate analysis, factors that increased the risk for CLABSI were TIVAP insertion prior to chemotherapy (risk ratio [RR] = 1.56; P < 0.01), white blood cell count less than 1,000 mm(-3) on the day of implantation (RR = 1.64; P < 0.01), and chronic malnutrition (RR = 1.41; P < 0.05). Median time without CLABSI following TIVAP insertion was 74.5 days. Conclusions: Risk factors for CLABSI in pediatric cancer patients with a TIVAP may be related to the severity of the child's condition at catheter insertion. Insertion of the catheter before chemotherapy and unfavorable conditions such as malnutrition and bone marrow aplasia can increase the risk of CLABSI. Protocols must be revised and surveillance increased over the first 10 weeks of treatment.
Background: Totally implantable venous access port systems are widely used in oncology, with frequent complications that sometimes necessitate device removal. The aim of this study is to investigate the impact of the time interval between port placement and initiation of chemotherapy and the neutropenia-inducing potential of the chemotherapy administered upon complication-related port removal. Patients and methods: Between January 2010 and December 2013, 4045 consecutive patients were included in this observational, single-center prospective study. The chemotherapy regimens were classified as having a low (<10%), intermediate (10-20%), or high (>20%) risk for inducing neutropenia. Results: The overall removal rate due to complications was 7.2%. Among them, port-related infection (2.5%) and port expulsion (1%) were the most frequent. The interval between port insertion and its first use was shown to be a predictive factor for complication-related removal rates. A cut-off of 6 days was statistically significant (p = 0.008), as the removal rate for complications was 9.4% when this interval was 0-5 days and 5.7% when it was ≥6 days. Another factor associated with port complication rate was the neutropenia-inducing potential of the chemotherapy regimens used, with removal for complications involved in 5.5% of low-risk regimens versus 9.4% for the intermediate- and high-risk regimens (p = 0.003). Conclusion: An interval of 6 days between placement and first use of the port reduces the removal rate from complications. The intermediate- and high-risk for neutropenia chemotherapy regimens are related to higher port removal rates from complications than low-risk regimens.