Clinical Question 1
In patients with cancer, does catheter type, insertion site, or placement affect complication rates?
Recommendation 1.1. There is insufficient evidence to recommend one type of central venous catheter (CVC) routinely for all patients with cancer. The choice of catheter should be influenced by the expected duration of use, the chemotherapy regimen, and the patient's ability to provide care. The minimum number of lumens essential for the management of the patient is recommended. These issues should be discussed with the patient.
Recommendation 1.2. There is insufficient evidence to recommend one insertion site or approach (left sided or right sided) for tunneled CVCs for patients with cancer. Individual risks and benefits (comfort, security, and maintenance of asepsis) of the catheter site should be considered. The Panel recommends that CVC insertion into the femoral vein be avoided because of increased infection risks and concerns about thrombosis, except in certain emergency situations.
Recommendation 1.3. Most CVC placement in patients with cancer is performed as an elective procedure. Although image-guided insertion (e.g., ultrasound-guided, fluoroscopy) of CVCs is recommended, well-trained providers who use the landmark method regularly (e.g., for subclavian or internal jugular) may have a high rate of success and a low incidence of acute and/or chronic complications.
Clinical Question 2
What is effective prophylaxis for the prevention of catheter-related infections?
Recommendation 2.1. A CVC care clinical bundle (including hand hygiene, maximal barrier precautions, chlorhexidine skin antisepsis during catheter insertion, optimal catheter site selection, and assessment of CVC necessity) is recommended for the placement and maintenance of all CVCs to prevent infections (see Table 2 in the original guideline document). There is no evidence that particular dressing types or more frequent intravenous (IV) set and/or dressing changes decrease the risk of infection. The use of topical antibiotic ointment or cream on insertion sites is not recommended because of the potential to promote fungal infections and resistance to antimicrobials. A scheduled guidewire exchange of CVCs may be associated with a greater risk of infection compared with catheter replacement at a new vascular site, and thus, guidewire exchange is not routinely recommended unless access options are limited.
Recommendation 2.2. The use of antimicrobial/antiseptic-impregnated or -coated CVCs (chlorhexidine and silver sulfadiazine [CH-SS] or minocycline/rifampin) and/or heparin-impregnated catheters is recommended to decrease the risk of catheter-related infections for short-term CVCs, particularly in high-risk groups such as bone marrow transplantation recipients or patients with leukemia. However, the relative benefit and increased cost must be carefully considered before they are routinely used.
Recommendation 2.3. The prophylactic use of systemic antibiotics (IV or oral) before insertion of a long-term CVC is not recommended.
Recommendation 2.4. There are conflicting data about the relative value of prophylactic heparin with saline flushes to prevent catheter-associated bloodstream infections (BSI) or thrombosis. Data are not sufficient to recommend for or against the routine use of antibiotic-flush/antibiotic-lock therapy.
Clinical Question 3
What are effective treatments for the management of catheter-related infections?
Recommendation 3.1. Cultures of blood from the catheter and when appropriate of soft tissues at the entrance-exit sites or tunnel should be obtained before the initiation of antibiotic therapy. Most exit- or entrance-site infections can be treated successfully with appropriate antimicrobial therapy without the need for catheter removal, although removal is usually needed for clinically apparent tunnel or port-site infections. Antimicrobial agents should be optimized once the pathogens are identified and antibiotic susceptibilities defined.
Immediate catheter removal is recommended for BSIs caused by fungi and nontuberculous mycobacteria (e.g., Mycobacterium chelonei, M. fortuitum, M. mucogenicum, M. abscessus). BSIs caused by Bacillus species, Corynebacterium jeikeium, Staphylococcus aureus, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, and vancomycin-resistant enterococci may be difficult to eradicate with antimicrobial therapy alone, and early catheter removal should be considered. Catheter removal is also recommended for patients with an apparent tunnel or port-site infection, persistent bacteremia after 48 to 72 hours of appropriate antimicrobial treatment in the absence of other obvious sites or sources of infection, infective endocarditis or peripheral embolization, presence of local catheter-associated complications not responsive to treatment, or relapse of infection with the same pathogen after the completion of an appropriate course of antibiotics.
Clinical Question 4
What is effective prophylaxis for the prevention of catheter-related thrombosis?
Recommendation 4.1. The use of systemic anticoagulation (warfarin, low-molecular weight heparin [LMWH], or unfractionated heparin) has not been shown to decrease the incidence of catheter-associated thrombosis, and therefore, routine prophylaxis with anticoagulants is not recommended for patients with cancer with CVCs. Routine flushing with saline of the CVC to prevent fibrin buildup is recommended.
Recommendation 4.2. Data are insufficient to recommend routine use of urokinase (not currently available in the United States) and/or other thrombolytics to prevent catheter occlusion.
Clinical Question 5
What are effective treatments for the management of catheter-related occlusions?
Recommendation 5.1. The instillation of 2-mg tissue plasminogen activator (t-PA) is recommended to restore patency and preserve catheter function.
Recommendation 5.2. Although it is appropriate to try to clear a thrombosis with the CVC in place, if there is radiologically confirmed thrombosis that does not respond to fibrinolytic therapy or if fibrinolytic or anticoagulation therapy is contraindicated, catheter removal is recommended. Prolonged retention of an unneeded CVC can lead to significant problems associated with thrombosis and fibrosis. Three to 6 months of anticoagulant therapy with LMWH or LMWH followed by warfarin (international normalized ratio, 2.0 to 3.0) is recommended for the treatment of symptomatic CVC thrombosis, with the duration depending on clinical issues in individual patients.