Low Rates of Femoral Catheter Infections Identified in the Pediatric ICU

NASHVILLE—Unlike in adults, femoral central venous catheters (CVC) in pediatric ICU patients are not associated with high rates of infections, reported Joel A. Reyes, DO, of the University of Texas Health Science Center at the Society of Critical Care Medicine’s 2009 Critical Care Congress. Furthermore, CVC infections in this population are associated with longer length of ICU stay but not with increased mortality, compared with ICU patients without infection, he added.

CDC recommendations suggest avoiding femoral catheters in adults and using the subclavian vein instead, because it increases the risk of deep vein thrombosis and infections, but no recommendations have been made for the pediatric population due to lack of data, Dr. Reyes stated. Nonetheless, in 2002, the National Nosocomial Infection Surveillance system reported a total of 7.6 infections per catheter days in the pediatric ICU—ranging from as low as 3.4 infections in respiratory patients to as high as 9.7 infections in burn patients.

In a retrospective cohort study, Dr. Reyes and colleagues ascertained the rate of CVC infection in major sites of cannulation (ie, subclavian, internal jugular, and femoral veins), and mortality risk in patients admitted to the pediatric ICU. Data was based on internal review and quality insurance reports from two pediatric ICUs in San Antonio between 1999 and 2008.

Included in the cohort were general pediatric ICU patients ages 17 or younger with a variety of conditions requiring a short-term catheter, including respiratory failure, sepsis, and congenital heart problems. Based on CDC criteria, a patient was considered to have a CVC infection if he or she had a recognized pathogen cultured from one or more blood cultures and if that pathogen was not related to an infection at another site.

A total of 4,748 patients with 5,286 CVCs met criteria for inclusion, making it one of the largest cohorts of its kind, according to Dr. Reyes. The number of catheters were relatively evenly distributed between all three major sites, he noted.

Catheter insertion lasted 5.7 days on average for femoral CVCs (total catheter days, 11,294) and approximately four days for both subclavian and jugular catheters (approximately 6,000 to 7,000 total catheter days).

Initially, raw data indicated a higher number of infections in femoral catheters (7.1/1,000 catheter days), compared with subclavian and jugular catheters (6.1 and 5.4, respectively). The proportion of lines that became infected also was lower for subclavian and jugular catheters (2.7% and 2.1%, respectively) compared with that of femoral catheters (4.2%).

However, after adjustment for covariates including age, disease severity (as determined by pediatric patient mortality scores), and duration of line placement, no site was associated with a significant increase in CVC infection risk when compared to the other sites. Hazard ratios for infection for the femoral, subclavian, and jugular insertion sites were 1.09, 1.11, and 0.93, respectively. “Based on this finding, there is no compelling argument to change a line at any particular day since the daily risk does not seem to dramatically change—at least in the first 30 days,” Dr. Reyes stated.

Additional analysis indicated that patients with CVC infections stayed approximately 4.6 days longer in the pediatric ICU than patients without infection, after adjustment for covariates.

“There were changes in practice over a nine year period, whether it is insertion techniques, types of catheter used, the use of chlorhexidine versus betadine, or even maintenance techniques that have evolved throughout the years,” Dr. Reyes acknowledged. In addition, catheters were not routinely cultured upon removal, and reasons for choosing a particular CVC site over another were not clear. Ongoing analysis is needed to adjust for these and other possible confounders, he concluded.

—Frederique H. Theuvenin

Suggested Reading
Sheridan RL, Weber JM. Mechanical and infectious complications of central venous cannulation in children: lessons learned from a 10-year experience placing more than 1000 catheters. J Burn Care Res. 2006;27(5):713-718.

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