中心静脈カテーテル感染の治療方針に関する検討

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  • A consideration on the treatment of central venous catheter-related infection.

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We examined 2, 202 central venous catheters (CVCs) inserted during the past 10 years to assess the severity of CVC-related infection (CRI) and to propose the proper treatment of CRI. Febrile catheterized patients (body temperature above 38°C) were diagnosed as having CRI when the cultures of CVC-tips were positive or when the fever dropped immediately (within 72 hours) after removal of the CVC. Cases were defined as ‘severe’ disease, when they showed hypotension (systolic blood pressure 5_90 mm Hg) and/or complication such as acute renal failure, heart failure, respiratory failure, or ophthalmitis. The rate of CRI was 10.6%(233/2, 202), and the rate of severe disease in CRI was 15.5%(36/233). There were no significant differences in the rate of severe disease according to age, sex, underlying disease, concurrent disease, or CVC indwelling time. The rate of severe disease was significantly higher (25.9%) among the patients whose CVCs were removed more than 72 hours after the initial febrile episode (P<0.05). The rate of severe disease was significantly higher (36.7%) in patients whose maximal body temperature was above 39°C and whose WBC counts were more than 10, 000/mm3. Of the 157 microorganisms isolated from CRI, 42.0% were gram-positive cocci (GPCs), 39.5% were fungi, and 16.6% were gram-negative rods (GNRs). Because more than a half of the GPCs and GNRs were resistant strains, blood and CVC-tips cultures were considered essential for proper choice of antimicrobials. The isolation rate of fungi decreased significantly in the final 3 years (P<0.001). The rate of severe disease in the cases in which GPCs were isolated (2.6%) was significantly lower (P<0.01) than in the cases in which GNRs (40.0%) or fungi (26.5%) were isolated. Early removal of infected CVCs was recognized as being important to prevention of deterioration of CRI. Patients whose body temperature is above 39°C and whose WBC count is more than 10, 000/mm3 were considered to have ‘moderate’ disease and should be treated in the same way as patients with severe disease. Patients with ‘mild’ disease (no complications and BT<39°C or WBC<10, 000/mm3) may be treated only by removal of infected CVC. In patients with moderate or severe disease, however empiric chemotherapy should be started along with removal of the CVC. The results of this study suggest that carbapenem is the agent of first choice for empiric chemotherapy of CRI. Azole should be added if serum β-D-glucan is positive, and vancomycin should be added when empiric chemotherapy with carbapenem with or without azole is not effective.

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