Martínez E, Mensa J, Rovira M, Martínez J A, Marcos A, Almela M, Carreras E
Department of Infectious Diseases, Institut de Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Spain.
Bone Marrow Transplant. 1999 Jan;23(1):41-4. doi: 10.1038/sj.bmt.1701538.
Current guidelines for the treatment of catheter-related bacteraemia (CRB) advise against central venous catheter (CVC) exchange because of the potential risk of prolonging infection. However, there are no consistent data proving this recommendation. We evaluated prospectively the usefulness of CVC exchange by guidewire for the treatment of CRB in patients undergoing BMT or intensive chemotherapy. CVC exchange was considered when fever and positive blood cultures persisted after 2 days of adequate antimicrobial therapy and no potential source of bacteraemia other than CVC could be identified. The guidewire exchange was preceded and followed by a slow infusion of adequate antimicrobial therapy. Bacteraemia was confirmed as catheter-related by demonstrating concordance between isolates from the tip and blood cultures by pulsed-field electrophoresis of genomic DNA. This procedure was performed in 19 episodes of bacteraemia during a 1-year period. Fourteen episodes (74%) were catheter-related and 71% of these were due to coagulase-negative staphylococci. Guidewire replacement was accomplished uneventfully 4 days after development of sepsis (range 3-6). In all cases, clinical signs of sepsis disappeared in less than 24 h after replacement. Definitive catheter withdrawal was carried out a median of 16 days (range 3-42) after guidewire exchange; in all cases, the tip culture was negative. We conclude that CVC replacement by guidewire under adequate antimicrobial therapy may be a reasonable option for the treatment of CRB when antimicrobial therapy alone has been unsuccessful.
当前关于导管相关菌血症（CRB）的治疗指南建议不要更换中心静脉导管（CVC），因为这可能存在延长感染时间的潜在风险。然而，尚无一致的数据证实这一建议。我们前瞻性地评估了在接受骨髓移植（BMT）或强化化疗的患者中，通过导丝更换CVC治疗CRB的有效性。当在充分的抗菌治疗2天后仍持续发热且血培养呈阳性，且除CVC外未发现其他潜在菌血症来源时，考虑进行CVC更换。在导丝更换前后均缓慢输注充分的抗菌治疗药物。通过对基因组DNA进行脉冲场凝胶电泳，证明导管尖端分离株与血培养分离株一致，从而确认菌血症与导管相关。在1年期间，对19例菌血症患者进行了该操作。14例（74%）与导管相关，其中71%是由凝固酶阴性葡萄球菌引起的。在脓毒症发生后4天（范围3 - 6天）顺利完成导丝更换。在所有病例中，更换后不到24小时脓毒症的临床症状就消失了。在导丝更换后中位数为16天（范围3 - 42天）进行了最终的导管拔除；在所有病例中，导管尖端培养均为阴性。我们得出结论，在充分的抗菌治疗下，通过导丝更换CVC可能是在单纯抗菌治疗失败时治疗CRB的合理选择。
