Fever in short gut patients with a central venous line (<18 years) - Curbside
Fever in short gut patients with a central venous line (<18 years)
Editors: Danielle Barnes, Rachel Bensen, Dan Imler, MD, & 2 more...
Inclusion Criteria  (All criteria are present)
  • GI patient with indwelling central venous catheter (i.e. - Broviac, Hickman, port, PICC)
  • Fever (≥ 38.0 C (100.4 F) in the past 24 hours)
Exclusion Criteria
  • Positive blood culture that has not been fully treated

Contact a pediatric gastroenterologist

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Evidence
Total Notes: 5
Evidence

1 Systemic inflammatory response syndrome

The systemic inflammatory response syndrome (SIRS) represents an inflammatory response that may be associated with infection. Criteria set for this entity allow early identification of patients at risk for severe infection and other diseases. Although sensitive in many studies, the specificity of SIRS (especially in pediatric patients) is often low. Therefore, it may be used as a general guide increasing the probability of infection, but cannot be used in isolation for diagnosis.



References:
  1. The pathophysiology and treatment of sepsis.
    Hotchkiss RS, Karl IE,
    N. Engl. J. Med. 2003 Jan;348(2):138-50.
  2. Immunoparalysis and nosocomial infection in children with multiple organ dysfunction syndrome.
    Hall MW, Knatz NL, Vetterly C, Tomarello S, Wewers MD, Volk HD, Carcillo JA,
    Intensive Care Med 2011 Mar;37(3):525-32.
  3. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics.
    Goldstein B, Giroir B, Randolph A, Randolph A,
    Pediatr Crit Care Med 2005 Jan;6(1):2-8.
  4. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine.
    Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, Doctor A, Davis A, Duff J, Dugas MA, Duncan A, Evans B, Feldman J, Felmet K, Fisher G, Frankel L, Jeffries H, Greenwald B, Gutierrez J, Hall M, Han YY, Hanson J, Hazelzet J, Hernan L, Kiff J, Kissoon N, Kon A, Irazuzta J, Irazusta J, Lin J, Lorts A, Mariscalco M, Mehta R, Nadel S, Nguyen T, Nicholson C, Peters M, Okhuysen-Cawley R, Poulton T, Relves M, Rodriguez A, Rozenfeld R, Schnitzler E, Shanley T, Kache S, Skache S, Skippen P, Torres A, von Dessauer B, Weingarten J, Yeh T, Zaritsky A, Stojadinovic B, Zimmerman J, Zuckerberg A,
    Crit. Care Med. 2009 Feb;37(2):666-88.
  5. Defining pediatric sepsis by different criteria: discrepancies in populations and implications for clinical practice.
    Weiss SL, Parker B, Bullock ME, Swartz S, Price C, Wainwright MS, Goodman DM,
    Pediatr Crit Care Med 2012 Jul;13(4):e219-26.
  6. Prevalence of systemic inflammatory response syndrome (SIRS) in hospitalized children: a point prevalence study.
    Pavare J, Grope I, Gardovska D,
    BMC Pediatr 2009;9:25.
  7. Reliability of the identification of the systemic inflammatory response syndrome in critically ill infants and children.
    Juskewitch JE, Prasad S, Salas CF, Huskins WC,
    Pediatr Crit Care Med 2012 Jan;13(1):e55-7.
  8. Improving adherence to PALS septic shock guidelines.
    Paul R, Melendez E, Stack A, Capraro A, Monuteaux M, Neuman MI,
    Pediatrics 2014 May;133(5):e1358-66.
  9. Respiratory rate criteria for pediatric systematic inflammatory response syndrome.
    Nakagawa S, Shime N,
    Pediatr Crit Care Med 2014 Feb;15(2):182.
  10. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.
    Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, Ramsay G,
    Intensive Care Med 2003 Apr;29(4):530-8.

2 Weight-based blood cultures

Blood cultures are necessary to determine potential pathogens. If a central catheter is present then cultures should be taken from each lumen. Taking two blood culture specimens increases the likelihood of discovering true bacteremia. In one study, 32 to 43 percent of double lumen catheter cultures that resulted positive were positive from only one of multiple lumens.

Controversy exists regarding the value of peripheral cultures in addition to central catheter cultures if a central catheter is present. Although peripheral cultures may allow for more specific diagnosis of central catheter infection, the treatment of both entities is similar and in only rarely changes management. This pathway does not advocate for peripheral cultures.

Weight-based blood cultures may improve the diagnostic sensitivity of testing and should be performed in the appropriate age groups.



References:
  1. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America.
    Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O'Grady NP, Raad II, Rijnders BJ, Sherertz RJ, Warren DK,
    Clin. Infect. Dis. 2009 Jul;49(1):1-45.
  2. Sensitivity of a blood culture drawn through a single lumen of a multilumen, long-term, indwelling, central venous catheter in pediatric oncology patients.
    Robinson JL,
    J. Pediatr. Hematol. Oncol. 2002 Jan;24(1):72-4.
  3. In situ diagnosis of central venous catheter-related bloodstream infection without peripheral blood culture.
    Franklin JA, Gaur AH, Shenep JL, Hu XJ, Flynn PM,
    Pediatr. Infect. Dis. J. 2004 Jul;23(7):614-8.
  4. Optimizing blood culture practices in pediatric immunocompromised patients: evaluation of media types and blood culture volume.
    Gaur A, Giannini MA, Flynn PM, Boudreaux JW, Mestemacher MA, Shenep JL, Hayden RT,
    Pediatr. Infect. Dis. J. 2003 Jun;22(6):545-52.

3 Short gut patients with a CVL and fever

Many patients with short gut syndrome will require chronic central venous catheter (CVC) for TPN and labs. This places them at increased risk of CVC related infections which may be severe. In addition, cholestasis and liver disease is associated with episodes of CVC infections.

Fever in this patient population should caregivers to the high risk of a serious bacterial infection in these patients and aggressive evaluation and possible empiric treatment is warranted. This is especially true in the first month after catheter placement when the risk is higher.



References:
  1. Infection and cholestasis in neonates with intestinal resection and long-term parenteral nutrition.
    Sondheimer JM, Asturias E, Cadnapaphornchai M,
    J. Pediatr. Gastroenterol. Nutr. 1998 Aug;27(2):131-7.
  2. Parenteral nutrition-related cholestasis in postsurgical neonates: multivariate analysis of risk factors.
    Beath SV, Davies P, Papadopoulou A, Khan AR, Buick RG, Corkery JJ, Gornall P, Booth IW,
    J. Pediatr. Surg. 1996 Apr;31(4):604-6.
  3. Characterization of posthospital bloodstream infections in children requiring home parenteral nutrition.
    Mohammed A, Grant FK, Zhao VM, Shane AL, Ziegler TR, Cole CR,
    JPEN J Parenter Enteral Nutr 2011 Sep;35(5):581-7.
  4. Remaining small bowel length: association with catheter sepsis in patients receiving home total parenteral nutrition: evidence of bacterial translocation.
    Terra RM, Plopper C, Waitzberg DL, Cukier C, Santoro S, Martins JR, Song RJ, Gama-Rodrigues J,
    World J Surg 2000 Dec;24(12):1537-41.
  5. The rate of bloodstream infection is high in infants with short bowel syndrome: relationship with small bowel bacterial overgrowth, enteral feeding, and inflammatory and immune responses.
    Cole CR, Frem JC, Schmotzer B, Gewirtz AT, Meddings JB, Gold BD, Ziegler TR,
    J. Pediatr. 2010 Jun;156(6):941-7, 947.e1.
  6. Bloodstream infections in very low birth weight infants with intestinal failure.
    Cole CR, Hansen NI, Higgins RD, Bell EF, Shankaran S, Laptook AR, Walsh MC, Hale EC, Newman NS, Das A, Stoll BJ, Stoll BJ,
    J. Pediatr. 2012 Jan;160(1):54-9.e2.

4 Laboratory investigation

Evaluating the source of fever with a through history, physical and laboratory testing is imperative in this population. Catheter-related bloodstream infection (CRBSI) should always be suspected if there is no obvious alternative source. 

Blood cultures are necessary to determine potential pathogens. If a central catheter is present then cultures should be taken from each lumen. Taking two blood culture specimens increases the likelihood of discovering true bacteremia. In one study, 32 to 43 percent of double lumen catheter cultures that resulted positive were positive from only one of multiple lumens.

Controversy exists regarding the value of peripheral cultures in addition to central catheter cultures if a central catheter is present. Although peripheral cultures may allow for more specific diagnosis of central catheter infection, the treatment of both entities is similar and in only rarely changes management. This pathway does not advocate for peripheral cultures.

Weight-based blood cultures may improve the diagnostic sensitivity of testing and should be performed in the appropriate age groups.



References:
  1. Differential quantitative blood cultures for the diagnosis of catheter-related bloodstream infections associated with short- and long-term catheters: a prospective study.
    Chatzinikolaou I, Hanna H, Hachem R, Alakech B, Tarrand J, Raad I,
    Diagn. Microbiol. Infect. Dis. 2004 Nov;50(3):167-72.
  2. How many sources should be cultured for the diagnosis of a blood stream infection in children with cancer?
    Doganis D, Asmar B, Yankelevich M, Thomas R, Ravindranath Y,
    Pediatr Hematol Oncol 2013 Aug;30(5):416-24.
  3. Peripheral vs. central blood cultures in patients admitted to a pediatric oncology ward.
    Adamkiewicz TV, Lorenzana A, Doyle J, Richardson S,
    Pediatr. Infect. Dis. J. 1999 Jun;18(6):556-8.
  4. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America.
    Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O'Grady NP, Raad II, Rijnders BJ, Sherertz RJ, Warren DK,
    Clin. Infect. Dis. 2009 Jul;49(1):1-45.
  5. Sensitivity of a blood culture drawn through a single lumen of a multilumen, long-term, indwelling, central venous catheter in pediatric oncology patients.
    Robinson JL,
    J. Pediatr. Hematol. Oncol. 2002 Jan;24(1):72-4.
  6. In situ diagnosis of central venous catheter-related bloodstream infection without peripheral blood culture.
    Franklin JA, Gaur AH, Shenep JL, Hu XJ, Flynn PM,
    Pediatr. Infect. Dis. J. 2004 Jul;23(7):614-8.
  7. Optimizing blood culture practices in pediatric immunocompromised patients: evaluation of media types and blood culture volume.
    Gaur A, Giannini MA, Flynn PM, Boudreaux JW, Mestemacher MA, Shenep JL, Hayden RT,
    Pediatr. Infect. Dis. J. 2003 Jun;22(6):545-52.

5 Severe sepsis

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012

TABLE 2: Severe Sepsis

Severe sepsis definition: sepsis-induced tissue hypoperfusion or organ dysfunction (any of the following thought to be due to the infection)

 

- Sepsis-induced hypotension
- Coagulopathy (INR >1.5)
- Platelet count <100,000 
- Creatinine >2.0mg/dL
- Lactate above the upper limits of laboratory normal
- Bilirubin >2mg/dL
- Urine output < 0.5mL/kg/hr fore more than 2 hours despite adequate fluid reuscitation
- Acute lung injury with paO2/FiO2


References:
  1. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.
    Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R, Moreno R,
    Crit. Care Med. 2013 Feb;41(2):580-637.