Candidemia in cancer patients: Impact of early removal of non-tunneled central venous catheters on outcome
Introduction
Candidemia in cancer patients often presents as a severe and rapidly progressive disease.1 Despite major progress in antifungal therapy, several issues continue to make management of candidemia challenging in this particularly susceptible population. Among these, the issue of managing central venous catheters (CVCs) is particularly controversial.2, 3 Although Candida species are well-known biofilm-forming pathogens and removal of CVCs has been considered to be the standard approach in candidemic patients,4 the decision of CVC removal can be complicated in conditions where central venous access is essential for treatment.5, 6
Several studies have demonstrated that retention of CVCs in cancer patients with candidemia is a significant independent risk factor of mortality or poor response to treatment both in individuals with candidemia alone7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and in those with cancer and candidemia.2, 17, 18, 19 Conversely, many other studies either did not evaluate the effects of CVC removal or found that it had a non-significant effect in multivariate analyses.3, 20, 21, 22, 23 There has been disagreement regarding the impact of CVC removal on outcome of candidemia.6, 24, 25 Furthermore, the optimal timing of CVC removal is not well established, despite numerous studies showing that CVC retention has a negative impact on the outcome of candidemia. Recently, studies addressing the issue of appropriate timing for CVC removal have yielded conflicting results.2, 26 Raad et al.2 found that removal of CVCs ≤72 h after diagnosis of candidemia resulted in an improved antifungal response in patients with catheter-related infection (CRI). In contrast, Rodriguez et al.26 showed little impact of early CVC removal on survival in candidemic patients whose CVCs were eventually all removed. These two reports and other studies2, 25, 26, 27 have also revealed that host factors and the severity of illness may be the key determinants of mortality in cancer patients with candidemia. In addition, these studies commonly included all types of CVCs in their analyses,2, 6, 26 including devices classified as temporary non-tunneled CVCs (most common), infusion ports (e.g., port-a-cath), tunneled CVCs (e.g., Hickmann catheters), and peripheral inserted CVCs (PICC). However, different types of CVCs may contribute differently to the pathogenesis and risks of CRI,28 with removal of different types of catheters resulting in a different impact on outcome. To date, only scant data2 has clearly defined the subpopulation of cancer patients that would derive the most benefit from removal of CVCs when host factors are taken into account.
The aim of the present study was to explore the impact of CVC removal and other potential risk factors (specifically, host factors) on patient outcome in a cancer subpopulation in which CVCs were required for treatment and only single, non-tunneled CVCs were placed. A second objective was to determine the optimal timing, if any, for CVC removal and whether early CVC removal was associated with a better outcome after controlling for important confounding factors.
Section snippets
Study design, patient population, and data collection
This study was a retrospective cohort analysis of consecutive cancer patients who were diagnosed with candidemia antemortem at Taipei Veteran General Hospital, a tertiary medical center with a 2900-bed capacity. Patients with candidemia were identified by reviewing culture records from the Department of Microbiology from January 2004 through January 2007. Included were adult patients with a single, non-tunneled CVC in place for ≥24 h prior to the onset of candidemia. Excluded were outpatients,
Patient characteristics
Review of culture records identified 207 cancer patients who had CVCs in place for ≥24 h before the onset of candidemia. Of those patients, 110 patients who had either single implantable ports (n = 83) or multiple CVCs in place (n = 27) were excluded. An additional 5 patients who died within 72 h post candidemia onset were also excluded owing failure to remove the CVC or inadequate application of antifungal treatment. A total of 92 eligible patients were enrolled for analysis. It was noted that 83%
Discussion
The results of the current study lend support for the main hypothesis that CVC retention has a significantly negative impact on outcome in cancer patients with candidemia. The second aim of the present study is also supported by results showing that early CVC removal in a subset of a relatively homogenous population of patients with cancer with a single, non-tunneled CVC was associated with a better outcome. Upon review of the medical literature pertaining to the issue of management of CVC in
Acknowledgements
We thank Ms. Pui-Ching Lee and Ms. Ya-Chuan Wang for their excellent assistance performing statistical analyses. This study was partially supported by a grant from the Taipei Veterans General Hospital (V96A-142).
References (37)
- et al.
Predictors of adverse outcome in cancer patients with candidemia
Am J Med
(1998) - et al.
The importance of central venous catheter removal in patients with candidaemia: time to rethink our practice?
Clin Microbiol Infect
(2008) - et al.
Impact of early central venous catheter removal on outcome in patients with candidaemia
Clin Microbiol Infect
(2007) - et al.
Predictors of outcome in cancer patients with candidemia
Ann Oncol
(2000) - et al.
The World Health Organization classification of neoplastic diseases of the hematopoietic and lymphoid tissues. Report of the Clinical Advisory Committee meeting, Airlie House, Virginia, November, 1997
Ann Oncol
(1999) Invasive candida infections–evolution of a fungal pathogen
N Engl J Med
(1991)- et al.
Management of central venous catheters in patients with cancer and candidemia
Clin Infect Dis
(2004) - et al.
Risk factors for death among cancer patients with fungemia
Clin Infect Dis
(1998) - et al.
Guidelines for treatment of candidiasis
Clin Infect Dis
(2004) - et al.
All catheter-related candidemia is not the same: assessment of the balance between the risks and benefits of removal of vascular catheters
Clin Infect Dis
(2002)