Although central venous access devices (CVADs) have become essential for the delivery of modern pediatric care, they are associated with serious, even life-threatening, complications. The most common serious complication is central line–associated bloodstream infection (CLABSI), in which bacteria or fungi enter the bloodstream through the lumen or the exit site of the CVAD. Approximately 10% of pediatric CLABSI episodes are associated with severe sepsis, causing organ damage or dysfunction that requires ICU-level care or results in death.1  An estimated 50% of children with CLABSI have persistent or recurrent infections that require catheter removal or replacement.1,2  In addition to the direct clinical impact, CLABSI adds to the expense of pediatric care, with each episode costing ∼$55 000 in the United States.3 

The guidelines/recommendations in this article are not American Academy of Pediatrics policy, and publication herein does not imply endorsement.

TABLE 1

Key Points for Infectious Diseases

Key Points
Consider shorter courses of antibiotics or switching to oral antibiotics when feasible to reduce the need for a CVAD 
Avoid femoral CVADs when possible and keep duration of use as short as possible when they are needed 
Use ports when intermittent central venous access is needed for a prolonged period, but avoid them if long-term continual access is needed for PN 
Additional research is needed to determine the best approach to primary and secondary prevention of CLABSI, especially in high-risk patients 
Key Points
Consider shorter courses of antibiotics or switching to oral antibiotics when feasible to reduce the need for a CVAD 
Avoid femoral CVADs when possible and keep duration of use as short as possible when they are needed 
Use ports when intermittent central venous access is needed for a prolonged period, but avoid them if long-term continual access is needed for PN 
Additional research is needed to determine the best approach to primary and secondary prevention of CLABSI, especially in high-risk patients 

Clinicians face complex decisions when balancing risks and benefits of venous access devices, such as the benefit of reliable venous access against the risk of CLABSI, infection relapse with a retained CVAD, complexity of CVAD removal, and need to replace a catheter removed prematurely. That is why we are encouraged to see that in Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC), differences in risk associated with device type, insertion site, and patient characteristics are discussed (Table 1). Three important highlights follow:

  1. Infectious diseases specialists have increasingly recognized that shorter courses of antibiotic therapy and early transition to highly bioavailable oral therapy, when appropriate, are preferable to prolonged intravenous therapy. For example, many bloodstream infections may be adequately treated with 7, rather than the traditional 10 to 14, days of treatment and may be treated partially with oral therapy.4  miniMAGIC notes that use of a peripheral intravenous catheter (PIVC) is preferred for courses of antibiotic therapy up to 14 days but that this may be challenging to achieve in patients with difficult veins. The panelists recommend that clinicians consider an alternative route or shorter course, rather than inserting a CVAD, if an appropriate option exists. This recommendation can prevent the paradox of inserting a CVAD “just to treat a CLABSI” while reducing the risk of CVAD-related complications.

  2. miniMAGIC takes into account that the risk of CLABSI differs between CVAD types. CLABSI risk appears lowest with PIVCs, followed by totally implanted venous devices (also known as ports) and then by peripherally inserted central catheters (PICCs) and tunneled CVADs. The risk may also be low with midline catheters, but a paucity of data from the pediatric population limits recommendations. The risk of CLABSI is highest with nontunneled CVADs, especially those placed in the femoral vein.1  miniMAGIC thus recommends the use of the lowest-risk CVAD and recommend an insertion site that is appropriate for each age group; PIVCs are typically preferred for short-term use for peripherally compatible infusates, and PICCs or tunneled devices are typically preferred for longer-term use. For nonperipherally compatible infusates, appropriateness criteria allow for the use of nontunneled CVADs or PICCs for short-term use, with PICCs, tunneled CVADs, or ports preferred if venous access for a longer period is anticipated. Similarly, femoral CVADs should only be considered when it is clear that this is the optimal route, such as in infants with congenital heart disease for whom occlusion of a large upper body vein, which can be caused by a CVAD, might interfere with subsequent life-saving surgery.

  3. Lastly, ports typically have a low risk of CLABSI and other complications, so some guidelines recommend ports for all long-term CVAD needs, including administration of long-term parenteral nutrition (PN). However, observational data reveal that in the pediatric population, continual access of ports for administration of PN is associated with a substantial increase in the risk of CLABSI (∼40 times) and of CVAD occlusion requiring thrombolytic therapy (∼10 times).5  Ports are also associated with a higher risk of infection relapse and are more complicated to remove and replace than tunneled external CVADs.2  Therefore, miniMAGIC urges caution for use of ports to administer long-term PN and rate the use of tunneled external CVADs as being appropriate for this purpose.

miniMAGIC aligns with many current practices for the use of venous access devices; however, some evidence gaps limit our ability to define optimal care. Many institutions prioritize CLABSI prevention, but CLABSIs still occur with some frequency, especially in children at high risk, such as those with cancer or intestinal insufficiency receiving PN. The optimal approach to secondary prevention of CLABSI is unknown; aspects such as need for CVAD removal, timing of CVAD replacement, duration of therapy, and efficacy of adjunctive treatments remain understudied. And, although miniMAGIC does rely on the anticipated duration of venous access for choosing a catheter, few data on when to remove or replace a catheter that has already been placed exist. Additional research in these areas is essential. In the meantime, adherence to and consideration of these thoughtfully crafted guidelines should reduce serious infections and save lives. These recommendations do not necessarily reflect the policy of the American Academy of Pediatrics.

Both authors drafted the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

CLABSI

central line–associated bloodstream infection

CVAD

central venous access device

miniMAGIC

Michigan Appropriateness Guide for Intravenous Catheters in pediatrics

PICC

peripherally inserted central catheter

PN

parenteral nutrition

PIVC

peripheral intravenous catheter

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Wolf has received research support from CareFusion Inc. Dr Milstone reports consulting for Becton Dickinson, which is unrelated to the current work.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.