Review
Management of infections related to totally implantable venous-access ports: challenges and perspectives

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Summary

Use of totally implantable venous-access ports (TIVAPs) is standard practice for patients with diseases such as solid-tumour cancers, haematological malignancies, and chronic digestive diseases. Use of TIVAPs allows long-term administration of venotoxic compounds, improves patients' quality of life, and reduces the risk of infection. Microbial contamination, formation of pathogenic biofilms, and infection, however, are associated with morbidity, mortality, and increased health-care costs. Local and systemic complications or infections related to specific pathogens might lead to device removal. Alternatively, conservative treatment with combined systemic antibiotics and antibiotic lock therapy might be useful. We discuss in-vitro and in-vivo basic and clinical research findings on the epidemiology, diagnosis, and prevention of TIVAP-related infections, the current challenges to management, promising strategies, and some treatments in development that are likely to improve outcomes of TIVAP-related infections, with a particular focus on antibiotic lock therapy.

Introduction

Some chronic diseases, such as solid-tumour cancers, haematological malignancies, digestive diseases, cystic fibrosis, and HIV, require long-term administration of potentially venotoxic compounds.1, 2 Long-term intravascular catheters (LTIVCs) were developed to reduce the risk of toxic effects and bacterial or fungal colonisation by use of a subcutaneous route or tunnel that impedes the migration of microorganisms present on the surface of the skin.3, 4 In the early 1980s a new type of LTIVC called a totally implantable venous-access port (TIVAP) was developed.5 A TIVAP comprises a subcutaneously implanted port (or reservoir) connected to a central venous catheter, most frequently inserted into the internal jugular, subclavian, or cephalic vein.2 Use of TIVAPs has become standard clinical practice and has greatly increased patients' comfort and quality of life compared with other LTIVCs.2 TIVAPs are inserted for the administration of antineoplastic chemotherapy, parenteral nutrition, blood products, and long-term antimicrobial treatment (eg, in cyctic fibrosis).2, 6, 7 The number of TIVAPs implanted is increasing, with more than 400 000 sold each year in the USA.8 Nevertheless, despite the reduced risk of microbial contamination, 3–10% of TIVAP carriers experience a related infection, which is the most frequent indication for TIVAP removal.9, 10, 11, 12, 13, 14 Thus, infections have a notable effect on the care of patients and require focused research.

In this Review we aim to provide insights into challenges associated with TIVAP-related infections, including diagnosis, and prevention, and discuss novel approaches that might improve management.

Section snippets

Epidemiology

Dependent on the indication for TIVAP insertion, patients' risk factors for infection differ and, therefore, infection rates also differ. For instance, with use of TIVAPs for antineoplastic chemotherapy or in patients with cystic fibrosis, the infection rate ranges from 0·11 to 0·37 per 1000 catheter-days.6, 9, 10, 13, 14, 15, 16, 17 In patients with cancer, the risk of TIVAP-related infection seems to have remained unchanged over time, with infection rates of 0·21 and 0·20 per 1000

Routes of contamination and risk factors

The discrepancies between different groups of patients probably reflect exposure to different risk factors. A prospective study showed that frequency of handling was one of the most important associated risk factors (panel 1).21 Unsurprisingly, therefore, coagulase-negative staphylococci, which are frequent colonisers of the human skin and mucosal flora, lead to a substantial proportion of TIVAP-related infections.27 For instance, among 29 cases of TIVAP-related infections, 57% were caused by

Prevention of colonisation

Owing to the reduced risk of infection, TIVAPs are favoured over other LTIVCs for use in treatment of solid tumours and haematological malignant disease in children.13, 25, 38 By contrast, because of the high risk of infection associated with TIVAPs used for total parenteral nutrition, a tunnelled catheter might be preferable if daily vascular access is required.1, 7 If a TIVAP is chosen for patients with oncological or haematological diseases, it should be inserted as early as possible because

Diagnosis of infections

TIVAP-related infection should be suspected if a patient exhibits local signs of infection, such as pain or erythema, at the site of implantation. If, however, patients have isolated fever, chills, or severe sepsis, diagnosis is more difficult. Guidelines have proposed classification of TIVAP-related infections into three subtypes: local complicated infections, defined as infection of the tunnel or port pocket with extended erythema or induration (more than 2 cm), purulent collection, skin

Removal or retention of the device

In the case of catheter-related bloodstream infection, the treatment of choice is systemic antimicrobial therapy in conjunction with removal of the colonised device.4 Nevertheless, reduced venous access, the potential for coagulation disorders, and the cost of a new procedure all support catheter salvage if the clinical situation allows it.72

TIVAP removal is mandatory, irrespective of the microbial cause, in complicated infections, which are defined by tunnel or port-pocket infections, severe

Directions for future developments

In view of limitations of current diagnostic, preventive, and therapeutic measures, many questions still need to be addressed about TIVAP-related infections.

Conclusions

30 years of intense study of TIVAP-related infections has led to improved delineation of risk factors, which is of key importance owing to the increasing number of TIVAPs being used. Although antibiotic lock therapy has proven to be a pivotal strategy for the conservative treatment of selected uncomplicated TIVAP-related bloodstream infections, much work still needs to be done, particularly because progress has been made on the reduction of antimicrobial tolerance by use of combinations of

Search strategy and selection criteria

We searched PubMed for papers published in English between January, 1980, and July, 2013, reporting on infections related to totally implantable venous-access ports for any indication. We used the search terms “totally implantable venous access”, “totally implantable port”, “port-a-cath”, “catheters, indwelling”, “central venous catheter”, “port-a-cath infection”, “port-pocket infection”, “catheter-related infections”, “bloodstream infections”, “bacteremia” and “infection”, and, related to

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