All Catheter-Related Candidemia Is Not the Same: Assessment of the Balance between the Risks and Benefits of Removal of Vascular Catheters

Received 2 November 2001; electronically published 24 January 2002. Reprints or correspondence: Dr. Thomas J. Walsh, Immunocompromised Host Section, Pediatric Oncology Branch, Bldg. 10, Room 13N240, 9000 Rockville Pike, National Cancer Institute, Bethesda, MD 20892 (walsht@mail.nih.gov). Clinical Infectious Diseases 2002; 34:600–2 2002 by the Infectious Diseases Society of America. All rights reserved. 1058-4838/2002/3405-0006$03.00 Ranking as the third to fourth most common cause of nosocomial bloodstream infections, candidemia is a life-threatening infection that occurs in seriously ill patients who usually have 1 intravascular catheter [1, 2]. In these patients, candidemia is associated with a high attributable mortality rate—it can be as high as 38% [3]. Under such circumstances, any and all measures that can possibly reduce the rates of morbidity and mortality are often pursued. Because Candida albicans and other Candida species adhere avidly to materials used in vascular catheters, removal of vascular catheters is advocated as an adjunctive strategy for treating patients who have catheter-related candidemia [4]. The rationale for such catheter removal is to eliminate a potential nidus of infection that may perpetuate seeding of the bloodstream. Unfortunately, removal of a vascular catheter is not necessarily a benign procedure. Removal of Hickmanor Broviac-type catheters may require another surgical procedure to replace such a catheter after the candidemia is treated. Removal of any type of central venous catheter will often require reinsertion of new catheters, which may be particularly hazardous in a patient who has thrombocytopenia or some other coagulopathy. An additional complication of reinsertion of new catheters is the possibility of pneumothorax. Thus, clinicians who treat patients with catheterrelated candidemia are confronted with a dilemma between removal of the catheter and potential increases in morbidity and mortality caused by reinsertion of new vascular catheters. Recent consensus guidelines have recommended removal of vascular catheters in patients with candidemia when it is feasible [5, 6]. Nevertheless, there have been no randomized controlled trials that have prospectively assessed the risk and benefits associated with catheter removal in patients with candidemia. Nucci and Anaissie are to be commended for their exhaustive analysis of the literature about catheter-related candidemia. They conducted an evidence-based, comprehensive, retrospective analysis to assess treatment outcomes associated with catheter withdrawal. This extensive review of the literature reflects the problems encountered in such an analysis, in which no prospective randomized trials have addressed this question as a primary objective. Despite these limitations, the findings of several studies support removal of vascular catheters when it is feasible in patients with candidemia [7, 8]. The factors weighing in that decision for individual patients are recapitulated by Nucci and Anaissie in a thoughtfully developed algorithm that should prove to be a valuable clinical tool. An understanding of the pathogenesis and epidemiology of catheter-related candidemia may further facilitate a rational approach for removal of vascular catheters in patients with candidemia. Independent of the vascular catheter, the human alimentary tract is an important source of C. albicans in patients with candidemia [9–11]. Molecular epidemiologic studies of isolates of Candida species recovered from a given patient reveal strong genetic relatedness between isolates from the alimentary tract and those in the bloodstream [11]. Patients undergoing cytotoxic chemotherapy for treatment of malignancies may sustain mucosal epithelial disruption that allows for translocation of Candida species through