Hepatosplenic Cat Scratch Disease and Prolonged Fever: When To Add Corticosteroids?

The indications for use of corticosteroids for persistent fever in cat scratch disease are controversial. We report the case of a 5-year-old boy diagnosed with systemic cat scratch disease, who presented with fever for 28 days and focal hepatosplenic lesions. He did not show improvement despite antibiotic treatment for 4 weeks, however, he became afebrile 24 hours after the administration of corticosteroids.

Intervention to reduce catheter-related bloodstream infections in a pediatric intensive care unit.

OBJECTIVE: Identification of catheter-related bloodstream infection (CR-BSI) risk factors and determination of whether intervention related to identified risk factors would reduce CR-BSI rates. DESIGN: Prospective, observational, interventional and interrupted time-series study. SETTING: Pediatric Intensive Care Unit (PICU) in a university hospital. METHODS: During a 7-year period, 609 central venous catheters (CVC) were placed in 389 patients. CR-BSI risk factors were determined by multivariate analysis during two periods (January 2000-November 2002 and January 2003-April 2007). An intervention to reduce identified risk factors was performed after the first period. CR-BSI rates per 1,000 catheters-days were compared during the two periods. RESULTS: The CR-BSI rate was 11.94 [(95% CI 7.94-15.94)/1,000 catheter-days during the first period]. Weight [OR 0.96 (0.91-0.99)], parenteral nutrition (PN) [OR 3.38 (1.40-8.19)] and indwelling time (IT) [OR 1.08 (1.02-1.14)] were CR-BSI risk factors. Practice changes aimed at reducing PN and IT were introduced. PN decreased from 49.8% [95% CI (49.7-49.9)] to 26.7% [(95% CI 26.6-26.8)] (p < 0.001), and IT dropped from 9.92 (95% CI 9.09-10.75) to 8.13 (95% CI 7.47-8.79) days (p < 0.001). The CR-BSI rate was reduced to 3.05 (95% CI 0.93-5.17)/1,000 catheter-days. During the last period, PN and IT were no longer CR-BSI risk factors. Type of catheterisation (guide wire exchange) [OR 6.66 (1.40-31.7)] was the only CR-BSI risk factor. CONCLUSIONS: PN and IT were independent CR-BSI risk factors during the first period. An intervention focused on PN and IT reduction resulted in a sustained decrease of CR-BSI rates in our PICU.

Mechanical complications during central venous cannulations in pediatric patients.

OBJECTIVE: Identification of early mechanical complications (EMC) of central venous catheterizations (CVC) in pediatric patients and determination of EMC risk factors. DESIGN: Prospective observational study. SETTING: Pediatric intensive-care unit in a university hospital. PATIENTS AND MEASUREMENTS: Eight-hundred and twenty-five CVC were performed in 546 patients. Age, weight, gender, mechanical ventilation, analgesia, resident CVC failure, CVC indication, admission diagnosis, emergency or scheduled procedure, type of catheter (diameter, lumen number), catheter final location, number of attempts, and EMC were recorded. Risk factors for EMC were determined by multivariate analysis. RESULTS: Median patient age was 22.0 months (0-216 months). CVC was an emergency procedure in 421 (51%) cases, scheduled in 336 (40.7%), and guide-wire exchanged in 68 (8.2%). There were 293 (35.5%) internal jugular, 116 (14.1%) subclavian, and 416 (50.4%) femoral catheters. CVC was performed by staff physicians in 35.8% cases, supervised residents in 43.4%, and staff after resident failure in 20.8%. 151 EMC occurred in 144 CVC (17.5%). The most common EMC were arterial puncture (n = 60; 7.2%), catheter malposition (n = 39; 4.7%), arrhythmias (n = 19; 2.3%), and hematoma (n = 12; 1.4%). Resident failure to perform CVC (OR 2.53; CI 95% 1.53-4.16), high venous access (subclavian or jugular) (OR 1.91; CI 95% 1.26-2.88), and number of attempts (OR 1.10; CI 95% 1.03-1.17) were independently associated with EMC. CONCLUSIONS: EMC of CVC were common in a teaching university hospital, but severe complications were very uncommon. Resident failure to perform CVC, high venous access, and number of attempts were independent risk factors for EMC of CVC.