Intestinal Failure and Central Venous Catheter (CVC) Patient with Fever

Pathway Background and Objectives

Patients with Intestinal Failure (IF) often require central venous catheter (CVCs) for extended periods of time used for administration of parenteral nutrition (PN), which is required to maintain adequate growth and hydration. This puts them at a risk of recurrent central-line associated bloodstream infections (CLABSIs), with rates being higher than other pediatric patients with central lines.

Bacterial translocation in patients with short bowel syndrome (SBS) is thought to contribute to risk for recurrent CVC infection. Septic complications, related to catheter-related bacteremia and liver failure, are the leading causes of morbidity and mortality in these PN-dependent patients.

There is a research-proven association between time to antibiotics (TTA) to survival in patients with sepsis or septic shock. Therefore, there are many efforts across different institutions to reduce the time to antibiotics (TTA) for these patients.

Algorithm  Educational Module

  • % patients with pathway order set usage
  • Time from ED arrival to antibiotic order
  • Time from antibiotic order to administration
  • Time from ED arrival to antibiotic administration
  • ALOS (ED, minutes)
  • ALOS (IP/OBS days)
  1. Szydlowski EG, Rudolph JA, Vitale MA, Zuckerbraun NS. Bloodstream Infections in Patients With Intestinal Failure Presenting to a Pediatric Emergency Department With Fever and a Central Line. Pediatr Emerg Care. 2017;33(12):e140-e145.
  2. Drews BB, Sanghavi R, Siegel JD, Metcalf P, Mittal NK. Characteristics of catheter-related bloodstream infections in children with intestinal failure: Implications for clinical management. Gastroenterol Nurs. 2009;32(6):385-90.
  3. Mermel LA, Allon M, Bouza E, et al. Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009:49:1-45.
  4. Gaieski DF, Mikkelsen ME, Band RA, et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med. 2010;38(4):1045–1053
  5. Kumar A, Roberts D, Wood KE, Light B, Parrillo JE, Sharma S, Suppes R, Feinstein D, Zanotti S, Taiberg L, Gurka D, Kumar A, Cheang M. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med. 2006 Jun;34(6):1589-96. doi: 10.1097/01.CCM.0000217961.75225.E9. PMID: 16625125.
  6. Hudgins JD, Goldberg V, Fell GL, Puder M, Eisenberg MA. Reducing Time to Antibiotics in Children With Intestinal Failure, Central Venous Line, and Fever. Pediatrics. 2017;140(5):e20171201.
  • Ensure effective and efficient treatment for febrile intestinal failure patients with indwelling catheters
  • Provide standard of care practices among these patients upon presentation to the ED
  • Decrease time to administration of antibiotics

The clinical pathways in the above links have been developed specifically for use at Connecticut Children’s and are made available publicly for informational and/or educational purposes only. The clinical pathways are not intended to be, nor are they, a substitute for individualized professional medical judgment, advice, diagnosis, or treatment. Although Connecticut Children’s makes all efforts to ensure the accuracy of the posted content, Connecticut Children’s makes no warranty of any kind as to the accuracy or completeness of the information or its fitness for use at any particular facility or in any individual case.