Watchful waiting versus immediate catheter removal in ICU patients with suspected catheter-related infection: a randomized trial.

Objective: To find a subset of patients with suspected central venous catheter (CVC)-related infection (CRI) in whom CVC removal is not needed.
Design: Randomized controlled trial.
Setting: Thirty-three-bed ICU.
Patients and Participants: One hundred and forty four patients with suspected CRI in which a change of CVCs was planned were evaluated for inclusion.
Interventions: Hemodynamically stable patients without proven bacteremia, no insertion site infection, and no intravascular foreign body were randomized to a standard-of-care group (SOC, all CVCs were changed as planned) or a watchful waiting group (WW, CVCs changed when bacteremia was subsequently confirmed or hemodynamic instability occurred).
Measurement and Results: Study groups were compared for incidence of CVC-related bloodstream infection (CR-BSI), resolution of fever, C-reactive protein, SOFA score, duration of ICU stay, and mortality. Of 144 patients with suspected CRI, 80 patients met exclusion criteria. Sixty-four were randomized. Forty-seven of 80 excluded patients were shown to be bacteremic, 20 (25%) of whom had a CR-BSI. Five of 64 (8%) included patients had a CR-BSI during their subsequent ICU stay (two in SOC and three in WW group). All 38 CVCs were changed in the SOC group versus 16 of 42 in the WW group (62% reduction, P<0.01). Resolution of fever, C-reactive protein, SOFA score, duration of ICU stay, and ICU mortality did not differ between SOC and WW group ( P>0.1 for all).
Conclusions: The use of a simple clinical algorithm permits a substantial decrease in the number of unnecessarily removed CVCs without increased morbidity.