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Foreign Body Infections

Foreign Body Infections

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Published by: api-3712326 on Oct 14, 2008
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03/18/2014

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"Foreign Body" (Device) Infections
Implanted Devices Vulnerable to Infection
Indwelling Intravenous catheters
Prosthetic cardiac valves
Prosthetic orthopedic devices (joint replacements) Cerebrospinal fluid
shunts/Ventriculostomy drains Peritoneal dialysis catheters
Arterious-venous anastomoses (dialysis) Vascular grafts

Mesh soft tissue support
Silicon Implants (plastic surgery)
Cardiac pacemakers

CPT Coding
Complication of an Internal Prosthesis, Implant or

Graft--infection or Inflammation
996.60 Unspecified 996.61 Cardiac 996.62 Vascular
996.63 Nervous system
996.64

Urinary catheter
(indwelling)
996.65
Genitourinary other
996.66
Joint prosthesis internal
996.67
Orthopedic other internal
996.69
Other Internal prosthesis
Intravascular Device Infections Types (Examples)

Peripheral Short Lines (Angiocath)
Peripheral Long Lines (Landmark)
Percutaneous CVP (Cooke triple lumen)
Pulmonary artery catheter (Swann-Ganz)
Tunnel/Cuff (Broviac)

Implanted Port (Port-a-Cath)
Intravascular Device Infections
Risk factors

Cutdowns > Percutaneous Insertion Central lines > peripheral Femoral >

Jugular \u2022 Subclavian
Long duration \u2022 short duration (< 72 hours) Polyvinyl chloride \u2022 Teflon or
silastic Direct insertion \u2022 tunneled Frequent access > Infrequent access
Parenteral nutrition \u2022 noninitiative fluids \u2022
antibiotics

Tegaderm \u2022 open air dressings

Intravascular Device Infections
Pathogenesis
Contamination of Intradermal Insertion
wound (+ bleeding)
Formation of intravascular "fibrin
sheath"

Colonization of catheter, formation of
"bifilms" and "macrocolonies" Infection of "fibrin sheath" Release of
"planktonic" organisms Local or generalized intravascular
infection
Intravascular Device Infections

Common organisms Coagulase-negative staphylococci Staph. aureus (including MRSA) Candida albicans Klebsiella - Enterobacter Enterococci (now including VRE) Pseudomonas aeruginosa

Intravascular Device Infections

Unusual organisms Corynebacterium jeikeium Pseudomonas cepacia Serratia marcescens Acinetobacter calcoaceticus Torulopsis glabrata Malassezia furfur Candida lusitaniae

Intravascular Device Infections

Clinical Manifestations Occult bacteremia Exit site Infections "Tunnel" infections
Sepsis/septic shock
Septic thrombophlebitis - peripheral or
central vein

Metastatic spread - eyes, CNS, lungs operative sites, other prosthetic devices,
heart
Intravascular Device Infections
Line Removal

Pros
Removes focus of infection
Shortens duration of therapy

Reduces chances of metastatic spread Cons
Local/systemic antibiotics may cure Multiple lines/uncertain source
Limited access
Need for line may be time-limited
Intravascular Device Infection
Antibiotics
Treat through all incriminated venous
lines and lumens
Synergistic/additive combinations Antibiotic "lock" technique
(heparin/antibiotic compatibility)
Don't use vancomycin unnecessarily Duration determined by response
and
presence of metastatic infection
Intravascular Device Infections
Prevention
Block adhesion of organisms new polymers, detergents, disaccharides
Prevent bacterial growth impregnated antibiotics, infused antibiotics, antibiotic
"lock" technique
Intravascular Device Infections
Diagnosis
Criteria for "significant" bacteremia < 48 hours to positive result 2/2 bottles
positive Repeated cultures positive
Intravascular Device Infections
Diagnosis

Other culture criteria Semiquantitative cath tip pneltive Pus expressed from tunnel positive Persistent bacteremia despite appropriate Rx Higher level bacteremia from incriminated

catheter
Intravascular Device Infections
Treatment options Line removal Antibiotics Both

Strategy, sites of new lines
Neurologic Device Infections Types of Devices (Examples)
External ventricular drains

(ventriculostomy)

Subcutaneous access ports (Ommaya) Ventriculo-peritoneal shunts (Hakim) V-atrial, V-jugular, V-pleural Subarachnoid screws/bolts (El Camino)

Neurologic Device Infections
Epidemiology/Risk Factors
Timing close to operation (<2 months) Overall rates 5-35%

Thin cortex \u2022 thick cortex High protein > low protein Low pressure > high pressure July \u2022 rest of academic year Repeat surgery \u2022 initial surgery Head shaving night before \u2022 shave at

operation
Neurologic Device Infections
Organisms

Coagulase-negative Staphylococci
Staph. aureus
Corynebacterium sp.
Propionibacterium acnes
Enteric gram negative rods

Candida sp.
Neurologic Device Infections Clinical Manifestations
Shunt malfunction-headache, vomiting,

irritability, mental status changes, coma Shunt reservoir doesn't "pump" properly Fever (not invariably present) Peritonitis (VP shunts) Bacteremia/sepsis/nephritis (V-A and V-J)

Neurologic Device Infections
Diagnosis

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