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Management of Intravascular Catheter related infection

Intern Supervisor: VS

Ref: Clinical Infectious Diseases 2001;32:1249-72

Types of intravascular devices

Epidemiology and pathogens


200000 nosocominal bloodstream infection /5million CVC placement annually in U.S. (4%) Case-fatality rate: 14%, 19% of these death can be attribute to catheter related infection. Coagulase negative staphylococci, S. aureus, aerobic gram negative bacilli, C. albicans.
Mortality rate of catheter related bacteremia varies from species to species Eg: S. aureus (8.2%) v. CNS (0.7%)

Specific culture methodology


Roll plate (Semi-quantitave) Vortex or Sonication (Quantitative)
Sensitivity: 80% v. 60% (roll plate) v. 40-50% (flush culture).

Quantitative culture of CVC blood sample.


Useful in diagnose the tunneled catheter related blood stream infection.

Differential time to positivity for CVC versus peripheral blood culture


Useful in hospital which do not have quantitative culture methods.

Diagnosis
One positive result of culture of blood samples obtained from the peripheral vein Clinical manifestations of infection. No apparent source for bloodstream infection One of the following should be present
a positive result of semiquantitative (15 cfu per catheter segment) or quantitative (102 cfu per catheter segment) catheter culture same organism (species and antibiogram) simultaneous quantitative cultures of blood samples with a ratio of 5:1 (CVC vs. peripheral); CVC sample differential time to positivity 2 h earlier than peripheral blood)

Diagnosis of non tunneled CVC infection

Diagnosis of tunneled CVC infection

Complication: Septic Thrombosis


Continued positive blood culture results after catheter withdrawal. S. aureus is the most common pathogen. Use of thrombolytic agents in addition to antimicrobial agents is not recommended. Heparin should be used in the treatment of septic thrombosis of the great central veins and arteries. Surgical exploration is needed when infection extends beyond the vein into surrounding tissue.

Complication: Persistent bloodstream infection and IE


Empirical therapy in this situation must include coverage for staphylococci. Remove the CVC 4 weeks of antimicrobial therapy in most cases and with surgical intervention when indicated. Exception: Uncomplicated tricuspid valve endocarditis due to staphylococci in injection drug users, a 2-week duration of antimicrobial therapy appears to be effective.

Management
Remove the central venous catheter / implantable device or not?
Depending on the complications and specific microorgainsm.

What antibiotics and the duration of treatment?


Depending on whether the device is salvaged, the complications and specific microorgainsm. From no antibiotics usage to 8 weeks.

Is antibiotics lock therapy useful?


In most GPC intraluminal infection, YES.

Antibiotics lock therapy


Antibiotic in a concentration of 15 mg/mL are usually mixed with 50100 U heparin to fill the catheter lumen and are installed or locked into the catheter lumen during periods when the catheter is not being used (e.g., for a 12-h period each night).
Several open trials of antibiotic lock therapy of tunneled catheter related bacteremia, have reported catheter salvage without relapse in 138 (82.6%) of 167 episodes, compared to 342 (66.5%) of 514 episodes which use standard parenteral therapy.

Specific pathogen: CNS


Coagulase-negative staphylococci, such as S. epidermidis, are the most common cause of catheter-related infections. Catheter-related infections due to CNS staphylococci predominantly manifest with fever alone or fever with inflammation at the catheter exit site. Vancomycin empirical therapy is appropriate before culture data to be obtained.

Specific pathogen: S. aureus


TEE should be done to r/o endocarditis. Vancomycin should not be used when theres infection with b-lactam susceptible S. aureus.
excessive vancomycin use selects vancomycinresistant organisms vancomycin has higher failure rates than do either oxacillin or nafcillin slower clearance of bacteremia among patients with S.aureus endocarditis

Specific pathogen: C. albicans


All patients with candidemia should be treated
Amphotericin B is recommended for hemodynamically unstable patients or who have received prolonged fluconazole therapy

Salvage therapy for infected tunneled CVCs or IDs is not recommended for routine use
Salvage rates with systemic fungal therapy and antibiotic lock therapy for Candida species have been about 30%.

Management of removable CVC infection

Management of tunneled CVC infection

Summery
Paired quantitative blood culture is recommended especially in tunneled CVD/ID to confirm diagnosis. TEE should be done to rule out vegetations in S. aureus bloodstream infection. For complicated infections, the CVC/ID should be removed. For uncomplicated intraluminal bacterial infection in the absence of tunnel or pocket infection, 2 weeks systemic therapy with antibiotic lock therapy add chance to salvage the CVC/ ID.

Areas of further research.


Do patients with positive results of catheter cultures but with negative blood culture results and no other obvious site of infection need to be treated with antibiotics? Prospective, randomized studies for the optimum duration of treatment when the catheters are left in place. Prospective, randomized studies to determine the efficacy of combined systemic and antibiotics lock therapy in specific pathogen.

Thanks for your attention