CATHETER RELATED BLOOD STREAM

INFECTIONS

DR ALI MEHDI
INTRODUCTION

 In the United States, more than 80,000 CVC(central venous catheter)-related bloodstream infections occur in
intensive care units each year.
 Each year in the United States, hospitals and clinics purchase >150 million intravascular devices to administer
intravenous fluids, medications, blood products, and parenteral nutrition fluids, to monitor hemodynamic status,
and to provide hemodialysis.
 Different types of intravascular catheters are currently being used, leading to a variety of infectious complications.
 CRBSIs independently increase hospital cost and length of stay.
COMMON RISK FACTORS FOR CRBSI’S

 The risk of bloodstream infection varies according to

1. The intravascular device.

2. The type of and intended use for the catheter.
3. The insertion site.
4. The experience and education of the individual who installs the catheter.
5. The frequency with which the catheter is accessed.
6. The duration of catheter placement.
7. The characteristics of the catheterized patient.
8. The use of proven preventative strategies.
 TYPES OF INTRAVASCULAR CATHETERS

Catheter Type Entery Site Length Of Catheter Comment

Peripheral venous catheters Veins of forearm or hand <3 inches Rarely CRBSI
Peripheral arterial catheters Radial/brachial/ <3 inches Low risk of infection
axillary,femoral/post.tibial
artery
Midline catheters Basalic/cephalic,no central 3 to 8 inches Anaphy.e elastomeric hydro
Nontunneled central venous Percutaneously inserted in >8 cm depending on patient Majority of CRBSI
catheters SC/IJV/femoral size
Pulmonary artery catheters SC/IJV/Fem via Teflon >30 cm Similar to CVC risk
introd
Peripherally inserted central Basalic/cephalic/branchial >20 cm Low rates of infection
venous catheters (PICC) vein then SVC
Tunneled central venous Subclavian(SC),IJV,Femoral >8 cm Low risk as cuff inhibits
catheters migration of organisms
Totally implantable Beneath skin+SC >8 cm Low risk
port+SC/IJ
CONTD.
COMMONLY USED CLINICAL DEFINITIONS OF INTRAVASCULAR
CATHETER-RELATED INFECTIONS.
Infection Definition
Catheter colonization Significant growth of a microorganism in a quantitative
or semiquantitative culture of the catheter tip
Phlebitis Induration or erythema, warmth, and pain or tenderness
along the tract of a catheter
Exit site infection
Microbiological Exudate at catheter exit site yields a microorganism
Clinical Erythema, induration, and/or tenderness within 2 cm of
the catheter exit site
Tunnel infection Tunnel infection Pocket infection Tenderness, erythema,
and/or induration 12 cm from the catheter exit site
Pocket infection Infected fluid in the subcutaneous pocket of a totally
implanted intravascular device
CONTD.

Infection Definition
Bloodstream infection
Infusate related Concordant growth of a microorganism from infusate
and cultures of percutaneously obtained blood cultures
with no other identifiable source of infection
Catheter related Bacteremia or fungemia in a patient who has an
intravascular device and 11 positive blood culture result
obtained from the peripheral vein, clinical
manifestations of infection
PATHOGENESIS OF CRBSI’S

 There are four recognized routes for contamination of catheters:

1. Migration of skin organisms at the insertion site into the cutaneous catheter tract and along the surface of the
catheter with colonization of the catheter tip (most common route of infection).
2. Direct contamination of the catheter or catheter hub by contact with hands or contaminated fluids or devices.
3. Less commonly, catheters might become hematogenously seeded from another focus of infection.
4. Rarely, infusate contamination might lead to CRBSI.
 CONTD.

 Important pathogenic determinants of CRBSI are:

1. The material of which the device is made.

2. The host factors consisting of protein adhesions, such as fibrin and fibronectin, that form a sheath around the
catheter.
3. The intrinsic virulence factors of the infecting organism, including the extracellular polymeric substance (EPS)
produced by the adherent organisms.
4. Some catheter materials also have surface irregularities that enhance the microbial adherence of certain species
(e.g., S. Epidermidis on silastic made catheter,and C. Albicans on silicon elastomer catheter)
5. Certain catheter materials are more thrombogenic than others, a characteristic that also might predispose to catheter
colonization and infection. This association has led to emphasis on preventing catheter-related thrombus as an
additional mechanism for reducing CRBSI
 CONTD.

 The adherence properties of a given microorganism in relationship to host factors are also important in the
pathogenesis of CRBSI. For example, S. aureus can adhere to host proteins (e.g., fibrinogen, fibronectin)
commonly present on catheters by expressing clumping factors (ClfA and ClfB) that bind to the protein adhesins.
 Adherence is enhanced through the production by microbial organisms of an extracellular polymeric substance
(EPS) consisting mostly of an exopolysaccharide that forms a microbial biofilm layer. This biofilm matrix is
enriched by divalent metallic cations, such as calcium, magnesium and iron, which make it a solid enclave in
which microbial organisms can embed themselves.
 Such a biofilm potentiates the pathogenicity of various microbes by allowing them to withstand host defense
mechanisms (e.g., acting as a barrier to engulfment and killing by polymorphonuclear leukocytes) or by making
them less susceptible to antimicrobial agents.
DIAGNOSIS: WHEN AND HOW SHOULD CATHETER CULTURES
AND BLOOD CULTURES BE DONE

 Intravenous Catheter Cultures: Recommendations

1. Catheter cultures should be done when a catheter is removed because of suspected CRBSI; catheter cultures
should not be obtained routinely.
2. Qualitative broth culture of catheter tips is not recommended.
3. For CVCs, culture the catheter tip, not the subcutaneous segment.
4. When catheter-related infection is suspected and there is a catheter exit site exudate, swab the drainage to obtain
samples for culture and Gram staining.
5. Growth of >15 cfu from a 5-cm segment of the catheter tip by semiquantitative (roll-plate) culture or growth of
>102 cfu from a catheter by quantitative (sonication) broth culture reflects catheter colonization.
CONTD.
 Short-term catheters, including arterial catheters

1. The roll plate technique is recommended for routine clinical microbiological analysis.
2. For suspected pulmonary artery catheter-related infection, culture the introducer tip.
 Long-term catheters

1. Semiquantitative growth of >15 cfus/plate of the same microbe from both the insertion site culture and catheter hub culture strongly
suggests that the catheter is not the source of a bloodstream infection.
2. If a venous access subcutaneous port is removed because of suspected CRBSI, send the port to the microbiology laboratory for
qualitative culture of the port reservoir contents, in addition to the catheter tip.
 Blood Cultures: Recommendations

1. Obtain blood cultures prior to initiation of antibiotic therapy.

2. For suspected CRBSI, paired blood samples drawn from the catheter and from a peripheral vein should be cultured before initiation of
antimicrobial therapy, and the bottles should be appropriately marked to reflect the site from which the cultures were obtained.
3. A definitive diagnosis of CRBSI requires that the same organism grow from at least 1 percutaneous blood sample culture and from the
catheter tip
CATHETER-RELATED INFECTIONS MANAGEMENT IN GENERAL

 Vancomycin is recommended for empirical therapy in heath care settings with an increased prevalence of MRSA.
 Empirical coverage for gram-negative bacilli should be based on local antimicrobial susceptibility data and the severity of
disease (e.g., a fourth-generation cephalosporin, carbapenem, or b-lactam/b-lactamase combination, with or without an
aminoglycoside).
 Empirical combination antibiotic coverage for MDR gram-negative bacilli, such as P. aeruginosa, should be used when
CRBSI is suspected among neutropenic patients, severely ill patients with sepsis, or patients known to be colonized with
such pathogens.
 Empirical therapy for suspected catheter-related candidemia should be used for septic patients with any of the following
risk factors: total parenteral nutrition, prolonged use of broad-spectrum antibiotics, hematologic malignancy, receipt of
bone marrow or solid-organ transplant, femoral catheterization, or colonization due to Candida species at multiple sites.
 Four to 6 weeks of antibiotic therapy should be administered to patients with persistent fungemia or bacteremia after
catheter removal
SELECTION OF CATHETERS AND SITES

 Peripheral and Midline Catheter Recommendations

1. In adults, use an upper-extremity site for catheter insertion. Replace a catheter inserted in a lower extremity site to
an upper extremity site as soon as possible.
2. Inpediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used as the
catheter insertion site.
3. Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter,
when the duration of IV therapy will likely exceed six days.
4. Evaluate the catheter insertion site daily by palpation through the dressing to discern tenderness and by inspection
if a transparent dressing is in use. Gauze and opaque dressings should not be removed if the patient has no clinical
signs of infection. If the patient has local tenderness or other signs of possible CRBSI, an opaque dressing should
be removed and the site inspected visually.
CONTD.

 Central Venous Catheters Recommendations

1. Weigh the risks and benefits of placing a central venous device at a recommended site to reduce infectious complications
against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein
laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism, and catheter misplacement)
2. Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled
CVC placement.
3. Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein
stenosis
4. Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of
cannulation attempts and mechanical complications.
5. Use a fistula or graft in patients with chronic renal failure instead of a CVC for permanent access for dialysis.
STRATEGIES FOR PREVENTION OF CATHETER-RELATED
INFECTIONS IN PEDIATRIC PATIENTS

 The benefits of catheter removal must be weighed against the difficulty of obtaining alternate venous access for an
individual patient.
 Children treated without catheter removal should be closely monitored with clinical evaluation and additional
blood cultures; the device should be removed if there is clinical deterioration or persistent or recurrent CRBSI.
 In general, empirical antibacterial therapy for children with CRBSI should be similar to that for adults.
 Antimicrobial agents that are appropriate for infants and children and the recommended dosages of specific
agents, by patient age and weight should be administered through the involved catheter.
 In contrast to the recommendation for adults, empirical antifungal coverage in critically ill patients with femoral
catheters is not recommended for children. Antifungal therapy should be initiated when yeast is isolated from a
blood culture or when the suspicion of fungemia is high.
 PATIENTS WHO ARE RECEIVING HEMODIALYSIS THROUGH
CATHETERS

 In patients with suspected CRBSI for whom blood cultures have been obtained and for whom antibiotic therapy has been
initiated, antibiotic therapy can be discontinued if both sets of blood cultures have negative results and no other source of
infection is identified.
 The infected catheter should always be removed for patients with hemodialysis CRBSI due to S. aureus, Pseudomonas
species, or Candida species and a temporary (nontunneled catheter) should be inserted into another anatomical site.If
absolutely no alternative sites are available for catheter insertion, then exchange the infected catheter over a guidewire .
 Empirical antibiotic therapy should include vancomycin and coverage for gram-negative bacilli, based on the local
antibiogram (e.g., third-generation cephalosporin, carbapenem, or b-lactam/b-lactamase combination).
 A 4–6-week antibiotic course should be administered if there is persistent bacteremia or fungemia (i.e., 172 h in duration)
after hemodialysis catheter removal or for patients with endocarditis or suppurative thrombophlebitis.
 Surveillance blood cultures should be obtained 1 week after completion of an antibiotic course for CRBSI if the catheter
has been retained
ANTIBIOTIC DOSING FOR PATIENTS WHO ARE UNDERGOING
HEMODIALYSIS.

 Empirical dosing pending culture results:Vancomycin plus empirical gram-negative rod coverage based on local
antibiogram data.
 Vancomycin plus gentamicin:

1. Vancomycin: 20-mg/kg loading dose infused during the last hour of the dialysis session, and then 500 mg during
the last 30 min of each subsequent dialysis session.
2. Gentamicin (or tobramycin:) 1 mg/kg, not to exceed 100 mg after each dialysis session.
 For Candida infection:An echinocandin (caspofungin 70 mg iv loading dose followed by 50 mg iv daily;
intravenous micafungin 100 mg iv daily; or anidulafungin 200 mg iv loading dose, followed by 100 mg iv daily);
fluconazole (200 mg orally daily); or amphotericin-B
PATIENTS WITH LONG-TERM CVCS OR IMPLANTED CATHETER-RELATED
INFECTIONS THAT ARE NOT ASSOCIATED WITH HEMODIALYSIS CATHETERS

 Patients with tunnel infection or port abscess require removal of the catheter, incision and drainage if indicated,
and 7–10 days of antibiotic therapy in the absence of concomitant bacteremia or candidemia.
 Uncomplicated exit site infections should be managed with topical antimicrobial agents on the basis of the exit
site culture results.
 If an uncomplicated exit site infection fails to resolve with topical therapy or if it is accompanied by purulent
drainage, then systemic antibiotics should be administered on the basis of the antimicrobial susceptibility of the
causative pathogen; the catheter should be removed if treatmentwithsystemic antibiotics fails.
 If other vascular sites are unavailable and/or the patient is at increased risk for bleeding diathesis in the setting of
CRBSI not complicated by an exit site or tunnel infection, an antimicrobial-impregnated catheter with an
antiinfective intraluminal surface should be considered for catheter exchange
ANTIBIOTIC LOCK THERAPY

 Antibiotic lock solutions contain the desired antimicrobial concentration and they are usually mixed with 50–100 units of heparin or
normal saline in sufficient volume to fill the catheter lumen (usually 2–5 mL).
 For CRBSI, antibiotic lock should not be used alone; instead, it should be used in conjunction with systemic antimicrobial therapy,
with both regimens administered for 7–14 days.
 Reinstallation of lock solution should take place every 24 h for ambulatory patients with femoral catheters. However, for patients
who are undergoing hemodialysis, the lock solution can be renewed after every dialysis session.
 Catheter removal is recommended for CRBSI due to S. aureus and Candida species, instead of treatmentwithantibiotic lock and
catheter retention, unless there are unusual extenuating circumstances (e.g., no alternative catheter insertion site).
 For patients with multiple positive catheter-drawn blood cultures that grow coagulase-negative staphylococci or gramnegative bacilli
and concurrent negative peripheral blood cultures, antibiotic lock therapy can be given without systemic therapy for 10–14 days.
 For vancomycin, the concentration should be at least 1000 times higher than the MIC (e.g., 5 mg/mL) of the microorganism
involved.
 PERSISTENT BLOODSTREAM INFECTION AND INFECTIVE
ENDOCARDITIS

 TEE should be done for patients with CRBSI who have any of the following: a prosthetic heart valve, pacemaker,
or implantable defibrillator; persistent bacteremia or fungemia and/or fever 172 h after initiation of appropriate
antibiotic therapy and catheter removal, in addition to a search for metastatic foci of infection, as indicated; and
any case of S. aureus CRBSI in which duration of therapy less than 4–6 weeks is being considered.
 Catheter withdrawal is required in the management of catheter-related infective endocarditis.
 Unless the clinical condition of the patient dictates otherwise, perform a TEE at least 5–7 days after the onset of
bacteremia or fungemia and consider repeating the TEE for patients with a high index of suspicion for infective
endocarditis in whom the initial TEE had negative findings.
Thank You