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  1. 1. Central Line Associated Blood Streams Infection
  2. 2. Introduction Venous access via catheter insertion is common practice in the hospital for various purposes, including hemodynamic monitoring, renal replacement therapy, nutritional support and medication administration. As a consequence of their increasing use, bloodstream infections resulting from intravascular catheters have become a costly complication of health care.
  3. 3. Epidemiology More than 250,000 central line associated blood stream infections (CLABSI) occur annually in India with mortality rate of 12-25%. Each episode significantly increases hospital stay with additional health care cost.
  4. 4. Definition CRBSI (catheter related blood stream infection)- refers to blood stream infection attributed to an intravascular catheter by quantitative culture of the catheter tip or by differences in growth between catheter and peripheral venipuncture blood cultures specimens. CLABSI ( central line associated blood stream infection)- refers to blood stream infection that appears in the presence of a central venous catheter or within 48 hr of removal of a central venous catheter and which cannot be attributed to an infection unrelated to catheter. CLABSI was developed to serve as a surrogate measure of CRBSI.
  5. 5. Risk Factors It includes Patient, Operator and Catheter related factors. Patient Factors-  Increasing severity of illness  Granulocytopenia (decrease of blood granulocytes)  Compromised integrity of skin  Presence of distant infection
  6. 6. Catheter factors-  Catheter - Antibiotic or antimicrobial coating of catheter can reduce risk of CRBSI.  For non tunneled catheters risk of bsi varies by anatomical sites- max for groin insertion, intermediate for neck insertion and lowest for chest or upper extremity insertion.
  7. 7. Pathogenesis  Migration of skin organism at the insertion site into catheter tract along the surface of catheter with colonization of catheter tip.  Direct contamination of catheter or catheter hub by contact with hands or contaminated fluid or device. Colonization of device may be from surrounding skin or catheter tip Organism adhering to device followed by creation of biofilm.
  8. 8. Microbiology Organisms commonly associated with CLABSIs are-  Coagulase negative staph-31%  S. aureus- 20%.  Enterococci- 9%.  E. coli- 6%.  Klebsiella species-5%.  Candida species- 9%. • A large study found that the rates of MRSA has increased from 22% in 1995 to 57% in 2001. • Rates of ceftazidime resistant P .aeruginosa has increased from 12% in 1995 to 29% in 2001.
  9. 9. Diagnosis Exit sites of all percutaneous vascular devices should be assesse to identify obvious inflammation. Quantitative culture of the distal (5 cm) tip of central venous and arterial catheters should be performed when they are removed for suspected infection. The tip of the introducer should be sent for culture when a pulmonary artery line is removed.
  10. 10. For patients with short-term central venous catheters without severe sepsis or shock. catheter may be exchanged over a guide wire for a new catheter allowing culture of the tip of the removed catheter without immediately sacrificing the site of insertion. At least 2 blood cultures should be obtained when catheter infection is suspected.
  11. 11. When the tip of a catheter is sent for culture, the 2 blood cultures may be obtained by peripheral venipuncture. Alternatively or when culture of the tip of the catheter is not performed, one blood culture should be obtained by peripheral venipuncture and at least one blood culture should be obtained from a lumen of the catheter.
  12. 12. Management- General For emperical treatment-  vancomycin in institutions where the prevalence of MRSA is increased (otherwise use a 1st gen cephalosporin).  daptomycin in place of vancomycin in facilities where the prevalence of MRSA with reduced vancomycin susceptibility is increased.  antibiotics active against Gram-negative bacilli, based upon local susceptibility patterns, in the setting of increased severity of illness or femoral catheterization;
  13. 13. Antibiotics active against Pseudomonas aeruginosa, in the setting of severe illness, or known colonization. If blood cultures fail to yield growth, the need for further empiric antibiotic therapy should be reassessed.
  14. 14. 5 to 7 days for coagulase-negative staphylococci. 7 to 14 days for enterococci and Gram-negative bacilli. 14 days in the absence of evidence fungal retinitis for Candida species. For patients with susceptible pathogens and a functioning GI tract, oral linezolid or fluconazole may be considered for treatment of MRSA, Gram-negative bacilli, and candida,
  15. 15. Management: Long-Term Central Venous CRBSI Catheter should be removed immediately especially for S aureus, Bacillus species, micrococcus, P aeruginosa, candida, or mycobacterial infection. 4 to 6 weeks of therapy is often required for S aureus infection. when S aureus or other bacterial infection resolves within 72 hours of antibiotic initiation and catheter removal.
  16. 16. For patients with candida infection in whom there is no suspicion or evidence of infection and for whom fungemia and evidence of infection resolve promptly upon catheter removal. antifungal therapy should be continued for 14 days after the first negative blood culture.
  17. 17. Education, Training and Staffing Healthcare personnel should be educated regarding the indications proper procedures for the insertion and maintenance of intravascular catheters. Periodically assess knowledge of and adherence t o guidelines for all personnel involved in the insertion and maintenance of intravascular catheters .
  18. 18. Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters. Ensure appropriate nursing staff levels in ICUs.
  19. 19. Selection of Catheters and Sites Peripheral Catheters and Midline Catheters  In adults, use an upper-extremity site for catheter insertion.  Select catheters on the basis of the intended purpose and duration of use, known infectious and non-infectious complications and experience of individual catheter operators.
  20. 20.  Evaluate the catheter insertion site daily by palpation through the dressing to a transparent dressing is in use.  Gauze and opaque dressings should not be removed if the patient has no clinical signs of infection.  Remove peripheral venous catheters if the patients develops signs of infection, or a malfunctioning catheter.
  21. 21. Hand Hygiene and Aseptic Technique
  22. 22. Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol- based hand rubs. Maintain aseptic technique for the insertion and care of intravascular catheters. Sterile gloves should be worn for the insertion of arterial, central, and midline catheters. Use new sterile gloves before handling the new catheter when guide wire exchanges are performed. Wear either clean or sterile gloves when changing the dressing on intravascular catheters.
  23. 23. Maximal Sterile Barrier Precautions Maximal sterile barrier precautions like cap, mask, sterile gown, sterile gloves, and a sterile full body drape, should be used for the insertion.
  24. 24. Skin Preparation  Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, or alcoholic chlorhexidine gluconate solution) before peripheral venous catheter insertion. Anticoagulants  Do not routinely use anticoagulant therapy to reduce the risk of catheter-related infection in general patient population.
  25. 25. Catheter Site Dressing Regimens  Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site.  Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance.  Do not submerge the catheter or catheter site in water.  Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings.
  26. 26. Surveillance and Reporting:-  Hospital-based infection control teams begin surveillance for bloodstream infections by regularly reviewing results of blood cultures obtained at their facilities.