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catheter related blood stream infection

catheter related blood stream infection

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catheter related blood stream infection

  1. 1. Catheter related blood stream infection (CRBSI)
  2. 2. 2 Central line-associated bloodstream infection: a laboratory- confirmed bloodstream infection not related to an infection at another site that develops within 48 hours of a central line placement. CLABSI
  3. 3. CRBSI Catheter-related bloodstream infection: a bloodstream infection attributed to an intravascular catheter by quantitative culture of the catheter tip or by differences in growth between catheter and peripheral venipuncture blood culture specimens. 3
  4. 4. Risk factors: Host factors that increase the risk of CLABSI are chronic illnesses, immune compromised states, malnutrition, total parenteral nutrition, extremes of age, loss of skin integrity (burns), prolonged hospitalization before line insertion, catheter type, catheter location, conditions of insertion, catheter site care, and skill of the catheter inserter 4
  5. 5. × Fever × Inflammation or purulence (at insertion site) × Hemodynamically instability Clinical manifestations: × s/s of sepsis × Complications related to bloodstream infection* × Catheter dysfunction × AMS 5
  6. 6. Diagnosis Cultures of blood & catheter should be taken in the setting of clinical suspicion for CRBSI 6
  7. 7. Culture 7 • Paired blood samples drawn from the catheter and a peripheral vein should be obtained prior to initiation of antibiotic therapy. • The same volume of blood should be inoculated for each culture.
  8. 8. Diagnostic Criteria 8 Culture of the same organism from both the catheter tip and at least one percutaneous blood culture. Culture of the same organism from at least two blood samples meeting criteria for quantitative blood cultures or differential time to positivity.
  9. 9. × Quantitative blood cultures demonstrating a colony count from the catheter hub sample ≥3-fold higher than the colony count from the peripheral vein sample (or a second lumen). × Semi-quantitative cultures demonstrating >15 colony forming units (CFU)/mL of the same microbe from the insertion site, hub site, and peripheral blood culture. 9
  10. 10. 10 Differential time to positivity (DTP) refers to growth detected from the catheter hub sample at least two hours before growth detected from the peripheral vein sample.
  11. 11. Treatment: Cases where systemic AB is not rcd: × Positive catheter tip culture in the absence of clinical signs of infection. × Positive blood cultures obtained through a catheter with negative cultures through a peripheral vein. × Phlebitis in the absence of infection. 11
  12. 12. 12 Catheter Management: salvage, exchange, removal Indications to remove Catheter:  Severe sepsis.  Hemodynamic instability.  Endocarditis or evidence of metastatic infection.  Erythema or exudate due to thrombophlebitis.  Persistent bacteremia after 72 hours of antimicrobial therapy to which the organism is susceptible.
  13. 13. • Short-term catheters (indwelling <14 days) removed if S.aureus, enterococci, gram-negative bacilli, fungi, and mycobacteria. • Long-term catheters (indwelling ≥14 days) removed if S. aureus, P.aeruginosa, fungi, or mycobacteria. 13 Catheter removal in terms of pathogen:
  14. 14. 14 Catheter Salvage • Catheter salvage may be attempted in the setting of uncomplicated CRBSI involving long-term catheters due to pathogens other than S. aureus, P. aeruginosa, fungi, or mycobacteria. • If salvage is attempted, both systemic and antimicrobial lock therapy may be administered through the colonized catheter for the duration of therapy, depending upon the microorganism. • Two sets of blood cultures should be obtained after 72 hours of appropriate antimicrobial therapy (for neonates, one set is acceptable); positive cultures should prompt catheter removal.
  15. 15. 15 • For circumstances in which catheter removal is necessary for suspected catheter related infection and the risk for mechanical complications or bleeding during catheter reinsertion is high, guidewire exchange of the catheter is acceptable (except in the setting of sepsis). Catheter removal The tip of the removed catheter should be sent for culture; if the results are positive or if there is evidence of phlebitis, thrombosis, or purulence, the newly inserted catheter should be relocated to a new site.
  16. 16. Abx- empiric therapy  The severity of illness.  The risk factors for infection.  The likely pathogens associated with the specific intravascular device. 16
  17. 17. × CNST is the most common cause of infection  Vancomycin × Daptomycin* × Additional agents with activity against CNS and MRSA include daptomycin, linezolid, tedizolid, telavancin, dalbavancin, oritavancin, ceftaroline, and quinupristin- dalfopristin.** × In certain circumstances w/ certain pts we should cover G- ve in empiric treatment × In case of sepsis or NF: empiric antibiotic therapy for gram- negative bacilli (including Pseudomonas) is appropriate . 17
  18. 18. Candida is suspected: Septic patients with the following risk factors: × Total parenteral nutrition × Prolonged use of broad-spectrum antibiotics × Hematologic malignancy × Bone marrow or solid organ transplant × Femoral catheterization × Colonization due to Candida species at multiple sites Should be given: × Appropriate agents: echinocandin or azole drugs 18
  19. 19. Tailored therapy- CNST  Coagulase-negative staphylococci are the most common cause & the most common blood culture contaminant.  This makes it difficult to interpret blood cultures positive with S. epidermidis.  Best indicator for true CRBSI is positive blood cultures drawn from both peripherally and through the suspected catheter. 19
  20. 20. × Treatment with antibiotics following catheter removal (5-7 days). × However, such infections may resolve with removal of the catheter in the absence of antibiotic therapy × If no endovascular hardware, no abx therapy is warranted unless fever and/or bacteremia persist after catheter withdrawal. × Patients with endovascular hardware should have the catheter removed and more prolonged therapy is warranted. (4-6wks) × If infective endocarditis is excluded, three weeks of therapy is appropriate. × If catheter salvage is necessary, antibiotic therapy is warranted (systemically as well as via antibiotic lock therapy [ALT] in some cases) for 10 t o 14 days. 20
  21. 21. Staphylococcus aureus: × Catheter removal and systemic antibiotic therapy. (A new catheter may be placed if additional blood cultures demonstrate no growth at 72 hours). × Treatment with vancomycin should be initiated. If CRBSI is 2/2 MSSA, switch to nafcillin or oxacillin. × Transesophageal echocardiogram (TEE) should be pursued in the setting of S. aureus bacteremia to rule out IE (5-7) days after the onset of bacteremia. 21
  22. 22. × Risk factors for hematogenous complications:  Community-acquired infection (suggesting longer duration of bacteremia)  Prosthetic intravascular device.  Co-morbid immunocompromising conditions.  Valvular abnormality predisposing to endocarditis.  Dialysis dependence.  suppurative thrombophlebitis.  Delay in catheter removal. 22
  23. 23. × No hematogenous complications -> ≥14 days. × Hematogenous complications -> 4-6 weeks. × If pt have 1 positive and 1 negative culture then 2 cultures are repeated (catheter and blood). If both repeat cultures are positive, treatment for CRBSI is warranted. × Clinical signs of infection should prompt catheter removal. 23
  24. 24. Antibiotic lock therapy × ALT is to achieve sufficient therapeutic concentrations to kill microbes growing in a biofilm. × Its used as adjunct therapy for intraluminal infections 2/2 CNST or gram-negative organisms when the catheter cannot be removed. × ALT should not be used for extraluminal infections nor for management of infections due to S. aureus, P. aeruginosa, drug- resistant gram-negative bacilli, or Candida. 24

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