SlideShare verwendet Cookies, um die Funktionalität und Leistungsfähigkeit der Webseite zu verbessern und Ihnen relevante Werbung bereitzustellen. Wenn Sie diese Webseite weiter besuchen, erklären Sie sich mit der Verwendung von Cookies auf dieser Seite einverstanden. Lesen Sie bitte unsere Nutzervereinbarung und die Datenschutzrichtlinie.
SlideShare verwendet Cookies, um die Funktionalität und Leistungsfähigkeit der Webseite zu verbessern und Ihnen relevante Werbung bereitzustellen. Wenn Sie diese Webseite weiter besuchen, erklären Sie sich mit der Verwendung von Cookies auf dieser Seite einverstanden. Lesen Sie bitte unsere unsere Datenschutzrichtlinie und die Nutzervereinbarung.
chronic illnesses (hemodialysis, malignancy, gastrointestinal tract disorders, pulmonary hypertension) immune compromised states (bone marrow transplant, end-stage renal disease, diabetes mellitus), catheter location (femoral line has the highest, followed by internal jugular, then subclavian) conditions of insertion (emergent versus elective) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805442/
Fever: sensitive but not specific Inflammation or purulence specific but poor sensitivity thrombophlebitis, endocarditis, osteomyelitis, metastatic infection +ve culture for S.aureus, CNST, Candida increase suspicion for CRBSI Clinical improvement w/in 24h following catheter removal suggest CRBSI but not definitive)
In renal insufficiency, collection of peripheral blood samples from vessels intended for future use in creating a dialysis fistula should be avoided. If cannot be drawn from a peripheral vein, then blood can be drawn from different lumens of multilumen catheters. If this approach is pursued, ≥2 blood samples should be drawn though catheter lumens at different times. Cultures of blood samples obtained through catheters are associated with a higher rate of false-positive results than cultures of percutaneous blood samples. ->The specificity and positive predictive value forculturing blood samples from peripheral veins are higher than for culturing blood samples obtained through catheters.
To confirm the diagnosis the presence of blood stream infection must be established, and it must be demonstrated that it is -in fact- related to the catheter, no alternative source for bacteremia. Culture of the same organism from at least two blood samples (one form a catheter hub and the other from a peripheral vein or second lumen)
In the setting of a single positive blood culture positive for coagulase-negative staphylococci, repeat blood samples should be obtained for culture prior to initiation of antimicrobial therapy, both through the suspected catheter and from a peripheral vein In the setting of positive catheter-drawn blood cultures for coagulase-negative staphylococci or gram-negative bacilli and negative concurrent percutaneous blood cultures, an intraluminally colonized catheter may be present. As such, there may be an increased risk for subsequent CRBSI in these patients, especially if the device is left in place. In such circumstances, we favor following the patient closely and obtaining additional percutaneous blood cultures if the patient continues ot exhibit clinical manifestations of CRBSI. However, some clinicians may prefer to remove the device or exchange it over a guide wire. Alternatively, antibiotic lock therapy (without systemic therapy) may be administered if removal is not feasible.
Most isolated are resistant to methicillin, Linezolid is not good as empiric therapy *In institutions with high rates of infection due to MRSA isolates with vancomycin (MIC) ≥2 mcg/mL, daptomycin should be used. ** limited data for their use
Fluconazole is appropriate for patients without azole exposure in the previous three months and in settings where the risk of Candida krusei or Candida glabratais very low.
Possible exceptions are patients whose fever and bacteremia resolve within 72 hours following catheter removal who have no underlying cardiac predisposing conditions or clinical signs of endocarditis.
catheter related blood stream infection
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
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.
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
× Inflammation or
purulence (at insertion
× s/s of sepsis
× Complications related to
× Catheter dysfunction
Cultures of blood & catheter should be
taken in the setting of clinical suspicion
• Paired blood samples drawn from the catheter and a
peripheral vein should be obtained prior to initiation of
• The same volume of blood should be inoculated for
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
× 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.
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.
Cases where systemic AB is not rcd:
× Positive catheter tip culture in the absence of clinical signs
× Positive blood cultures obtained through a catheter with
negative cultures through a peripheral vein.
× Phlebitis in the absence of infection.
Catheter Management: salvage, exchange, removal
Indications to remove Catheter:
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.
• Short-term catheters (indwelling <14 days) removed if
S.aureus, enterococci, gram-negative bacilli, fungi, and
• Long-term catheters (indwelling ≥14 days) removed if S.
aureus, P.aeruginosa, fungi, or mycobacteria.
Catheter removal in terms of
• 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
cultures should prompt
• 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).
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
The severity of illness.
The risk factors for infection.
The likely pathogens associated with the
specific intravascular device.
× CNST is the most common cause of infection Vancomycin
× Additional agents with activity against CNS and MRSA
include daptomycin, linezolid, tedizolid, telavancin,
dalbavancin, oritavancin, ceftaroline, and quinupristin-
× 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 .
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
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
× 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.
× 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.
× 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
× Clinical signs of infection should prompt catheter
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
× 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.