Catheter Related Blood

Streams Infections

Speaker-Dr Rahul Arya

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.

Epidemiology

More than 250,000 central line associated blood

stream infections (CLABSI) occur annually in USA

with mortality rate of 12-25%.

Each episode significantly increases hospital stay

with additional health care cost ranging from

$4,000 to $56,000 per episode.

Incidence density of CRBSI in USA vary between

0.1-22.5% and b/w 0.1 and 2.7 per 1000 central

line day.

The rate of CLABSIs in limited-resource countries

ranged from 1.6 to 44.6 cases per 1000 central line

(CL) days in adult and pediatric ICUs.

In India Mehta et al reported an overall CLABSI

rate of 7.9 per 1000 CL days.

Kaur et al and Patil et al from hospitals in India

reported CLABSI rate of 2.8 per 1000 CL days and

18.5%, respectively.

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.

Risk Factors

It includes Patient, Operator and Catheter related

factors.

Patient Factors-

Increasing severity of illness

Granulocytopenia

Compromised integrity of skin

Presence of distant infection.

Operator Factors- risk increases after breaks in

aseptic technique during placement and

maintenance and with frequency of catheter

access.

Catheter factors-

Catheter type- risk of bsi increases with increasing

lumen number.

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.

Pathogenesis

The pathogenesis is attributed to 4 primary causes-

Migration of skin organism at the insertion site into catheter tract along the surface of catheter with colonization of catheter tip- M/C

Direct contamination of catheter or catheter hub by contact with hands or contaminated fluid or device.

Hematogenous spread of infection from another focus.

Contamination of infusate.

Colonization of device may be either extra luminal

from surrounding skin or hematogenous seeding of

catheter tip or

Intraluminal caused by an organism adhering to

device followed by creation of biofilm.

In short term devices extra luminal route is more

common whereas intraluminal route is more

common in long term devices (>10 days) or short

term devices left in longer than 4-7 days.

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 (SCOPE 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.

Diagnosis

CRBSI should be suspected in pt with iv cath who develop clinical or lab criteria of SIRS i.e. temperature <36ºC or > 38ºC, HR> 90/min, RR>20/min or TLC <4000/µl or >12000/µl.

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.

For patients with short-term central venous

catheters without severe sepsis or shock, in whom

the index of suspicion for catheter-related infection

is moderate or less, the 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.

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.

for multilumen catheters, drawing multiple catheter

blood cultures, one from each lumen of the catheter

suspected of infection, in addition to one blood culture

obtained by peripheral venipuncture will enhance

detection of catheter infection.

For patients with multiple central venous and/or

arterial catheters, a blood culture should be drawn

through each catheter in addition to that obtained

by peripheral venipuncture.

To reduce the incidence of blood culture

contamination, the skin and the hub of the catheter

must be cleansed with alcohol, tincture of iodine or

alcohol chlorhexidene, and allowed to dry, before

specimen collection.

Methods not requiring CVC removal

Diagnostic

Methods

Description Criteria for

positivity

Sensitivity % Specificity %

Qualitative blood

culture through device

One or more blood

cultures drawn

through CVC

Any growth 87 83

Quantitative blood

culture through device

Blood culture drawn

through

CVC,processed by

pour-plate methods or

a lysis-centrifugation

technique

≥100 CFU/ml 77 90

Paired quantitative

blood cultures

Simultaneous cultures

drawn through CVC

and percutaneously

Both cultures

positive with CVC

culture yielding 5-

fold higher or more

than peripherally

drawn culture

87 98

Differential time to

positivity

Simultaneous blood

cultures drawn

through CVC and

percutaneously and

monitored

continuously

Both cultures

positive with CVC

positive ≥2 hr

earlier than

peripherally drawn

culture

85 81

Methods requiring CVC removalDiagnostic

method

Description Criteria for

positivity

Sensitivity

%

Specificity

%

Qualitative

catheter segment

culture

Segment from

removed CVC is

immersed in broth

media and

incubated for 24-72

hr

Any growth 90 72

Semi quantitative

catheter segment

culture

A 5 cm segment

from removed CVC

is rolled 4 times

across a blood

agar plate and

incubated

≥15 CFU 85 82

Quantitative

catheter segment

culture

Segment from

removed CVC is

flushed or

sonicated with

broth, serially

diluted, plated on

blood agar and

incubated

≥1000 CFU 83 87

A diagnosis of CRBSI is achieved by any of the following 3 criteria-

same organism recovered from percutaneous blood culture and from quantitative (>15 colony-forming units) culture of the catheter tip

same organism recovered from a percutaneous and a catheter lumen blood culture, with growth detected 2 hours sooner ( i.e., 2 hours less incubation) in the latter.

same organism recovered from a quantitative percutaneous and a catheter lumen blood culture, with 3-fold greater colony count in the latter.

Management- General

For emperical treatment-

vancomycin in institutions where the prevalence of MRSA is increased (otherwise use a 1st gen cephalosporin such as cefazolin or an anti-staphylococcal penicillin such as nafcillin).

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;

antibiotics active against Pseudomonas

aeruginosa, in the setting of neutropenia, severe

illness, or known colonization.

antimicrobials active against candida in the setting

of femoral catheterization, TPN, prolonged

administration of broad-spectrum antibiotics,

hematologic malignancy, or solid organ or

hematopoietic stem cell transplantation

If blood cultures fail to yield growth, the need for

further empiric antibiotic therapy should be

reassessed.

Management: Short Term Central

Venous or Arterial CRBSI Cultures confirmed CRBSI-: empiric antibiotic therapy

according to susceptibility profile of the recovered

pathogen.

The infected catheter, or the catheter placed over a

guide wire in exchange for the infected catheter, should

be removed expeditiously.

For uncomplicated bloodstream infection that arises in

the absence of factors that increase the risk of

hematogenous spread of infection and which resolves

within 72 hours of catheter removal, systemic

therapeutic, intravenous antibiotic treatment is

recommended for:

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.

14 days in the absence of evidence of endocarditis

clinically and by transesophageal

echocardiography (TEE), for S aureus.

For patients with susceptible pathogens and a

functioning GI tract, oral linezolid, fluoroquinolones,

or fluconazole may be considered for treatment of

MRSA, Gram-negative bacilli, and candida,

For patients with CRBSI lasting over 72 hours, or

with factors that increase the risk of metastatic

infection, longer duration of antibiotic

administration directed by patient, pathogen, and

disease characteristics will be required.

Management: Long-Term Central

Venous CRBSI Catheter should be removed immediately

especially for S aureus, Bacillus species,

micrococcus, propionibacterium, P aeruginosa,

candida, or mycobacterial infection.

4 to 6 weeks of therapy is often required for S

aureus infection.

14 days for non diabetic, non neutropenic, non

immunosuppressed patients without septic

thrombosis, endocarditis (TEE negative),

metastatic infection, or prosthetic intravascular

devices when S aureus or other bacterial infection

resolves within 72 hours of antibiotic initiation and

catheter removal.

For patients with candida infection in whom there is

no suspicion or evidence of metastatic 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.

A new long term central venous catheter can be

placed at a new anatomic site after 72 hours of

effective antibiotic administration and lack of

growth in repeat blood cultures.

Systemic therapeutic antibiotics should be given for

10 to 14 days. Meanwhile, antibiotic lock solution,

appropriate for the pathogen and for the catheter

must be administered to every lumen, daily with

24-hour dwell time.

The catheter should be removed if there is

evidence of clinical deterioration or ongoing

bloodstream infection from catheter infection during

antibiotic lock solution administration.

Blood cultures to be repeated1 week after

completion of treatment for patients with long-term

central venous catheters treated with antibiotic lock

therapy for catheter salvage.

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 to

guidelines for all personnel involved in the insertion

and maintenance of intravascular catheters .

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.

Selection of Catheters and

Sites Peripheral Catheters and Midline Catheters

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.

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.

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.

Remove peripheral venous catheters if the patients

develops signs of phlebitis (warmth, tenderness,

erythema or palpable venous cord), infection, or a

malfunctioning catheter.

Central Venous Catheters 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.

Avoid using the femoral vein for central venous access in adult patients.

Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled CVC placement.

Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein stenosis

Use a fistula or graft in patients with chronic renal

failure instead of a CVC for permanent access for

dialysis.

Use ultrasound guidance to place central venous

catheters (if this technology is available) to reduce the

number of cannulation attempts and mechanical

complications.

Use a CVC with the minimum number of ports or

lumens essential for the management of the patient

Promptly remove any intravascular catheter that is no

longer essential.

Hand Hygiene and Aseptic

Technique

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.

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 of CVCs,

PICCs, or guide

wire exchange.

Skin Preparation

Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, or alcoholic chlorhexidinegluconate solution) before peripheral venous catheter insertion.

Prepare clean skin with a >0.5% chlorhexidinepreparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes.

If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives.

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 every

2 days for gauze dressings.

Replace dressings used on short-term CVC sites at

least every 7 days for transparent dressings.

Monitor the catheter sites visually when changing

the dressing or by palpation through an intact

dressing on a regular basis.

If patients have tenderness at the insertion site,

fever without obvious source, or other

manifestations suggesting local or bloodstream

infection, the dressing should be removed to allow

thorough examination of the site.

Encourage patients to report any changes in their

catheter site or any new discomfort to their

provider.

Patient Cleansing

Use a 2% chlorhexidine wash for daily skin

cleansing to reduce CRBSI.

Systemic Antibiotic Prophylaxis

Do not administer systemic antimicrobial

prophylaxis routinely before insertion or during use

of an intravascular catheter to prevent catheter

colonization or CRBSI.

Antibiotic/Antiseptic Ointments

Use povidone iodine antiseptic ointment or

bacitracin/gramicidin/ polymyxin B ointment at the

hemodialysis catheter exit site after catheter

insertion and at the end of each dialysis session.

Antibiotic Lock Prophylaxis, Antimicrobial

Catheter Flush and Catheter Lock Prophylaxis

Use prophylactic antimicrobial lock solution in

patients with long term catheters who have a

history of multiple CRBSI despite optimal maximal

adherence to aseptic technique.

Anticoagulants

Do not routinely use anticoagulant therapy to reduce the risk of catheter-related infection in general patient population.

Replacement of Peripheral and Midline Catheters

There is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce risk of infection and phlebitis in adults.

Replace midline catheters only when there is a specific indication.

Replacement of CVCs, Including PICCs and Hemodialysis Catheters

Do not routinely replace CVCs, PICCs, hemodialysiscatheters, or pulmonary artery catheters to prevent catheter-related infections.

Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter.

Do not use guide wire exchanges routinely for non-tunneled catheters to prevent infection.

Do not use guide wire exchanges to replace a non-tunneled catheter suspected of infection.

Use a guide wire exchange to replace a

malfunctioning non-tunneled catheter if no

evidence of infection is present.

Use new sterile gloves before handling the new

catheter when guide wire exchanges are

performed.

Replacement of Administration Sets

In patients not receiving blood, blood products or

fat emulsions, replace administration sets that are

continuously used no more frequently than at 96-

hour intervals, but at least every 7 days.

No recommendation can be made regarding the

frequency for replacing intermittently used

administration sets.

Replace tubing used to administer blood, blood

products, or fat emulsions within 24 hours of

initiating the infusion.

Surveillance and Reporting:-

Hospital-based infection control teams

begin surveillance for bloodstream

infections by regularly reviewing results of

blood cultures obtained at their facilities.

Conclusion Catheter-related bloodstream infections are costly

complications of hospital care that have occurred with

greater frequency in the ICU settings.

Accurate diagnosis can be established by culture of

appropriately collected specimens of blood and catheter

tips.

Evidence-based guidance is available to inform

antibiotic treatment and catheter management when

infection occurs.

Risk of CRBSI can be reduced by optimizing catheter

selection, insertion and maintenance, and by removing

catheters when they are no longer needed.