intravascular catheter-related infection
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Etiology
- infection due to
- exit site infection
- tunnel infection
- bacteremia
- fungemia
- septic thrombophlebitis
- etiologic agents[12]
- coagulase negative Staphylococci (majority)[2]
- Staphylococcus aureus
- gram-negative rods
- Enterobacteriaceae especially in oncology wards[12]
- gram-positive rods
- fungi - Candida (27% of CLABSI* adult ICU wards in 2017)[12]
- risk factors
- neutropenia
- prolonged hospitalization
- central line in femoral vein > internal jugular vein[10]
- inadequate skin preparation, improper catheter care or failure of sterile technique during catheter insertion
- prolonged duration of catherization
- total parenteral nutrition delivered through central venous catheter
- highest risk in neonates
- male
- immunodeficiency
- mutilumen catheters
- emergency catheterization
* CLABSI = central-line associated bloodstream infections
Epidemiology
- catheter colonization common (25-30%) in critically ill patients[2]
- 65-70% of catheter-related infections may be preventable[1]
Pathology
Clinical manifestations
- fever
- purulence or cellulitis at catheter insertion site
- no correlation between signs of inflammation at insertion site & catheter-related sepsis or catheter colonization
Laboratory
- paired quantitative cultures of:[3]
- catheter segment (culture of catheter tip)
- culture of catheter-drawn blood or peripheral blood cultures
- sensitivity 77-87%
- specificity 87-97%
Diagnostic procedures
- transesophageal echocardiogram (TEE) to assess endocarditis on all patients with positive blood cultures[1]
- evaluate patients with candidemia for Candida endophthalmitis
Complications
- suppurative thrombophlebitis
- endocarditis
- osteomyelitis
- other site(s) of deep-seeded infection
Management
- empiric antibiotics:
- coverage for potentially resistant gram-positive infections: vancomycin, plus
- coverage for gram-negative infections
- anti-pseudomonal penicillin, or
- fluoroquinolone, or
- third-generation cephalosporin
- treat 5-7 days if blood culture is negative
- if blood culture is positive & TEE is negative for endocarditis, treat for 2 weeks
- if TEE is positive for endocarditis, treat for 4 weeks
- fungemia
- echinocandins now antimicrobials of choice for candidemia & other forms of invasive candidiasis[1]
- transition to fluconazole can occur after 5-7 days of echinocandin therapy if isolate is susceptible & repeat blood cultures are negative
- liposomal amphotericin B used for severely ill patients, those with persistent candidemia & infections caused by Candida tropicalis or Candida krusei is nephrotoxic[1]
- catheter removal
- short-term peripheral catheters
- all cases of tunnel infection, sepsis, septic thrombosis,
- endocarditis, osteomyelitis
- Staphylococcus aureus infection, gram-negative infection (Pseudomonase & others)
- ALL cases of fungemia (including Candidemia)
- exceptions:
- isolated exit site infection
- transient coagulase-negative staphylococcal bacteremia without evidence of tunnel infection, metastatic complications or sepsis
- see antibiotic therapy (below)
- if there is no evidence of catheter tunnel infection, dialysis catheters can be exchanged over a wire in asymptomatic patients on antibiotics for >= 48 hours[1]
- repeat blood cultures after catheter removal[1]
- antibiotic therapy
- reduces bacteremia after removal of S aureus colonized catheters[4]
- duration of antibiotic therapy
- S aureus: >= 14 days (generally 4 weeks, catheter removed)[1]
- coagulase-negative staphylococcal bacteremia:
- 5-7 days if catheter removed
- alternatively, repeat blood cultures to document clearance of bacteremia[1]
- 10-14 days if catheter not removed
- after each dialysis session for 10 days (NEJM)[13]
- others: 7-14 days (catheter removed)
- candidemia (no retinitis): remove catheter
- continue antifungal agent for 14 days after 1st negative blood culture[1]
- osteomyelitis: 6-8 weeks
- endocarditis: 4-6 weeks
- suppurative thrombophlebitis: 4-6 weeks
- prevention
- sterile technique
- chlorhexidine for skin decontamination
- antibiotic coated catheters
- catheter care teams
- remove catheter as soon as indicated
- routine replacement of central venous catheters not indicated[1]
- routine changes of catheter dressings not indicated[1]
- avoid femoral vein insertion[5]
- care bundles & checklists can reduce catheter-associated infections by > 60%[9]
More general terms
Additional terms
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2021.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ 2.0 2.1 2.2 Journal Watch 23(3):22, 2003 Safdar N & Maki DG, Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters. Crit Care Med 30:2632, 2002 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12483050
- ↑ 3.0 3.1 Journal Watch 25(9):72, 2005 Safdar N, Fine JP, Maki DG. Meta-analysis: methods for diagnosing intravascular device- related bloodstream infection. Ann Intern Med. 2005 Mar 15;142(6):451-66. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15767623
- ↑ 4.0 4.1 Ekkelenkamp MB et al, Bacteremic complications of intravascular catheters colonized with Staphylococcus aureus. Clin Infect Dis 2008, 46:114 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18171225
- ↑ 5.0 5.1 Pronovost PJ et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study. BMJ 2010 Feb 4; 340:c309. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/20133365 <Internet> http://dx.doi.org/10.1136/bmj.c309
- ↑ Mermel LA, Allon M, Bouza E, Craven DE et al Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2009 Jul 1;49(1):1-45. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19489710
corresponding NGC guideline withdrawn Dec 2014 - ↑ O'Grady NP, Alexander M, Burns LA, Dellinger EP et al Summary of recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections. Clin Infect Dis. 2011 May;52(9):1087-99 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21467014
- ↑ Weber DJ, Rutala WA. Central line-associated bloodstream infections: prevention and management. Infect Dis Clin North Am. 2011 Mar;25(1):77-102 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21315995
- ↑ 9.0 9.1 Blot K et al. Prevention of central line-associated bloodstream infections through quality improvement interventions: A systematic review and meta-analysis. Clin Infect Dis 2014 Apr 9 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24723276 <Internet> http://cid.oxfordjournals.org/content/early/2014/04/09/cid.ciu239
- ↑ 10.0 10.1 Parienti JJ et al Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med 2015; 373:1220-1229. September 24, 2015. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26398070 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1500964
- ↑ Marschall J, Mermel LA, Fakih M et al Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Jul;35(7):753-71. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24915204
- ↑ 12.0 12.1 12.2 12.3 Novosad SA, Fike L, Dudeck MA et al. Pathogens causing central-line-associated bloodstream infections in acute-care hospitals - United States, 2011-2017. Infect Control Hosp Epidemiol 2020 Jan 9; PMID: https://www.ncbi.nlm.nih.gov/pubmed/31915083 https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/pathogens-causing-centrallineassociated-bloodstream-infections-in-acutecare-hospitalsunited-states-20112017/61188313265980B8C83CC36FCC469594
- ↑ 13.0 13.1 NEJM Knowledge+