Intravascular catheter-related infections (IDSA 2009): Difference between revisions
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+ | IDSA guidelines for the diagnosis and management of intravascular catheter-related bloodstream infection. ''Clin Infect Dis''. 2009;49(11):1770-1. doi: [https://doi.org/10.1086/648113 10.1086/648113]. |
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* Short-term catheters are those left in for less than 14 days |
* Short-term catheters are those left in for less than 14 days |
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* CRBSIs involve the insertion site, the hub, or both |
* CRBSIs involve the insertion site, the hub, or both |
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− | == Organisms == |
+ | === Organisms === |
* Percutaneously-inserted catheters |
* Percutaneously-inserted catheters |
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** ''Pseudomonas aeruginosa'' |
** ''Pseudomonas aeruginosa'' |
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− | = Diagnosis = |
+ | == Diagnosis == |
− | == Catheter Cultures == |
+ | === Catheter Cultures === |
* Should be done when a catheter-related bloodstream infection is suspected |
* Should be done when a catheter-related bloodstream infection is suspected |
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* Catheter site swab when there is drainage |
* Catheter site swab when there is drainage |
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− | == Blood Cultures == |
+ | === Blood Cultures === |
* However, positive cultures for typical organisms in the abscense of another focus of infection is suggestive |
* However, positive cultures for typical organisms in the abscense of another focus of infection is suggestive |
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** They should be done at the same time with the same volume of blood per bottle |
** They should be done at the same time with the same volume of blood per bottle |
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− | == |
+ | == General Management == |
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− | ![Figure 1: Methods for the diagnosis of acute fever for a paitent suspected of having short-term central venous catheter infection or arterial cather infection](Figure 1.png) |
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− | = General Management = |
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* Day 1 is the first day of negative blood culture results |
* Day 1 is the first day of negative blood culture results |
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− | == Empiric antimicrobials == |
+ | === Empiric antimicrobials === |
* Empiric treatment must include Gram-positives |
* Empiric treatment must include Gram-positives |
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** Prolonged broad-spectrum antibiotics |
** Prolonged broad-spectrum antibiotics |
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** Hematologic malignancy |
** Hematologic malignancy |
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− | ** Bone marrow or solid |
+ | ** Bone marrow or solid organ transplant |
** Femoral catheterization |
** Femoral catheterization |
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** Colonization from ''Candida'' at many sites |
** Colonization from ''Candida'' at many sites |
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* If fungemia or bacteremia persists after removing the line beyond 72 hours, treat for 4 to 6 weeks |
* If fungemia or bacteremia persists after removing the line beyond 72 hours, treat for 4 to 6 weeks |
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− | == Removing the line == |
+ | === Removing the line === |
* Long-term catheters should be removed if: |
* Long-term catheters should be removed if: |
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* Both catheters should generally be removed in cases of difficult-to-treat bacteria: ''Bacillus'' spp, ''Micrococcus'' spp, or ''Propionibacterium'' |
* Both catheters should generally be removed in cases of difficult-to-treat bacteria: ''Bacillus'' spp, ''Micrococcus'' spp, or ''Propionibacterium'' |
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− | == Salvaging the line == |
+ | === Salvaging the line === |
* Only do it if not meeting the above criteria |
* Only do it if not meeting the above criteria |
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* Lock therapy should be used concurrently with systemic antimicrobials |
* Lock therapy should be used concurrently with systemic antimicrobials |
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− | = Short-term PIVs = |
+ | == Short-term PIVs == |
* IVs that have pain, induration, erythema, or exudate should be removed |
* IVs that have pain, induration, erythema, or exudate should be removed |
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* Exudate should be sent for culture, including fungi and AFB if immunocompromised |
* Exudate should be sent for culture, including fungi and AFB if immunocompromised |
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− | = Short-term CVCs and arterial lines = |
+ | == Short-term CVCs and arterial lines == |
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− | ![Figure 2](Figure 2.png) |
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− | = Long-term CVCs = |
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− | ![Figure 3](Figure 3.png) |
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− | = |
+ | == Long-term CVCs == |
+ | == Tunneled lines == |
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− | ![Figure 4](Figure 4.png) |
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− | = Specific antimicrobial therapy = |
+ | == Specific antimicrobial therapy == |
+ | {| class="wikitable" |
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− | {| |
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! Pathogen |
! Pathogen |
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! Preferred agent |
! Preferred agent |
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− | [[Category: |
+ | [[Category:Hospital-acquired infections]] |
Latest revision as of 21:02, 6 August 2020
IDSA guidelines for the diagnosis and management of intravascular catheter-related bloodstream infection. Clin Infect Dis. 2009;49(11):1770-1. doi: 10.1086/648113.
Background
- Short-term catheters are those left in for less than 14 days
- More commonly skin flora on the external surface
- Long-term catheters are ≥14 days
- Increasingly likely to have intraluminal spread from the catheter hub
- CRBSIs involve the insertion site, the hub, or both
Organisms
- Percutaneously-inserted catheters
- Coagulase-negative staphylococci
- Staphylococcus aureus
- Candida spp
- Enteric Gram-negative bacilli
- Surgically-implanted catheters and peripherally-inserted central lines
- Coagulase-negatives staphylococci
- Enteric Gram-negative bacilli
- Staphylococcus aureus
- Pseudomonas aeruginosa
Diagnosis
Catheter Cultures
- Should be done when a catheter-related bloodstream infection is suspected
- Culture the tip, either with a 5 cm roll-plate culture or sonication
- Positive when > 15 cfu from roll-tip or >10^2^ cfu from sonication
- Catheter site swab when there is drainage
Blood Cultures
- However, positive cultures for typical organisms in the abscense of another focus of infection is suggestive
- They should be obtained prior to starting antibiotics
- Make sure skin and hub are cleaned with alcohol prior to drawing cultures
- Growth from the central line detected at least 2 hours before growsth from the peripheral blood culture (i.e. differential time-to-positivity) is most predictive
- They should be done at the same time with the same volume of blood per bottle
General Management
- Day 1 is the first day of negative blood culture results
Empiric antimicrobials
- Empiric treatment must include Gram-positives
- Vancomycin is the preferred empiric choice for settings with high rates of MRSA; daptomycin if there are high rates of MIC >2
- Linezolid is to be avoided
- For femoral catheters in critically ill patients, also cover Gram-negative bacilli and Candida
- May need to cover Candida in the following situations:
- TPN
- Prolonged broad-spectrum antibiotics
- Hematologic malignancy
- Bone marrow or solid organ transplant
- Femoral catheterization
- Colonization from Candida at many sites
- Empiric candidal coverage should be with an echinocandin
- Fluconazole is an alternative if no azole exposure in 3 months and hospital has low risk of C. krusei or C. glabrata
- If fungemia or bacteremia persists after removing the line beyond 72 hours, treat for 4 to 6 weeks
Removing the line
- Long-term catheters should be removed if:
- Severe sepsis
- Suppurative thrombophlebitis
- Endocarditis
- Bloodstream infection despite >72 hours of therapy
- Infections due to S. aureus, P. aeruginosa, fungi, or mycobacteria
- Short-term catheters should be removed if:
- Gram-negative bacilli, S. aureus, enterococci, fungi, or mycobacteria
- Both catheters should generally be removed in cases of difficult-to-treat bacteria: Bacillus spp, Micrococcus spp, or Propionibacterium
Salvaging the line
- Only do it if not meeting the above criteria
- Additional blood cultures should be obtained, and line removed if persistently positive
- Lock therapy should be used concurrently with systemic antimicrobials
Short-term PIVs
- IVs that have pain, induration, erythema, or exudate should be removed
- Exudate should be sent for culture, including fungi and AFB if immunocompromised
Short-term CVCs and arterial lines
Long-term CVCs
Tunneled lines
Specific antimicrobial therapy
Pathogen | Preferred agent | Alternative |
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MSSA | Clox 2 g q4h | Cefaz 2 g q8h, or Vanco 15 mg/kg q12h |
MRSA | Vanco 15 mg/kg q12h | |
MS-CoNS | Clox 2 g q4h | Cefaz or vanco or Septra |
MR-CoNS | Vanco 15 mg/kg q12h | Dapto 6 mg/kg q24h, or Linezolid, or Quin/Dalf |
Amp-S Enterococcus | Amp 2g q4-6h ± Gent 1 mg/kg q8h |
Vanco |
Vanco-S Enterococcus | Vanco 15 mg/kg q12h ± Gent 1 mg/kg q8h |
Linezolid, or Dapto 6 mg/kg q24h |
Vanco-R Enterococcus | Linezolid 600mg q12, or Dapto 6 mg/kg q24h |
Quin/dalf 7.5 mg/kg q8h |
E. coli & Klebsiella | Ceftriax 1-2 g q24h | Cipro or Aztreonam |
ESBL E. coli & Klebsiella | Erta 1 g q24h | Cipro or Aztreonam |
Enterbacter and Serratia | Erta 1 g q24h | Cefipime or Cipro |
Acinetobacter | Amp/Sulb 3g q6h, or Mero 1g q8h |
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Pseudomonas aeruginosa | Cefipime 2g q8h, or Mero 1g q8h, or Pip/tazo 4.5g q6h |
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Burkholderia cepacia | Septra 3-5 mg/kg q8h, or Mero 1g q8h |
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Candida spp. | Caspo 70 mg load then 50 mg daily, or Mica 100 mg daily, or Anidula 200 mg load then 100 mg daily, or Fluc 400-600 mg daily |
Lipid Amphotericin B |
Corynebacterium jeikeium | Vanco 15 mg/kg q12h | Linezolid |
Chryseobacterium | Levo 750 mg | Septra or Mero |
Ochrobacterium anthropi | Septra 3-5 mg/kg q8h, or Cepri 400 mg q12h |
Mero or Erta plus AG |
Malassezia furfur | Ampho B | |
Mycobacterium spp. | Based on susceptibility |