Intravascular catheter-related infections (IDSA 2009): Difference between revisions

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= Intravascular catheter-related infection (IDSA 2009) =
  
= Intravascular catheter-related infection (IDSA 2009) =
   
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== Background ==
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= Background =
   
 
* 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 ===
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== Organisms ==
   
 
* Percutaneously-inserted catheters
  
* Percutaneously-inserted catheters
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** ''Pseudomonas aeruginosa''
  
** ''Pseudomonas aeruginosa''
   
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== Diagnosis ==
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= Diagnosis =
   
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=== Catheter Cultures ===
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== 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 ===
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== 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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=== Summary ===
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== Summary ==
   
 
![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)
  
![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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= General Management =
   
 
* 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 ===
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== Empiric antimicrobials ==
   
 
* Empiric treatment must include Gram-positives
  
* Empiric treatment must include Gram-positives
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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 ===
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== 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 ===
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== 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 ==
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= 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
 
* 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 ==
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= Short-term CVCs and arterial lines =
   
 
![Figure 2](Figure 2.png)
  
![Figure 2](Figure 2.png)
   
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== Long-term CVCs ==
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= Long-term CVCs =
   
 
![Figure 3](Figure 3.png)
  
![Figure 3](Figure 3.png)
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![Figure 4](Figure 4.png)
  
![Figure 4](Figure 4.png)
   
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== Specific antimicrobial therapy ==
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= Specific antimicrobial therapy =
   
 
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[[Category:Healthcare-associated infections]]

Revision as of 08:05, 13 August 2019

Intravascular catheter-related infection (IDSA 2009)

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

Summary

![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)

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

![Figure 2](Figure 2.png)

Long-term CVCs

![Figure 3](Figure 3.png)

Tunneled lines

![Figure 4](Figure 4.png)

Specific antimicrobial therapy

Pathogen Preferred agent Alternative
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
Pseudomonas aeruginosa Cefipime 2g q8h, or
Mero 1g q8h, or
Pip/tazo 4.5g q6h
Burkholderia cepacia Septra 3-5 mg/kg q8h, or
Mero 1g q8h
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
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