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Diagnosis and management of central line infections
1. By- Dr. Armaan Singh
CENTRAL LINE
INFECTION: PULL OR
LEAVE IT IN
2. Objective
etermine catheter related blood stream infection (CRBSI)
ey Factors to consider when removing cathether:
• Patient-related factors
• Organism
• Catheter
3. Case 1
5 y/o pmhsx DMII, HTN, CAD presents with severe sepsis
likely source PNA into ICU, had right IJ central line placed
and all the right abx and pressors started. Several days
later, noticed that the patient had developed fever and
leukocytosis, which had been trending down to normal.
Site of IJ is slightly erythematous, not too tender, no pus
drainage. Patient’s MAP > 65, not tachycardic, has been off
of pressors for 1 day. How do you proceed?
5. Diagnosis
lood cultures from catheter AND peripheral vein at ~ same time. (A-II)
f cannot get peripheral vein, get 2 or more blood samples through
different catheter lumens (C-III)
ifferential time to positivity (DTP)
uantitative blood culture (not used by our micro lab)*
6. Dx: Differential time to positivity
atheter microbial growth detected 2 hours before peripheral vein
ens: 85% and spec 91% (1)
ore cost-effective than quantitative method and can be done here at
UCI
7. Case 1 revisited… Next steps
btain blood culture from peripheral vein and from the central line.
f the blood culture from the central line becomes positive at least two
hours before that of the peripheral line, then diagnosis of CRBSI.
ow do you proceed if positive CRBSI?
8. Treatment
hat to do with the catheter?
• Remove vs
• Salvage vs
• Exchange
ype of device: short vs long term (excluding HD)
nfecting pathogens
resence of alternative venous access sites
uration of anticipated need for access
9. Catheter removal indications
evere sepsis
emodynamic instability
ndocarditis or evidence of metastatic infection
rythema due to suppurative thrombophlebitis
ersistent bacteremia after 72 hrs abx to which organism is susceptible
10. Case 2
5 y/o with DMII, HTN p/w LLL PNA. Had L IJ line placed
(difficult stick) as this was the weekend and could not get
PICC. Pt’s vitals on admission only significant for fever 38.9.
Treating for CAP.
days later, pt’s bp drops to 80s/40s hr: 120s, febrile again
39.3, pt more lethargic. Blood cultures drawn from
periphery and central line, UA and CXR unremarkable, WBC
increased to 16, lactate 4. How do you proceed?
11. Case 2
A. Keep the line, transfer the patient to the ICU and
broaden abx.
B. Change the line via guidewire as patient is difficult stick
and broaden abx.
C. Transfer pt to ICU (IVF and pressors) and broaden abx.
Obtain another access site, pull the line.
D. Keep the line, keep pt on floor, fluid boluses and follow
up on cultures in the morning.
12. Case 2
A. Keep the line, transfer the patient to the ICU and
broaden abx.
B. Change the line via guidewire as patient is difficult stick
and broaden abx.
C. Transfer pt to ICU (IVF and pressors) and broaden abx.
Obtain another access site, pull the line.
D. Keep the line, keep pt on floor, fluid boluses and follow
up on cultures in the morning.
13. Case 3
5 y/o woman with DMII, HTN p/w sepsis 2/2 UTI. PICC line
was placed on previous admission so pt can get home IV
abx. You obtain blood cultures from that line and
periphery and blood culture from line grew out s. aureus 1
day prior to periphery which also grew out same organism.
Pt currently hemodynamically stable, afebrile on
ceftriaxone for UTI. Leukocytosis has improved to normal
range now. How should you proceed?
14. Case 3
A. Treat with vancomycin and await sensitivities.
B. Obtain another set of blood cultures from PICC and peripheral.
Start vancomycin thereafter.
C. Obtain another set of blood cultures from PICC and periphery, pull
the line and start vancomycin.
D. Pull the line, that things been in there for way too long.
15. Catheter removal indications
hort term catheters (< 14 days)
• S. aureus, enterococci, gram neg bacilli, fungi, and mycobacteria
• Erythema or purulence at insertion site
ow virulence but difficult to eradicate (eg, Bacillus spp, Micrococcus
spp, or Propionibacteria)
• No evidence for catheter exchange i.e. salvage
16. Case 3
A. Treat with vancomycin and await sensitivities.
B. Obtain another set of blood cultures from PICC and
peripheral. Start vancomycin thereafter.
C. Obtain another set of blood cultures from PICC and
periphery, pull the line and start vancomycin.
D. Pull the line, that things been in there for way too long.
17. Case 3
A. Treat with vancomycin and await sensitivities.
B. Obtain another set of blood cultures from PICC
and peripheral. Start vancomycin thereafter.
C. Obtain another set of blood cultures from PICC
and periphery, pull the line and start
vancomycin.
D. Pull the line, that thing has been in there for
way too long.
18. pproach to the management of patients with short-term central venous catheter–related or arterial catheter–
related bloodstream infection. CFU, colony-forming units; S. aureus, Staphylococcus aureus.
19. Case 4
2 y/o w/hsx of liver mets has a Port-a-cath presents with
altered mental status. Not receiving chemotherapy
currently. Family says that after discharge, pt has become
more confused, no fever, cough, dysuria or hematuria,
diarrhea. PE: no erythema or tenderness at site or port-a-
cath. UA Blood cultures grew out E.coli from portacath
site. Repeat cultures demonstrated same organism from
catheter and peripheral site. What should be done next?
20. Catheter removal indications
ong term catheters (> 14 days)
• S. aureus, Gram negative bacilli, P. aeruginosa, fungi, or mycobacteria
• Tunnel infection, port abscess
Hickman catheter,
tunneled
Port-A-Cath
21. pproach to the treatment of a patient with a long-term central venous catheter
(CVC) or a port (P)-related bloodstream infection.
22. Case 4
ssentially you need to remove this catheter as you cannot
treat through this in light of cultures growing out E.coli.
emember the other organisms that require removal:
• S. aureus, Gram negative bacilli, P. aeruginosa, fungi, or
mycobacteria
ther scenarios that necessitate removal:
• Tunnel infection, port abscess
23. Factors Affecting Abx Choice
actors:
• severity of illness
• risk factors for infection
• likely pathogens a/w specific catheter
tart with Vancomycin
• Coag negative staph are most common and usually resistant to
methicillin.
• Be careful with Vanc resistance daptomycin
eutropenia, sepsis empiric coverage for gram negative
24. Empiric Antibiotic
over for candidemia when (B-II):
• TPN
• Prolonged use of broad-spectrum abx
• Hematologic malignancy
• Bone marrow or solid organ transplant
• Femoral catherization
• Colonization due to Candida species at multiple sites
x: caspo, micafungin, fluconazole (if organism is
susceptible) (A-II)
25. Antibiotic Duration
ypically 10 to 14 days (day one is the first day on which negative blood
cultures are obtained)
to 6 weeks in patients with recent prosthetic valve placement placed
prosthetic valves, even if investigation fails to demonstrate evidence of
IE.
atients with persistent bacteremia >72 hours following catheter removal
should generally receive tx for at least 4 to 6 weeks
omplications related to bacteremia (such as suppurative
thrombophlebitis, endocarditis, osteomyelitis, metastatic infection) the
duration of therapy should be tailored accordingly depending on the
nature of infection.
26. Take home points
ime to positivity dx: catheter site culture should have
growth at least 2 hrs before peripheral site
atheter removal:
• “complicated” infection,
• short term CVC: S. aureus, enterococci, gram neg bacilli, fungi, and
mycobacteria
• Long term CVC: S. aureus, P. aeruginosa, fungi, or mycobacteria
bx choice: depends on severity of illness, risk factors
(neutropenia, candida coverage)
Editor's Notes
Typically we begin to suspect that the patient may have a catheter related blood stream infection when there is fever that has been unaccounted for and that they may have had a catheter in place for some time or it may be unclear whether pt may have a CRBSI and thus it is left in. Therefore, will first talk about the diagnosis of catheter related blood stream infection through blood cultures as opposed to diagnosing after the catheter has been pulled and that the tip is cultured.
Some important points about diagnosis of CRBSI:
Clinical findings are unreliable poor sensitivity and specificity
Most sensitive is fever, but has poor specificity
Inflammation or pururlence around insertion site has greater specificity but poor sensitivity
In general blood cultures positive for the following species should make you more suspicious of CRBSI:
S. aureus
Coag-neg staph
Candida species
Recently inserted catheter (i.e. one that had ben indwelling &lt; 14 days) is commonly colonized from skin microorganisms along the external surface of the catheter.
Antimicrdobial coatings may lead to fal-negative culture results, but can use silver sulfadizine or chlorhexidine coated catheters specific inhibitors to abrogate this effect.
* More info on quantitative blood culture at the end of the presentation.
Definition of positive CRBSI via Differential time to positivity is comparing the catheter to the peripheral vein to see which sample grows out first.
Monitoring for growth is based on radiometric methods
So the theory is that the greater the inoculum of microbes inoculated into blood cultures bottles, the shorter the incubation required to detect microbial growth, one would expect the catheter to have the greater inoculum.
85-89% sensitivity and 81-83% specificity in meta-analysis of 8 studies
Obtain blood culture from peripheral vein and from the central line.
If the blood culture from the central line becomes positive at least two hours before that of the peripheral line, then diagnosis of CRBSI.
How do you proceed from here if positive CRBSI?
Other treatment modalities not discussed:
Salvage
Exchange
Antibiotic lock therapy
Main point of this slide is to say that these are “COMPLICATED” infection scenarios that require catheter removal. You’ll see this reiterated in the flow diagram towards the end of this presentation. Anything that falls under “complicated” means you need to remove the catheter.
This patient has criteria for severe sepsis. He/She needs to have fluid boluses and likely pressors to be given as well. The issue here is to obtain another access site and pull the line as this is short term catheter and patient is hemodynamically unstable with the likely source as the catheter since he/she has been doing ok up until this point with current abx for CAP.
Keeping the line is an option, but since this is the likely source of infection better to take it out in light of new hemodynamic instability requiring pressors, and broadening of abx coverage. In addition, treating through the infection is indicated in cases where cultures for the following bugs are not found: s. aureus, pseudomonas, fungi or mycobacteria.
Changing the line via guidewire is not indicated in this case if you can obtain another line else where. Guidewire exchange is 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). Clinical scenarios: liver disease, coagulopathy, medication induced.
D) D is not an option as patient has criteria for severe sepsis and hemodynamically unstable, pt needs closer monitoring.
Essentially this slide is further breaking down other reasons why you should remove the catheter into the organisms associated with short term and long term catheters (does not apply to hemodialysis catheters).
Removal of long term catheters is a management challenge, particularly in the setting of surgically implantable intravascular devices. Therefore, it is important to establish true CRBSI.
In the setting of CRBSI due to organisms of relatively low virulence that are difficult to eradicate (eg, Bacillus spp, Micrococcus spp, or Propionibacteria), removal of both short and long term catheters is appropriate if blood culture contamination has been ruled out (eg, based on multiple positive culture results with at least one sample drawn from a peripheral vein) There is no evidence to support routine catheter exchange.
Basically don’t remove catheter in patient with negative blood cultures and hemodynamically stable but you have unexplained fever, unless patient has endovascular prosthetic material (such as a prosthetic valve, pacemaker, or vascular graft).
S. aureus, enterococci, gram neg bacilli, fungi, and mycobacteria
Low virulence but difficult to eradicate (eg, Bacillus spp, Micrococcus spp, or Propionibacteria)
S. aureus, enterococci, gram neg bacilli, fungi, and mycobacteria
Low virulence but difficult to eradicate (eg, Bacillus spp, Micrococcus spp, or Propionibacteria)
Essentially a summarized approach to the above discussion/slides
Ares to emphasize/reiterate to the audience:
Complicated = indications to remove the catheter
But also take note that in this setting coag neg staph, s. aureus, enterococcus, gram neg bacilli and candida ALL require removal of catheter
Remove it!!!
Essentially this slide is further breaking down other reasons why you should remove the catheter into the organisms associated with short term and long term catheters (does not apply to hemodialysis catheters).
Removal of long term catheters is a management challenge, particularly in the setting of surgically implantable intravascular devices. Therefore, it is important to establish true CRBSI.
In the setting of CRBSI due to organisms of relatively low virulence that are difficult to eradicate (eg, Bacillus spp, Micrococcus spp, or Propionibacteria), removal of both short and long term catheters is appropriate if blood culture contamination has been ruled out (eg, based on multiple positive culture results with at least one sample drawn from a peripheral vein) There is no evidence to support routine catheter exchange.
Basically don’t remove catheter in patient with negative blood cultures and hemodynamically stable but you have unexplained fever, unless patient has endovascular prosthetic material (such as a prosthetic valve, pacemaker, or vascular graft).
Approach to the treatment of a patient with a long-term central venous catheter (CVC) or a port (P)-related bloodstream infection.
Points to highlight:
“Complicated infections” take out the catheter
Staph aureus take out catheter mortality is high if try to treat through the infection
Gram negative bacilli take out catheter
Candida take out
May retain and try to treat through: coag neg staph, enterococcus, but if no clinical improvement take it out.
Essentially going over some scenarios and how these will affect empiric antibiotic choice.
Initial choice of antibiotics for catheter-related blood stream infection (CRBSI) depends on the clinical circumstances, including the severity of illness, the risk factors for infection, and the likely pathogens associated with the specific intravascular device.
In general, coagulase negative staphylococci are the most common cause of catheter-related infection; most isolates are resistant to methicillin. Therefore empiric therapy of CRBSI in health care settings should consist of vancomycin.
In institutions with high rates of infection due to MRSA isolates with vancomycin MIC ≥2 mcg/mL, an alternative agent such as daptomycin should be used.
Linezolid is not an appropriate agent for empiric therapy of CRBSI.
Addition of empiric coverage for gram negative organisms depends on individual circumstances and the severity of disease.
In the setting of suspected CRBSI among patients with neutropenia or sepsis, empiric antibiotic therapy for gram negative bacilli (including Pseudomonas) is appropriate.
Patients known to be colonized with drug resistant organisms should receive empiric antibiotic therapy selected accordingly
Essentially going over some scenarios to keep in mind.
Empiric therapy for suspected catheter-related candidemia should be administered for septic patients with the above risk factors.
Empiric treatment include echinocandin or azole drugs.
Fluconazole if no azole exposure in previous 3 months and in settings where the risk of C. krusei or C. glabrata is very low.
If catheter removal is not possible, antibiotics should be administered through the colonized catheter, although recurrent bacteremia is more likely if therapy is administered through a retained catheter than if the catheter is removed
10 to 14 days (day one is the first day on which negative blood cultures are obtained)
The duration of therapy may be extended to 4 to 6 weeks in patients with recent prosthetic valve placement placed prosthetic valves, even if investigation fails to demonstrate evidence of IE.
Patients with persistent bacteremia &gt;72 hours following catheter removal should generally receive treatment for at least 4 to 6 weeks. For patients with complications related to bacteremia (such as suppurative thrombophlebitis, endocarditis, osteomyelitis, metastatic infection) the duration of therapy should be tailored accordingly depending on the nature of infection.