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Crbsi kamran

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Crbsi kamran

  1. 1. CENTRAL VENOUS CATHETER-RELATED BLOODSTREAM INFECTIONS DR KAMRAN AFZAL DEPARTMENT OF PATHOLOGY
  2. 2. CENTRAL VENOUS CATHETER-RELATED BLOODSTREAM INFECTIONS CVC an important part of critical care medicine CR-BSI occur in 5 – 20% of hospitalized catheterized patients Attributable mortality rate: 10 – 20% More than 90% of nosocomial BSI are associated with CVC
  3. 3. CENTRAL VENOUS CATHETERS (CVC) PERCUTANEOUS – NTCVC SHORT TERM – PICC SUBCUTANEOUS – TCVC TOTALLY IMPLANTED – TID
  4. 4. USES Fluids Blood products Drugs Parenteral nutrition Infusion therapy Pressure monitoring
  5. 5. RISK FACTORS Frequent manipulations Prolonged use Repeated use Violation of asepsis Site of insertion Insertion / maintenance by inexperienced staff Immunocompromised state
  6. 6. ETIOLOGIC AGENTSCoagulase negative StaphylococcusStaphylococcus aureusEnterococcus sppPseudomonas sppAcinetobacter sppEscherichia coliKlebsiella sppEnterobacter sppCorynaebacterium sppCandida spp
  7. 7. CASE DEFINITIONS- ICATHETER CONTAMINATION< 103 CFU / ml (catheter tip)Organisms reach, adhere, multiplyCATHETER COLONIZATION> 103 CFU / ml (catheter tip)Blood culture negative for same organism / 24 hrs
  8. 8. CASE DEFINITIONS- IILOCAL INFECTION> 103 CFU / ml (catheter tip)Local signs and symptoms within 2 cm of skinCATHETER-RELATEDBLOODSTREAM INFECTION> 103 CFU / ml (catheter tip)Blood culture positive for same organism / 24 hrsDefervescence on removal of catheter
  9. 9. PATHOGENESIS- I• Adherence of microorganisms• Formation of thrombin biofilm
  10. 10. PATHOGENESIS- II MATERIAL Teflon, Polyurethane, Silicone ADHERENCE PROPERTIES Coagulase negative Staphylococcus Slime: glycocalyx formation on polymer surface Staphylococcus aureus Host protein: fibronectin, coagulase production Candida albicans Surface receptors: thrombin biofilm
  11. 11. PATHOGENESIS- IIIROUTES OF INFECTION SHORT TERMExtra-luminal <14 daysIntra-luminal Skin microorganismsHaematogenous Cutaneous tract Extra-luminal colonizationInfusates LONG TERM >14 days Contamination of catheter hub Intra-luminal colonization
  12. 12. COMPLICATIONS OF CVCFAULTY INSERTION THROMBOSISPneumothorax LocalHaemothorax CV thrombosisArterial punctureAir embolism INFECTIONThoracic duct laceration Exit siteBrachial plexus injury BacteraemiaCatheter malposition SepticaemiaMECHANICAL METASTASISKinking OsteomyelitisCracking PneumoniaDisplacement Endocarditis
  13. 13. LAB DIAGNOSISQUANTITATIVE CULTURE PAIRED QUANTITATIVEAccurate CULTUREHigh sensitivity and Accurate specificity 10 : 1 CFU / ml> 103 CFU / ml between CVC andSonication peripheral bloodUltra-sonicationVortex DIFFERENTIAL TIME TO POSITIVITYSurface and lumen Cut off: 120 minutesSEMI-QUANTITATIVECULTURE GRAM STAIN AND AOLCSimplest and commonly Rapid used Simple> 15 CFU InexpensiveExternal surface High sensitivity and specificity
  14. 14. SPECIMEN COLLECTION- I INSERTION Aseptic procedure CVC: In OT under GA CVP: In ward under LA REMOVAL Suspicion of infection (local / systemic) No longer required Aseptic procedure COLLECTION Sterile container
  15. 15. SPECIMEN COLLECTION- II BLOOD CULTURE At the time of catheter insertion and then at removal Fever >1010 F, chills, shock PUS / PUS SWAB Site of insertion Local signs and symptoms
  16. 16. BACTERIAL CULTURE CATHETER TIP Cleri’s quantitative culture method Blood and MacConkey agar at 370 C aerobically for 24 - 48 hrs BLOOD BHI broth at 370 C aerobically for up to 7 days Sub-culture on days 1, 2, 4 and 7 on Blood and MacConkey agar PUS / PUS SWAB Blood and MacConkey agar at 370 C aerobically for 24 - 48 hrs
  17. 17. FUNGAL CULTURE CATHETER TIP Sabouraud’s agar at 220 C aerobically for up to 14 days BLOOD CULTURE Trypticase soy broth at 220 C aerobically for up to 14 days PUS / PUS SWAB Sabouraud’s agar at 220 C aerobically for up to 14 days
  18. 18. IDENTIFICATION BACTERIAL ISOLATES Colony morphology Gram’s stain Biochemical tests Serology API galleries FUNGAL ISOLATES Colony morphology Gram’s stain Lactophenol blue stain Biochemical tests API Candida
  19. 19. ANTIMICROBIAL SUSCEPTIBILITY TESTING BACTERIAL ISOLATES Modified Kirby-Bauer disk diffusion method CLSI FUNGAL ISOLATES MICs by Etest
  20. 20. PREVENTIONAPPROACH EFFECTCATHETER DESIGN• Smooth topography Discourages thrombus formation, microbial adherence, colonization• Antibiotic coating Reduces microbial adherenceCARE OF INSERTION SITE• Skin preparation and antisepsis Reduces possibility of catheter contamination• Application of antimicrobials Reduces skin microbial load (mupirocin) at insertion site• Use of (silver-impregnated) Prevents migration of organismsantimicrobial cuff at insertion site down the external surface of catheter• Use of antibiotic-heparin flush soln Discourages fibrin collection / biofilm• Regular use of antiseptics on hub Reduces hub contamination• Use of prophylactic antibiotics Reduces catheter-related infections
  21. 21. TREATMENTGlycopeptides with / without gram negative coverageSubstitution of catheter with / without replacing it atan alternate siteGuide-wire exchangeSystemic antimicrobial therapy without removingcatheterAntibiotic-lock techniqueAntibiotic and heparin lock solution
  22. 22. INCIDENCE OF CR-BSIINCIDENCE TYPE OF YEAR REFERENCE CATHETER 16.8% CVC 2003 AFIP study 19.8% CVC / 1999 Souweine et al Peripheral 17.6% CVC / 2000 Petrosillo et al Peripheral 15.1% Peripheral 2001 Hafeez et al 12.0% CVC 2001 Nicastri et al 10.1% CVC / 2000 Kinkelstein et al Peripheral 8.9% CVC 1999 Timsit et al 3.3% CVC 2000 Sherertz et al
  23. 23. CONCLUSIONS• Central venous catheter is an important source of bloodstream infection in catheterized patients• A glycopeptide and a carbapenem, or pipracillin- tazobactam, or cefoperazone-sulbactam are recommended to be included in the empirical regimen in high risk cases• There is a need to implement more effective infection control measures and more advanced technologies in an effort to reduce this high incidence

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