catheter related blood stream infections are important cause of increase hospital stay and financial burden on patient.

1. Catheter Related Blood
Streams Infections
Speaker-Dr Rahul Arya

2. Introduction
 Venous access via catheter insertion is common
practice in the hospital for various purposes,
including hemodynamic monitoring, renal
replacement therapy, nutritional support and
medication administration.
 As a consequence of their increasing use,
bloodstream infections resulting from intravascular
catheters have become a costly complication of
health care.

3. Epidemiology
 More than 250,000 central line associated blood
stream infections (CLABSI) occur annually in USA
with mortality rate of 12-25%.
 Each episode significantly increases hospital stay
with additional health care cost ranging from
$4,000 to $56,000 per episode.
 Incidence density of CRBSI in USA vary between
0.1-22.5% and b/w 0.1 and 2.7 per 1000 central
line day.

4.  The rate of CLABSIs in limited-resource countries
ranged from 1.6 to 44.6 cases per 1000 central line
(CL) days in adult and pediatric ICUs.
 In India Mehta et al reported an overall CLABSI
rate of 7.9 per 1000 CL days.
 Kaur et al and Patil et al from hospitals in India
reported CLABSI rate of 2.8 per 1000 CL days and
18.5%, respectively.

5. Definition
 CRBSI (catheter related blood stream infection)-
refers to blood stream infection attributed to an
intravascular catheter by quantitative culture of the
catheter tip or by differences in growth between
catheter and peripheral venipuncture blood cultures
specimens.
 CLABSI ( central line associated blood stream
infection)- refers to blood stream infection that appears
in the presence of a central venous catheter or within
48 hr of removal of a central venous catheter and which
cannot be attributed to an infection unrelated to
catheter.
 CLABSI was developed to serve as a surrogate
measure of CRBSI.

6. Risk Factors
 It includes Patient, Operator and Catheter related
factors.
 Patient Factors-
 Increasing severity of illness
 Granulocytopenia
 Compromised integrity of skin
 Presence of distant infection.
 Operator Factors- risk increases after breaks in
aseptic technique during placement and
maintenance and with frequency of catheter
access.

7.  Catheter factors-
 Catheter type- risk of bsi increases with increasing
lumen number.
 Antibiotic or antimicrobial coating of catheter can
reduce risk of CRBSI.
 For non tunneled catheters risk of bsi varies by
anatomical sites- max for groin insertion,
intermediate for neck insertion and lowest for chest
or upper extremity insertion.

8. Pathogenesis
 The pathogenesis is attributed to 4 primary causes-
 Migration of skin organism at the insertion site into
catheter tract along the surface of catheter with
colonization of catheter tip- M/C
 Direct contamination of catheter or catheter hub by
contact with hands or contaminated fluid or device.
 Hematogenous spread of infection from another
focus.
 Contamination of infusate.

9.  Colonization of device may be either extra luminal
from surrounding skin or hematogenous seeding of
catheter tip or
 Intraluminal caused by an organism adhering to
device followed by creation of biofilm.
 In short term devices extra luminal route is more
common whereas intraluminal route is more
common in long term devices (>10 days) or short
term devices left in longer than 4-7 days.

10. Microbiology
 Organisms commonly associated with CLABSIs
are-
 Coagulase negative staph-31%
 S. aureus- 20%
 Enterococci- 9%
 E. coli- 6%
 Klebsiella species-5%
 Candida species- 9%
• A large study (SCOPE study) found that the rates
of MRSA has increased from 22% in 1995 to 57%
in 2001.
• Rates of ceftazidime resistant P. aeruginosa has
increased from 12% in 1995 to 29% in 2001.

11. Diagnosis
 CRBSI should be suspected in pt with iv cath who
develop clinical or lab criteria of SIRS i.e. temperature
<36ºC or > 38ºC, HR> 90/min, RR>20/min or TLC
<4000/µl or >12000/µl.
 Exit sites of all percutaneous vascular devices should
be assesse to identify obvious inflammation.
 Quantitative culture of the distal (5 cm) tip of central
venous and arterial catheters should be performed
when they are removed for suspected infection.
 The tip of the introducer should be sent for culture when
a pulmonary artery line is removed.

12.  For patients with short-term central venous
catheters without severe sepsis or shock, in whom
the index of suspicion for catheter-related infection
is moderate or less, the catheter may be
exchanged over a guide wire for a new catheter
allowing culture of the tip of the removed catheter
without immediately sacrificing the site of insertion.
 At least 2 blood cultures should be obtained when
catheter infection is suspected.

13.  When the tip of a catheter is sent for culture, the 2
blood cultures may be obtained by peripheral
venipuncture.
 Alternatively or when culture of the tip of the catheter is
not performed, one blood culture should be obtained by
peripheral venipuncture and at least one blood culture
should be obtained from a lumen of the catheter.
 for multilumen catheters, drawing multiple catheter
blood cultures, one from each lumen of the catheter
suspected of infection, in addition to one blood culture
obtained by peripheral venipuncture will enhance
detection of catheter infection.

14.  For patients with multiple central venous and/or
arterial catheters, a blood culture should be drawn
through each catheter in addition to that obtained
by peripheral venipuncture.
 To reduce the incidence of blood culture
contamination, the skin and the hub of the catheter
must be cleansed with alcohol, tincture of iodine or
alcohol chlorhexidene, and allowed to dry, before
specimen collection.

15. Methods not requiring CVC removal
Diagnostic
Methods
Description Criteria for
positivity
Sensitivity % Specificity %
Qualitative blood
culture through device
One or more blood
cultures drawn
through CVC
Any growth 87 83
Quantitative blood
culture through device
Blood culture drawn
through
CVC,processed by
pour-plate methods or
a lysis-centrifugation
technique
≥100 CFU/ml 77 90
Paired quantitative
blood cultures
Simultaneous cultures
drawn through CVC
and percutaneously
Both cultures
positive with CVC
culture yielding 5-
fold higher or more
than peripherally
drawn culture
87 98
Differential time to
positivity
Simultaneous blood
cultures drawn
through CVC and
percutaneously and
monitored
Both cultures
positive with CVC
positive ≥2 hr
earlier than
peripherally drawn
85 81

16. Methods requiring CVC removal
Diagnostic
method
Description Criteria for
positivity
Sensitivity
%
Specificity
%
Qualitative
catheter segment
culture
Segment from
removed CVC is
immersed in broth
media and
incubated for 24-72
hr
Any growth 90 72
Semi quantitative
catheter segment
culture
A 5 cm segment
from removed CVC
is rolled 4 times
across a blood
agar plate and
incubated
≥15 CFU 85 82
Quantitative
catheter segment
culture
Segment from
removed CVC is
flushed or
sonicated with
broth, serially
diluted, plated on
blood agar and
incubated
≥1000 CFU 83 87

17.  A diagnosis of CRBSI is achieved by any of the
following 3 criteria-
 same organism recovered from percutaneous
blood culture and from quantitative (>15 colony-
forming units) culture of the catheter tip
 same organism recovered from a percutaneous
and a catheter lumen blood culture, with growth
detected 2 hours sooner ( i.e., 2 hours less
incubation) in the latter.
 same organism recovered from a quantitative
percutaneous and a catheter lumen blood culture,
with 3-fold greater colony count in the latter.

18. Management- General
 For emperical treatment-
 vancomycin in institutions where the prevalence
of MRSA is increased (otherwise use a 1st gen
cephalosporin such as cefazolin or an anti-
staphylococcal penicillin such as nafcillin).
 daptomycin in place of vancomycin in facilities
where the prevalence of MRSA with reduced
vancomycin susceptibility is increased.
 antibiotics active against Gram-negative bacilli,
based upon local susceptibility patterns, in the
setting of increased severity of illness or femoral
catheterization;

19.  antibiotics active against Pseudomonas
aeruginosa, in the setting of neutropenia, severe
illness, or known colonization.
 antimicrobials active against candida in the setting
of femoral catheterization, TPN, prolonged
administration of broad-spectrum antibiotics,
hematologic malignancy, or solid organ or
hematopoietic stem cell transplantation
 If blood cultures fail to yield growth, the need for
further empiric antibiotic therapy should be
reassessed.

20. Management: Short Term Central
Venous or Arterial CRBSI
 Cultures confirmed CRBSI-: empiric antibiotic therapy
according to susceptibility profile of the recovered
pathogen.
 The infected catheter, or the catheter placed over a
guide wire in exchange for the infected catheter, should
be removed expeditiously.
 For uncomplicated bloodstream infection that arises in
the absence of factors that increase the risk of
hematogenous spread of infection and which resolves
within 72 hours of catheter removal, systemic
therapeutic, intravenous antibiotic treatment is
recommended for:

21.  5 to 7 days for coagulase-negative staphylococci.
 7 to 14 days for enterococci and Gram-negative
bacilli.
 14 days in the absence of evidence fungal retinitis
for Candida species.
 14 days in the absence of evidence of endocarditis
clinically and by transesophageal
echocardiography (TEE), for S aureus.

22.  For patients with susceptible pathogens and a
functioning GI tract, oral linezolid, fluoroquinolones,
or fluconazole may be considered for treatment of
MRSA, Gram-negative bacilli, and candida,
 For patients with CRBSI lasting over 72 hours, or
with factors that increase the risk of metastatic
infection, longer duration of antibiotic
administration directed by patient, pathogen, and
disease characteristics will be required.

23. Management: Long-Term Central
Venous CRBSI
 Catheter should be removed immediately
especially for S aureus, Bacillus species,
micrococcus, propionibacterium, P aeruginosa,
candida, or mycobacterial infection.
 4 to 6 weeks of therapy is often required for S
aureus infection.
 14 days for non diabetic, non neutropenic, non
immunosuppressed patients without septic
thrombosis, endocarditis (TEE negative),
metastatic infection, or prosthetic intravascular
devices when S aureus or other bacterial infection
resolves within 72 hours of antibiotic initiation and
catheter removal.

24.  For patients with candida infection in whom there is
no suspicion or evidence of metastatic infection
and for whom fungemia and evidence of infection
resolve promptly upon catheter removal, antifungal
therapy should be continued for 14 days after the
first negative blood culture.
 A new long term central venous catheter can be
placed at a new anatomic site after 72 hours of
effective antibiotic administration and lack of
growth in repeat blood cultures.

25.  Systemic therapeutic antibiotics should be given for
10 to 14 days. Meanwhile, antibiotic lock solution,
appropriate for the pathogen and for the catheter
must be administered to every lumen, daily with
24-hour dwell time.
 The catheter should be removed if there is
evidence of clinical deterioration or ongoing
bloodstream infection from catheter infection during
antibiotic lock solution administration.

26.  Blood cultures to be repeated1 week after
completion of treatment for patients with long-term
central venous catheters treated with antibiotic lock
therapy for catheter salvage.

28. Education, Training and
Staffing
 Healthcare personnel should be educated
regarding the indications proper procedures for the
insertion and maintenance of intravascular
catheters.
 Periodically assess knowledge of and adherence to
guidelines for all personnel involved in the insertion
and maintenance of intravascular catheters .

29.  Designate only trained personnel who demonstrate
competence for the insertion and maintenance of
peripheral and central intravascular catheters.
 Ensure appropriate nursing staff levels in ICUs.

30. Selection of Catheters and
Sites
 Peripheral Catheters and Midline Catheters
 In adults, use an upper-extremity site for catheter
insertion.
 Replace a catheter inserted in a lower extremity
site to an upper extremity site as soon as possible.
 Select catheters on the basis of the intended
purpose and duration of use, known infectious and
non-infectious complications and experience of
individual catheter operators.

31.  Evaluate the catheter insertion site daily by palpation
through the dressing to discern tenderness and by
inspection if a transparent dressing is in use.
 Gauze and opaque dressings should not be removed if
the patient has no clinical signs of infection. If the
patient has local tenderness or other signs of possible
CRBSI, an opaque dressing should be removed and the
site inspected visually.
 Remove peripheral venous catheters if the patients
develops signs of phlebitis (warmth, tenderness,
erythema or palpable venous cord), infection, or a
malfunctioning catheter.

32.  Central Venous Catheters
 Weigh the risks and benefits of placing a central venous
device at a recommended site to reduce infectious
complications against the risk for mechanical
complications.
 Avoid using the femoral vein for central venous access
in adult patients.
 Use a subclavian site, rather than a jugular or a femoral
site, in adult patients to minimize infection risk for
nontunneled CVC placement.
 Avoid the subclavian site in hemodialysis patients and
patients with advanced kidney disease, to avoid
subclavian vein stenosis

33.  Use a fistula or graft in patients with chronic renal
failure instead of a CVC for permanent access for
dialysis.
 Use ultrasound guidance to place central venous
catheters (if this technology is available) to reduce the
number of cannulation attempts and mechanical
complications.
 Use a CVC with the minimum number of ports or
lumens essential for the management of the patient
 Promptly remove any intravascular catheter that is no
longer essential.

34. Hand Hygiene and Aseptic
Technique

35.  Perform hand hygiene procedures, either by washing
hands with conventional soap and water or with alcohol-
based hand rubs.
 Maintain aseptic technique for the insertion and care of
intravascular catheters.
 Sterile gloves should be worn for the insertion of
arterial, central, and midline catheters.
 Use new sterile gloves before handling the new
catheter when guide wire exchanges are performed.
 Wear either clean or sterile gloves when changing the
dressing on intravascular catheters.

36. Maximal Sterile Barrier
Precautions
Maximal sterile
barrier precautions
like cap, mask,
sterile gown, sterile
gloves, and a
sterile full body
drape, should be
used for the
insertion of CVCs,
PICCs, or guide
wire exchange.

37.  Skin Preparation
 Prepare clean skin with an antiseptic (70% alcohol,
tincture of iodine, or alcoholic chlorhexidine
gluconate solution) before peripheral venous
catheter insertion.
 Prepare clean skin with a >0.5% chlorhexidine
preparation with alcohol before central venous
catheter and peripheral arterial catheter insertion
and during dressing changes.
 If there is a contraindication to chlorhexidine,
tincture of iodine, an iodophor, or 70% alcohol can
be used as alternatives.

38.  Catheter Site Dressing Regimens
 Use either sterile gauze or sterile, transparent,
semipermeable dressing to cover the catheter site.
 Do not use topical antibiotic ointment or creams on
insertion sites, except for dialysis catheters, because of
their potential to promote fungal infections and
antimicrobial resistance.
 Do not submerge the catheter or catheter site in water.
 Replace dressings used on short-term CVC sites every
2 days for gauze dressings.
 Replace dressings used on short-term CVC sites at
least every 7 days for transparent dressings.

39.  Monitor the catheter sites visually when changing
the dressing or by palpation through an intact
dressing on a regular basis.
 If patients have tenderness at the insertion site,
fever without obvious source, or other
manifestations suggesting local or bloodstream
infection, the dressing should be removed to allow
thorough examination of the site.
 Encourage patients to report any changes in their
catheter site or any new discomfort to their
provider.

40.  Patient Cleansing
 Use a 2% chlorhexidine wash for daily skin
cleansing to reduce CRBSI.
 Systemic Antibiotic Prophylaxis
 Do not administer systemic antimicrobial
prophylaxis routinely before insertion or during use
of an intravascular catheter to prevent catheter
colonization or CRBSI.

41.  Antibiotic/Antiseptic Ointments
 Use povidone iodine antiseptic ointment or
bacitracin/gramicidin/ polymyxin B ointment at the
hemodialysis catheter exit site after catheter
insertion and at the end of each dialysis session.
 Antibiotic Lock Prophylaxis, Antimicrobial
Catheter Flush and Catheter Lock Prophylaxis
 Use prophylactic antimicrobial lock solution in
patients with long term catheters who have a
history of multiple CRBSI despite optimal maximal
adherence to aseptic technique.

42.  Anticoagulants
 Do not routinely use anticoagulant therapy to
reduce the risk of catheter-related infection in
general patient population.
 Replacement of Peripheral and Midline
Catheters
 There is no need to replace peripheral catheters
more frequently than every 72-96 hours to reduce
risk of infection and phlebitis in adults.
 Replace midline catheters only when there is a
specific indication.

43.  Replacement of CVCs, Including PICCs and
Hemodialysis Catheters
 Do not routinely replace CVCs, PICCs, hemodialysis
catheters, or pulmonary artery catheters to prevent
catheter-related infections.
 Do not remove CVCs or PICCs on the basis of fever
alone. Use clinical judgment regarding the
appropriateness of removing the catheter.
 Do not use guide wire exchanges routinely for non-
tunneled catheters to prevent infection.
 Do not use guide wire exchanges to replace a non-
tunneled catheter suspected of infection.

44.  Use a guide wire exchange to replace a
malfunctioning non-tunneled catheter if no
evidence of infection is present.
 Use new sterile gloves before handling the new
catheter when guide wire exchanges are
performed.

45.  Replacement of Administration Sets
 In patients not receiving blood, blood products or
fat emulsions, replace administration sets that are
continuously used no more frequently than at 96-
hour intervals, but at least every 7 days.
 No recommendation can be made regarding the
frequency for replacing intermittently used
administration sets.
 Replace tubing used to administer blood, blood
products, or fat emulsions within 24 hours of
initiating the infusion.

46.  Surveillance and Reporting:-
 Hospital-based infection control teams
begin surveillance for bloodstream
infections by regularly reviewing results of
blood cultures obtained at their facilities.

47. Conclusion
 Catheter-related bloodstream infections are costly
complications of hospital care that have occurred with
greater frequency in the ICU settings.
 Accurate diagnosis can be established by culture of
appropriately collected specimens of blood and catheter
tips.
 Evidence-based guidance is available to inform
antibiotic treatment and catheter management when
infection occurs.
 Risk of CRBSI can be reduced by optimizing catheter
selection, insertion and maintenance, and by removing
catheters when they are no longer needed.