Catheter related blood stream nanoti sir

1. Catheter - Related
Blood Stream
Infection
(CRBSI)
By
Dr Girish Nanoti
Associate Professor (Dept. of Paediatrics)

2. Learning Objectives
 Introduction
 Epidemiology & pathogenesis
 Common Definitions of IV related infections
 Diagnosis
 Management
 Antibiotic Lock Therapy
 Unresolved issue

3. Introduction
 Due to increased invasive monitoring and
prolonged stay in ICUs use of intravascular
catheters and instruments has increased
tremendiously.
 This has led to increase in Catheter related blood
stream infections (CRBSI) leading to increase in
morbidity and mortality .
 Therefore CRBSI should be identified early and
treated immediately .

4. Epidemiology
 In America 150 million IV catheter & IV devices
are used per year ,out of which 80,000 patients
develops CRBSI.
 In India exact data about use of IV catheter &
devices not known ,but rate of CRBSI is 1.5 – 2.4
per 1000 days of catheter used (MOSER Study
,2011)
 Indian critical society of Medicine is doing
Observational study at multiple centres and its
results are due in a year .

5. Aetiology
 Staph. aureus , Coag. Neg. Staph ,Enterococcus
,Gram negative bacilli and Candida species.
These five organisms are responsible for > 95%
of CRBSI
 In neutropenic patients : patients with immuno
deficiency –pseudomonas (MDR strain )

6. Pathogenesis
HEMATOGENOU
S
CONTAMINATE
D HUBS
CONTAMINAT
ED INFUSATE

7. RISK FACTORS FOR CRBSI
 Duration of catheter / IV device
 Age : Highest in preterm/Old age
 Immunodeficiency ,Neutropaenic patients
 Cancer patients /patient on chemotherapy
 Frequency of handling the device
 Site of insertion of CVC - Femoral has highest
incidence

8. Common Definitions

9.  CATHETER COLONIZATION
 Significant growth of 1 microorganism in a quantitative or
semiquantitative culture of the catheter tip, subcutaneous
catheter segment, or catheter hub
 PHLEBITIS
 Induration or erythema, warmth, and pain or tenderness along
the tract of a catheterized or recently catheterized vein

 EXIT SITE INFECTION
 Erythema, induration, and/or tenderness within 2 cm of the
catheter exit site; may be associated with other signs and
symptoms of infection, such as fever or purulent drainage
emerging from the exit site, with or without concomitant
bloodstream infection
 TUNNEL INFECTION
 Tenderness, erythema, and/or induration 12 cm from the
catheter exit site, along the subcutaneous tract of a tunneled
catheter (e.g., Hickman or Broviac catheter), with or without
concomitant bloodstream infectiona

10. Continued..
 POCKET INFECTION
 Infected fluid in the subcutaneous pocket of a totally
implanted intravascular device; often associated with
tenderness, erythema, and/or induration over the pocket;
spontaneous rupture and drainage, or necrosis of the
overlying skin, with or without concomitant bloodstream
infection
 BLOOD STREAM INFECTION
 INFUSATE RELATED : Concordant growth of a
microorganism from infusate and cultures of percutaneously
obtained blood cultures with no other identifiable source of
infection
 CATHETER RELATED : Bacteremia or fungemia in a
patient who has an intravascular device and >1 positive
blood culture result obtained from the peripheral vein, clinical
manifestations of infection (e.g., fever, chills, and/ or
hypotension), and no apparent source for bloodstream

11. TYPES OF INTRAVASCULAR DEVICES

12. TYPES OF INTRAVASCULAR DEVICES AND THEIR USE
Peripheral venous
catheter
Usually inserted into the veins of the forearm or the hand; the most
commonly used short-term intravascular device
Peripheral arterial
catheter
commonly used to monitor hemodynamic status and to determine
blood gas levels of critically ill patients
Midline catheter Peripheral catheter is inserted via the antecubital fossa into the
proximal basilic or cephalic veins
Short-term CVC Most commonly used CVC; accounts for the majority of all catheter-
related bloodstream infections
Pulmonary artery catheter Inserted through a teflon introducer and typically remains in place
for an average duration of only 3 days
Pressure-monitoring
system
Used in conjunction with arterial catheter
Peripherally inserted
central catheter
Provides an alternative to subclavian or jugular vein catheterization;
is inserted via the peripheral vein into the superior vena cava,
Long-term CVC Surgically implanted CVC with the tunneled portion exiting the skin
and a dacron cuff just inside the exit site; used to provide vascular
access to patients who require prolonged chemotherapy
Totally implantable device A subcutaneous port or reservoir with self-sealing septum is
tunneled beneath the skin and is accessed by a needle through
intact Skin

13. Diagnosis
(when and how should catheter cultures and blood cultures be done?)

14. GRADING SYSTEM FOR RANKING RECOMMENDATIONS IN CLINICAL
GUIDELINES.
Grade Definition
Strength of recommendation
A Good evidence to support a recommendation for or against use
B Moderate evidence to support a recommendation for or against use
C Poor evidence to support a recommendation.
Quality of Evidence
I Evidence from 1 properly randomized, controlled trial.
II Evidence from 1 well-designed clinical trial, without randomization;
from cohort or case-controlled analytic studies (preferably from 11
center); from multiple time-series; or from dramatic results from
uncontrolled experiments.
III Evidence from opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert committees.

15. GENERAL
Strength or
quality of
recommendati
on
Catheter cultures should be performed when a catheter is
removed for suspected CRBSI; catheter cultures should not
be obtained routinely
A-II
Qualitative broth culture of catheter tips is not
recommended
A-II
For central venous catheters (CVCs), the catheter tip
should be cultured, rather than the subcutaneous Segment
B-III
For cultures of an anti-infective catheter tip, use specific
inhibitors in the culture media
A-II
Growth of >15 cfu from a 5-cm segment of the catheter tip
by semiquantitative (roll-plate) culture or growth of >102 cfu
from a catheter by quantitative (sonication) broth culture
reflects catheter colonization
A-I
When catheter infection is suspected and there is a catheter
exit site exudate, swab the drainage to collect specimens B-III

16. SHORT-TERM CATHETERS, INCLUDING
ARTERIAL CATHETERS
(<14 days)
Strength or
quality of
recommend
ation
For short-term catheter tip cultures, the roll
plate technique is recommended for routine
clinical microbiological Analysis
A-II
For suspected pulmonary artery catheter
infection, culture the introducer tip
A-II

17. LONG-TERM CATHETERS
(>14 days)
Strength
or
quality of
recommen
dation
Semiquantitative growth of <15 cfu/plate of the
same microbe from both the insertion site
culture and the catheter hub culture strongly
suggests that the catheter is not the source of
a bloodstream infection
A-II
If a venous access subcutaneous port is
removed for suspected CRBSI, send the port
to the microbiology laboratory for qualitative
culture of the port reservoir contents, in
B-II

18. BLOOD CULTURES
Strength
or
quality of
recomme
ndation
Same organism grow from at least 1 percutaneous blood
culture
and from a culture of the catheter tip
A-I
2 blood samples be drawn (one from a catheter hub and the
other from a peripheral vein) that, when cultured, meet
CRBSI criteria for quantitative blood cultures or DTP
A-II
2 quantitative blood cultures of samples obtained through 2
catheter lumens in which the colony count for the blood
sample drawn through one lumen is at least 3-fold greater
than the colony count for the blood sample obtained from the
second lumen
B-II
For quantitative ,colony count of microbes grown from blood
obtained through the catheter hub that is at least 3-fold
greater than the colony count from blood obtained from a
peripheral vein best defines CRBSI
A-II

19. Diagnostic criteria for
A) Intravascular catheters :
 Short term catheters
 Method use is roll plate method (semi quantative )
 Long term catheters
 Method used is qualitative broth culture (sonication)
 Growth of > 15 CFU per plate in roll plate method & >102
CFU in quantitative is diagnostic of CRBSI
 Alternative method swab samples are taken from around
catheter insertion site & inside of each catheter that
swab sample on blood agar plate .Growth of >15 CFU of
same microbe from both sites and peripheral blood
culture suggest CRBSI.
 It has more negative predective value

20. B) BLOOD CULTURE :
 Definitive diagnosis of CRBSI
1. Same organism grow from atleast 1 percutaneous
blood sample and from catheter tip (A1)
2. 2 blood cultures obtained from ,1 from catheter hub
and 1 from peripheral hub ,If colony count of microbes
grown from catheter hub are 3 folds greater than that
from peripheral blood .
3. Blood sample obtained from two catheter lumens in
which colony counts of blood culture from 1 lumen
atleast 3 fold greater than from other lumen
4. DTP (Differential time for positivity )it uses radiometric
methods for continuous measuring growth on blood
culture .If growth from sample from catheter occurs 2
hours before the growth from peripheral sample

21. Blood culture contamination
issues
1. Skin preparation with either alcohol, alcoholic chlorhexidine
(10.5%), or tincture of iodine (10%) leads to lower blood
culture contamination rates than does the use of povidone-
iodine
2. Contamination rates among blood samples obtained through
newly inserted intravenous catheters are higher than
contamination rates among blood samples obtained from
peripheral veins
3. Blood samples obtained through catheters that are in use are
associated with a higher rate of false-positive results,
compared with cultures of percutaneous blood samples
4. Growth of unusual pathogen usually indicates contamination.

22. Blood and catheter culture
methodology

23. Blood Culture
1. Tincture of iodine or 0.5% chlorhexidine in alcohol is preferred not
pivodine iodine
2. At least two sets of blood cultures must be drawn
3. Peripheral vene - puncture is preferred for blood draws
4. Each set should be drawn from a different venous site
5. Cultures drawn 10-15 minutes apart are acceptable
6. Sterile gloves should be worn after hand cleansing with antimicrobial
solution/ soap.
7. should not be less than 10 ml in adults
8. While injecting rubber stopper should be disinfected with alcohol.
9. Do not change needles to transfer contents to the culture bottle

24. Catheter Culture
1. The catheters should be removed using sterile
techniques
2. The catheter site is cleared of any blood or antimicrobial
ointment using an alcohol pledget
3. The catheter is withdrawn with sterile forceps, directing
it away from the skin.
4. If the catheter is <7 cms long the entire catheter is
cultured. For longer catheters, a 5-7 cm segment either
from the tip or from the skin-catheter interface is used
for the culture.
5. The segment is rolled or smeared at least 4 times over a
blood agar plate using a flamed forceps.
6. Counts exceeding 15-colonies/ plate or the presence of

25. Management
1. General management of CRBSI infection .
2. Management of short term catheter with CRBSI
.
3. Management of Long term catheter with CRBSI
.

26. PATIENT WITH SHORT TERM CENTRAL VENOUS CATHETER (CVC) OR ARTERIAL CATHETER (AC) &
AN ACUTE FEBRILE EPISODE
Mild or Moderately ill
(no hypotension or no
organ failure)
Seriously ill ( hypotension,
hypoperfusion, signs &
symptoms of organ failure)
If no source of fever
identified ,remove CVC &
AC ,culture tip & insert at
new site or exchange
over guidance wire
Blood
cultures 2
set (1
peripheral )
Consider
antimicrobia
l therapy
• Blood culture 2 set (1
peripheral)
• Remove CVC & AC
,culture tip ,Insert at
new site or exchange
over guide wire
Initiate
appropriate
anti
microbial
therapy
Blood culture (-) &
CVC and AC not
cultured
Blood culture (+) &
CVC and AC > 15 CFU
by roll- plate of >102
Sonication methods
Blood culture (-) &
CVC and AC > 15 CFU
Blood culture (-) & CVC
and AC cultures (-)
If continued fever &
no other source
found ,remove &
culture CVC and AC
Look for another
source of infection
• For S. aureus treat 5-7
days ,monitor closely
• Other microbe ,monitor
closely and repeat blood
culture accordingly
Proceed to next
protocol

27. SHORT TERM CENTRAL VENOUS CATHETER (CVC) OR ARTERIAL CATHETER (AC)
– RELATED BLOOD STREAM INFECTION
Complicated Uncomplicated (Fever < 72 hrs ,only
blood infection, no active malignancy
or immunosuppression
Suppurative
thrombophlebitis,
endocarditis,
osteomyelitis etc
Remove catheter &
treat with systemic
antibiotics for 4-6
weeks ; 6-8 weeks
for osteomyelitis in
adults
CONS S. aureus Candida sp.Enterococcus /
Gram negative
• Remove catheter
& treat with
systemic
antibiotics for 5-7
days
• If catheter
retained treat
with systemic
antibiotics +
antibiotic lock
therapy for 10-14
days
Remove
catheter
and treat
with
antibiotics
> 14 days
Remove
catheter
and treat
with
antibiotics
for 7-14
days
Remove
catheter &
treat with
antifungal
for 14 days
after the
first
negative
blood
culture

28. LONG TERM CENTRAL VENOUS CATHETER (CVC) OR PORT ( P) – RELATED BACTEREMIA OR FUNGEMIA
Complicated Uncomplicated
Tunnel
infection
,Port abscess
Remove
CVC/P &
treat with
antibiotic
for 7-10
days
CONS S. aureus Candida sp.Enterococcus/
Gram negative
• May retain CVC/P &
use systemic
antibiotics for 10-14
days + antibiotic lock
therapy for 10-14
days
• Remove CVC/P if
there is clinical
deterioration
persisting or
relapsing
bacteremia, work up
for complicated
infection and treat
accordingly
Remove
catheter
and treat
with 4-6
weeks of
antibiotics
Remove
catheter &
treat with
antifungal
for 14 days
after the
first
negative
blood
culture
Remove
CVC/P &
treat with
antibiotic
for 4-6
weeks ,6-8
weeks for
osteomyelit
is in adults.
Septic
thrombosis,
endocarditis,
osteomyelitis
May retain CVC/P &
use systemic
antibiotics for 10-
14 days +
antibiotic lock
therapy for 10-14
days
Remove CVC/P if there
is clinical
deterioration
persisting or
relapsing
bacteremia, work
up for complicated
infection and treat
accordingly

29. ANTIBIOTIC LOCK THERAPY
( What is antibiotic lock therapy and how is it
used to manage patients with catheter-related
infection?)

30. Antibiotic lock therapy
 Long-term catheters with no signs of exit site or tunnel infection & for whom
catheter salvage is the goal
 Antibiotic lock should not be used alone; should be used in conjunction with
systemic antimicrobial therapy, with both regimens administered for 7–14 days
 Dwell times for antibiotic lock solutions should not exceed 48 hr.
 Catheter removal is recommended for CRBSI due to S. Aureus and candida species,
instead of treatment with antibiotic lock and catheter retention, unless there are
unusual extenuating circumstances (e.g., No alternative catheter insertion site)
 Patients with multiple positive catheter-drawn blood cultures that grow coagulase-
negative staphylococci or gram-negative bacilli and concurrent negative peripheral
blood cultures, antibiotic lock therapy can be given without systemic therapy for
10–14 days
 For vancomycin, the concentration should be at least 1000 times higher than the
MIC (e.g., 5 mg/ml) of the microorganism involved

31. FINAL CONCENTRATIONS OF ANTIBIOTIC LOCK
SOLUTIONS USED FOR THE TREATMENT OF CATHETER-
RELATED BLOODSTREAM INFECTION.
Antibiotic and dosage Heparin or saline, IU/mL
Vancomycin, 5.0 mg/mL 0 or 5000
Ceftazidime, 0.5 mg/mL 100
Cefazolin, 5.0 mg/mL 2500 or 5000
Ciprofloxacin, 0.2 mg/mL 5000
Gentamicin, 1.0 mg/mL 2500
Ampicillin, 10.0 mg/mL 10 or 5000
Ethanol, 70% 0

32. 1. Long-term catheters should be removed from
patients with CRBSI associated with any of the
following conditions: severe sepsis; suppurative
thrombophlebitis; endocarditis; bloodstream
infection that continues despite >72 h of
antimicrobial therapy to which the infecting
microbes are susceptible; or infections due to S.
aureus, P. aeruginosa, fungi, or mycobacteria
(A-II).
2. Short-term catheters should be removed from
patients with CRBSI due to gram-negative
bacilli, S. aureus, enterococci, fungi, and
mycobacteria (A-II)

33. Important Message
1. There is higher specificity and a greater
positive predictive value when blood
samples are obtained from a peripheral vein
for culture, compared with when blood
samples are obtained through catheters for
culture
2. Negative predictive values are excellent for
cultures of blood samples obtained from
either a peripheral vein or a catheter.

34. UNRESOLVED ISSUES
 Prior guidelines call for negative Trans Esophageal Echocardiography
findings for all patients with S. aureus CRBSI to allow for a treatment
duration of only 2 weeks . However, some experts believe that a TEE is not
needed for patients without intravascular hardware who have rapid
resolution of bacteremia and signs and symptoms of acute infection.
 The true value and optimal duration of antimicrobial lock solutions as an
adjunctive to systemic antibiotic therapy administered through the catheter
remains unknown.
 Can antimicrobial therapy for CRBSI due to coagulase-negative
staphylococci be safely omitted for patients who are at low risk for
complications (i.e., those who no intravascular foreign body) when clinical
signs and symptoms have resolved promptly after catheter removal?

35. Cont..
 It remains unclear which strategy—CVC change over a guidewire,
insertion of a new CVC at a new site, or watchful waiting—is preferred
among patients with suspected but unconfirmed catheter-related
infection, pending blood culture results.
 How should patients be treated who have positive catheter drawn blood
culture results and negative percutaneous blood culture results?
 What is the optimal duration of antimicrobial use when an infected CVC is
not removed?
 Is the roll-plate method or the sonication method preferred for the
diagnosis of long-term catheter–related infection?
 Should blood cultures be routinely obtained after completing a course of
antibiotics for CRBSI?

37. REFERENCES
 Clinical Practice Guidelines for the Diagnosis and
Management of Intravascular Catheter-Related Infection:
2009 Update by the Infectious Diseases Society of
America
 David.g. Nichols, rogers textbook of pediatric intensive
care
 Indian Journal of critical Medicine December 2003
,Volume -7, suppliment 1 .
 Joshua Wolf and Patricia, Nelson textbook of pediatrics,

38. THANK YOU