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Dr mohammed abdelgawad crbsi
This document discusses the diagnosis and management of catheter-related bloodstream infections (CRBSI) in hemodialysis patients. It outlines the following key points: 1. CRBSI can be diagnosed through paired blood cultures, with the same organism growing in both indicating infection. Catheter tip cultures can also help diagnose CRBSI. 2. Management involves starting empirical antibiotics and antibiotic lock therapy, then assessing response and either continuing treatment, exchanging the catheter, or removing it depending on improvement. 3. Prevention strategies include using aseptic technique during catheter insertion and care, avoiding non-tunneled and femoral catheters when possible, monitoring exit sites, and considering antimicrobial lock therapy or
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Dr mohammed abdelgawad crbsi
- 1. Catheter Related Blood StreamInfection (CRBSI) Diagnosis & Management Step-Wise Practical Approach in HD Patients Mohammed Abdel Gawad Nephrology Specialist Kidney & Urology Center (KUC) Alexandria – EGY drgawad@gmail.com 1st Annual Interventional Nephrology Meeting – ESNT Mansoura, 26-27/Oct/2017
- 2. Talk Outline • Diagnosis •Management • Prevention
- 3. Talk Outline • Diagnosis •Management • Prevention
- 4. Paired Blood Cultures Peripheral vein Fromthe catheter Culture of the catheter tip (distal 5 cm) or
- 5. Paired Blood Cultures or Whena peripheral blood sample cannot be obtained From the catheter From Dialysis circuit 2 quantitative blood cultures of samples obtained through 2 catheter lumens
- 6. Culture Results Results Diagnosis Sameorganism from both samples CRBSI Confirmed Both negative CRBSI Unlikely Negative peripheral blood culture BUT Positive central blood culture Probably contamination (don’t treat EXCEPT if Staph. Aureus)
- 7. Talk Outline • Diagnosis •Management • Prevention
- 8. Talk Outline • Diagnosis •Management • Prevention
- 11. Start Empirical Antibiotics +Antibiotic Lock Therapy Reassess after 2-3 days: Clinically (fever) & Lab (WBC, CRP) Improving? Yes Continue antibotics, then: Pathway 3: Surveillance No Pathway 4: Catheter removal Pathway 1: Catheter Salvage
- 12. Empirical Antibiotics Antibiotic Tocover Condition Vancomycin MRSA for institutions in with preponderance of MRSA Gentamycin (if absolutely contraindicated use Quinolones) Gram –ve --------------------- Meropenem, Imipenem or Etrapenem or Piperacillin/Tazobactam in community with low incidence of antibiotic resistance MDR Gram –ve In neutropenic patients, severely ill patients with sepsis, or patients known to be colonized with such pathogens Fluconazole or Echinocandin Candidemia total parenteral nutrition, prolonged use of broad-spectrum antibiotics, hematologic malignancy, receipt of bone marrow or solid- organ transplant, femoral catheterization, or colonization due to Candida species at multiple sites
- 13. Alternatives to vancomycinas a first choice broad spectrum Condition Alternative the preponderance of MRSA isolates have vancomycin minimum inhibitory concentration (MIC) values 12 mg/mL Daptomycin
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- 16. Dialyziability & ResidualRenal Function Effect • Vancomycin is not removed by HD; gentamicin is. • Measure gent levels daily (levels will decrease sooner in patients with significant residual function). • Monitor predialysis trough levels if possible 2017
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- 22. Start Empirical Antibiotics +Antibiotic Lock Therapy Reassess after 2-3 days: Clinically (fever) & Lab (WBC, CRP) Improving? Yes Continue antibiotics, then: Pathway 3: Surveillance No Pathway 4: Catheter removal Pathway 1: Catheter Salvage
- 25. Start Empirical Antibiotics +Antibiotic Lock Therapy Reassess after 2-3 days: Clinically (fever) & Lab (WBC, CRP) Improving? Yes Continue antibiotics, then: Pathway 3: Surveillance No Pathway 4: Catheter removal Pathway 1: Catheter Salvage Duration of Systemic and Antibiotic Lock
- 26. Duration of Systemicand Antibiotic Lock Pathway 1: Catheter Salvage If catheter is retained for a patient with S. aureus CRBSI Continue systemic and antibiotic lock therapy for 4 weeks
- 27. Duration of Systemicand Antibiotic Lock Pathway 1: Catheter Salvage If catheter is retained for a patient with any other organism No clear data for systemic and antibiotic lock therapy salvage duration
- 28. Antibiotic Lock SpecialSituation Multiple positive catheter blood culture BUT concurrent negative peripheral blood cultures Antibiotic lock therapy without systemic therapy for 10–14 days
- 30. guide wire Start EmpiricalAntibiotics as in salvage pathway Reassess after 2-3 days: Clinically (fever) & Lab (WBC, CRP) Improving? Yes Exchange on guide wire Continue antibiotics Pathway 3: Surveillance No Pathway 4: Catheter removal Pathway 2: Exchange on guide wire Duration of Systemic and Antibiotic Lock
- 31. Duration of Systemicand Antibiotic Lock If catheter is exchanged for a patient with any organism No clear data for systemic and antibiotic lock therapy salvage duration Pathway 2: Exchange on guide wire
- 33. Pathway 3: Surveillance bloodstream infectionthat continues despite >72 h of antimicrobial therapy to which the infecting microbes are susceptible 2 sets of blood cultures obtained on a given day
- 34. Pathway 3: Surveillance Ifthe catheter has been retained Surveillance blood cultures 1 week after completion of an antibiotic course If blood cultures +ve → the catheter should be removed New, long term dialysis catheter after additional –ve blood cultures
- 36. Pathway 4: Catheter removal Removecatheter and culture tip (5 cm) Start empirical antibiotics as in salvage pathway Is access is needed urgently for dialysis? Yes Insert temporary catheter in another site for short period of time No Continue antibiotics Insert long term catheter ONLY if: 1- afebrile for 48-72 hours 2- CRP is normal 3- Blood cultures are -ve Duration?
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- 38. Persistent fungemia or bacteremia>72 h after catheter removal 4 to 6 weeks of antibiotic therapy should be administered Additional TEE should be obtained Catheter Removal Special Situation (1)
- 39. Catheter Removal SpecialSituation (2) Catheter tip grows S. aureus but Initial peripheral blood cultures -ve 5–7-day course of antibiotics Close monitoring for signs and symptoms of ongoing infection, including additional blood cultures, as indicated
- 40. Talk Outline • Diagnosis •Management • Prevention
- 41. Talk Outline • Diagnosis •Management • Prevention
- 42. Prevention - Catheter •Strict aseptic circumstances. • Avoid as much as possible: – using non-tunneled catheters. – using femoral • Monitor the catheter: – visually when changing the dressing – or by palpation through an intact dressing on a regular basis.
- 43. Prevention – ExitSite • Application of antibiotic ointment at the exit site until the insertion site has healed • The catheter exit site should be covered by a dressing as long as the catheter remains in place.
- 44. Prevention – AntimicrobialLock • Its use is debated. • Its use may be saved to patients with: – history of multiple CRBSI – those with high risk of severe sequelae (patients with pacemakers, prosthetic valve or IV devices). • Citrate locks have, for the time being, most extensively been studied. (The 4% solution seems to offer at present the best benefit/risk ratio).
- 45. Prevention – Staphylococcus •Eradication of Staphylococcus carriage (nasal mupirocin cream). • Consider IV antibiotics at insertion for patients with Staphylococcal skin colonisation.
- 46. Always re-evaluate foralternative access (AVF or AVG).
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