Catheter-Associated Bloodstream Infections Based on Infectious Disease Society of America guidelines

Clinical Infectious Diseases 2001;32:1249-72.

Rey Vivo, MDDepartment of Internal Medicine

Texas Tech University Health Sciences Center

CA-BSI

Case 1

• 57F was discharged from the hospital after a diagnosis of native valve endocarditis. A home nurse visited to give daily Vancomycin injections through the central venous catheter (CVC) placed into her left subclavian vein. 5 days after discharge, the nurse noticed that the surrounding skin appeared erythematous with scant yellow exudate; temp=99.8F. 2 sets of blood C/S drawn from different peripheral sites were negative. What is the best diagnosis?

• A. Exit-site infection• B. Catheter colonization• C. CA-BSI• D. Normal skin reaction

Catheter-related infections

• Phlebitis/Exit-site infection

• Tunnel/Pocket Infection

• Catheter colonization

• CA-BSI

Pathogenesis

• Extraluminal colonization

- from skin

- hematogenous seeding

of tip

- biofilm• Intraluminal

colonization of hub and lumen

Case 2

• 65M was admitted to the ICU for DKA and got a left femoral CVC for fluids and IV insulin (peripheral access was difficult). He continued to have problems with glycemic control and on the 4th HD developed a temp=102.7F; the rest of his vital signs were stable. What is the next best test to make a diagnosis of CA-BSI?

• A. No need for tests; clinical findings are sensitive and specific• B. Draw 2 sets of blood C/S from 2 different peripheral sites• C. Draw 2 sets of blood C/S, 1 through the CVC and 1

percutaneously• D. Remove the CVC and send the tip for culture

Definition and Diagnosis

• CA-BSI- bacteremia or fungemia in a patient with an IV device with:

(1) clinical signs of infection of no other apparent source; and (2) >1 (+) blood C/S drawn peripherally

- one of the ff should be present:

(1) (+) semi-quantitative [>15 cfu/segment] or quantitative [>102 cfu/segment] where same organism is isolated

from device and peripheral site;

(2) (+) simultaneous quantitative blood C/S with a ratio of >5:1 [CVC vs. peripheral]

(3) (+) differential time to positivity (at least 2 hours)

Answer

IDSA Guidelines, 2001

Case 3

• 49M with no medical history was admitted for extensive burns in his trunk and both arms. A CVC was inserted into his right internal jugular vein for fluids and blood products. On his 8th HD, he developed a fever (temp=103.1F). The rest of his vital signs were stable. CXR and urinalysis were normal. 2 sets of blood C/S drawn from the CVC and percutaneously revealed coagulase-negative Staphylococcus. Obtaining vascular access elsewhere is difficult. What is the next best step?

• A. Remove CVC and treat with antibiotics for 2 weeks• B. Remove CVC and treat with antibiotics for 4 weeks• C. Retain CVC and treat with antibiotics for 2 weeks• D. Retain CVC and treat with antibiotics for 4 weeks

Answer

IDSA Guidelines, 2001

Case 3B

• IV Vancomycin was started. Sensitivities later revealed Methicillin-susceptible coagulase-negative Staphylococcus and the antibiotic was switched to IV Nafcillin. The fever resolved on his third day on Nafcillin and his overall condition improved. The burn team advised discharge to home and the CVC was taken out. What is the best oral antibiotic to prescribe to this patient?

• A. Trimethoprim-sulfamethoxazole• B. Clindamycin• C. Levofloxacin• D. Linezolid

AnswerS. aureus Preferred Alternative

MSSA Nafcilllin or Oxacillin Cefazolin or Cefuroxime

MRSA Vancomycin Linezolid or Quin/Dalf

VRSA Linezolid or Quin/Dalf

Coag-neg Staph

Meth-susceptible Nafcillin or Oxacillin 1st gen ceph or TMP/SMX

Meth-resistant Vancomycin Linezolid or Quin/Dalf

Case 4• 37F diabetic, hospitalized for MRSA osteomyelitis of the right ankle,

was discharged without fever after 1 week. After receiving IV Vancomycin for 5 more weeks, the PICC line in her right arm was removed. 5 days after, she experienced chills, SOB and gradual swelling of her right arm. In the ED, vital signs were: BP 105/70, HR 120, RR 24, temp=103.4F. Her right upper extremity had erythema, warmth and edema extending to the ipsilateral neck. Chest was clear; no murmurs were auscultated. Blood C/S from 2 sites grew gram (+) cocci in clusters; sensitivities were pending. What is the next best step?

• A. Admit and treat with Vancomycin for 2 weeks• B. Admit and treat with Vancomycin for 6 weeks• C. Admit and treat with Vancomycin for 6 weeks;

send for spiral CT of the chest• D. Admit and treat with Vancomycin for 2 weeks;

start thrombolysis

Answer

IDSA Guidelines, 2001

Take Home Points

IDSA Guidelines, 2001

Thank you