CATHETER RELATED BLOOD STREAM

INFECTIONSDr. Anil Kumar.K.M

2nd year M.D. student Dept. of pediatrics

Goa medical college

AGENDA

• DEVICES AND INDICATIONS• EPIDEMIOLOGY• PATHOGENESIS• DIAGNOSIS• TREATMENT• PREVENTION

AGENDA

• DEVICES AND INDICATIONS• EPIDEMIOLOGY• PATHOGENESIS• DIAGNOSIS• TREATMENT• PREVENTION

IV DEVICES

• PERIPHERAL• ARTERIAL • VENOUS

• CENTRAL VENOUS CATHETERS• TUNNELLED• NON- TUNNELED• PICC• IMPLANTED PORTS

TUNNELED CVCs

• Used for long term therapy

• Needs surgical intervention or intervention radiology

• Does not need dressing

Non-Tunneled CVCs

• Used for short term therapy

• Inserted in • Subclavian• Jugular• Femoral vein

IMPLANTABLE PORT

• Used for long term therapy

• Surgically implanted

• Metal/plastic housing with silicone septum

• Catheter placed in superior vena cava

Peripherally inserted central catheters[PICC]• Used for short/ long

therapies

• Inserted percutaneously via• Basilic vein• Cephalic vein• Brachial vein• Saphenous vein

UMBILICAL CATHETERS

UVC UAC

OTHER DEVICES PERITONEAL CATHETER

URINARY CATHETER

INDICATIONS OF CENTRAL LINE• Poor venous access [ most common]• Prolonged venous access required• CVP monitoring• Volume resuscitation• Total parentral nutrition• Cardio pulmonary resuscitation• Medications like vasoactive substances• Frequent blood sampling• For certain extracorporeal support modality like CRRT.

AGENDA

• DEVICES • EPIDEMIOLOGY• PATHOGENESIS• DIAGNOSIS• TREATMENT• PREVENTION

CRBSI AND CLABSI

• Catheter related blood stream infection[CRBSI]• requires rigorous clinical definition, defined by precise laboratory findings that

identify the CVC as the source of the BSI. • Culturing the CVC segment/ tips is essential• Used for research purpose

• Central line associated blood stream infection [CLABSI] • is a primary (i.e., no apparent infection at another site) BSI in a patient that

had a central line within the 48-hour period before the development of the BSI. • The culture of the catheter tip is not a criterion for CLABSI.• Used for surveillance purpose

EPIDEMIOLOGY

• CLABSI incidence has been between 3.5 – 11.5/1000 catheter days according to various studies.

• In cancer patients the incidence has been as high as 25% according to indian studies

BIRTH WEIGHT UMBILICAL CA BSI /1000 CATH. DAYS

NON UMBILICAL CA BSI/1000 CATH. DAYS

<= 750 4 3.7751 - 1000 2.6 3.31001 - 1500 1.9 2.61501 - 2500 0.9 2.4>2500 1 1

IN NEONATES

ORGANISMS

• MOST COMMON• Coagulase-negative staphylococci[20% - 50%]

• COMMON• Enterobacter spp.• Escherichia coli 20%• Klebsiella spp.• Pseudomonas aeruginosa• Staphylococcus aureus[10%]• Enterococcus spp.• Candida spp.[10%]

AGENDA

• DEVICES• EPIDEMIOLOGY• PATHOGENESIS• DIAGNOSIS• TREATMENT• PREVENTION

SKIN ORGANIS

MS

CONTAMINATED HUBS

CONTAMINATED

INFUSATE

HEMATOGENOUS

BIOFILM FORMATION

• Strains like CONS and some candida species especially in presence of glucose can produce “BIO FILM”

• Protective barrier against host defense and antibiotics

RISK FACTORS FOR CRBSI

• CATHETER RELATED:• SITE OF INSERTION• REPEATED MANIPULATION• DURATION OF CATHEREIZATION• LUMENS, STOPCOCKS OR MONITORING DEVICES• ANTI SEPTIC / ANTIBIOTIC COATED OR NOT• TUNNELED OR NOT; IMPLANTED OR NOT

RISK FACTORS FOR CRBSI

•CATHETER RELATED:• SITE OF INSERTION• REPEATED MANIPULATION• DURATION OF CATHEREIZATION• LUMENS, STOPCOCKS OR MONITORING DEVICES• ANTI SEPTIC / ANTIBIOTIC COATED OR NOT• TUNNELED OR NOT; IMPLANTED OR NOT

RISK FACTORS FOR CRBSI

•CATHETER RELATED:• SITE OF INSERTION

• Groin and jugular are more colonized than upper extremity and chest • REPEATED MANIPULATION• DURATION OF CATHEREIZATION• LUMENS, STOPCOCKS OR MONITORING DEVICES• ANTI SEPTIC / ANTIBIOTIC COATED OR NOT• TUNNELED OR NOT; IMPLANTED OR NOT

RISK FACTORS FOR CRBSI

•CATHETER RELATED:• SITE OF INSERTION• REPEATED MANIPULATION• DURATION OF CATHEREIZATION• LUMENS, STOPCOCKS OR MONITORING DEVICES• ANTI SEPTIC / ANTIBIOTIC COATED OR NOT• TUNNELED OR NOT; IMPLANTED OR NOT

RISK FACTORS FOR CRBSI

•CATHETER RELATED:• SITE OF INSERTION• REPEATED MANIPULATION• DURATION OF CATHEREIZATION• LUMENS, STOPCOCKS OR MONITORING DEVICES• ANTI SEPTIC / ANTIBIOTIC COATED OR NOT• TUNNELED OR NOT; IMPLANTED OR NOT

RISK FACTORS FOR CRBSI

•CATHETER RELATED:• SITE OF INSERTION• REPEATED MANIPULATION• DURATION OF CATHEREIZATION• LUMENS, STOPCOCKS OR MONITORING DEVICES• ANTI SEPTIC / ANTIBIOTIC COATED OR NOT• TUNNELED OR NOT; IMPLANTED OR NOT

RISK FACTORS FOR CRBSI

•CATHETER RELATED:• SITE OF INSERTION• REPEATED MANIPULATION• DURATION OF CATHEREIZATION

• Biofilm formation increases the chances of colonization with time• LUMENS, STOPCOCKS OR MONITORING DEVICES• ANTI SEPTIC / ANTIBIOTIC COATED OR NOT• TUNNELED OR NOT; IMPLANTED OR NOT

RISK FACTORS FOR CRBSI

•CATHETER RELATED:• SITE OF INSERTION• REPEATED MANIPULATION• DURATION OF CATHEREIZATION• LUMENS, STOPCOCKS OR MONITORING DEVICES• ANTI SEPTIC / ANTIBIOTIC COATED OR NOT• TUNNELED OR NOT; IMPLANTED OR NOT

RISK FACTORS contd..

• Type of infusate• Parentral nutrirtion more chance of candida spp. Infection• Lipid formulation ---- CONS

• Host factors• Skin integrity• Skin flora• Immunocompetence

AGENDA

• DEVICES• EPIDEMIOLOGY• PATHOGENESIS• DIAGNOSIS• TREATMENT• PREVENTION

• Exit site infection

• Erythema or induration within 2 cm of the catheter insertion site

• Tunnel infection

• Tenderness, erythema or induration over the subcutaneous tunnel around 2 cm from the exit site

• Pocket infection

• Accompanied by subcutaneous purulent material with overlying erythema, tenderness or skin necrosis

Diagnosis of CRBSI

• Positive simultaneous blood cultures from the central venous catheter and peripheral vein yielding the same organism in the presence of at least one of the following:

Simultaneous quantitative blood cultures in which the number of cfu s isolated from blood drawn through the central catheter is at least fivefold greater than the number isolated from blood drawn peripherally

Positive semi quantitative (≥ 15 cfu/catheter segment) or quantitative (≥ 100 cfu/catheter segment) catheter tip cultures

Simultaneous blood cultures in which the central blood culture has growth in an automated system ≥ 2 hours earlier than the peripheral blood culture

Diagnosis of CRBSI contd..

• Practical difficulty in removing the catheter for diagnosis especially in pediatric patients where vascular acesss is difficult

• Multiple samples in different time frame – may be required due to intermittent bacteriemia

• Ideal blood to broth ratio of 1:5 or 1:10

AGENDA

• DEVICES• EPIDEMIOLOGY• PATHOGENESIS• DIAGNOSIS• MANAGEMENT• PREVENTION

Management of catheter

• In children, removal of a catheter not always feasible because of the potential for complications associated with reinsertion and limited vascular access sites.

• Therefore, treatment of CVC BSI without removal of the catheter is often attempted.

Indications of removal

• Exit site infection, if:• No longer required• Alternate site exists• Patient critically ill (e.g., hypotension)• Infection due to Pseudomonas aeruginosa or fungi

• Pocket infection

• Tunnel infection

• In CRBSI , removal is indicated in :• No longer required• Infection caused by Staphylococcus aureus, Candida species, or

mycobacteria• Patient critically ill• Failure to clear bacteremia in 48–72 hours• Persistent symptoms of bloodstream infection beyond 48–72 hours• Noninfectious valvular heart disease (increased risk of endocarditis)• Endocarditis• Metastatic infection• Septic thrombophlebitis

Antibiotic therapy for CRBSI• Depends on:

• Specific pathogen• Whether catheter is removed or not• Whether associated with thrombosis, endocarditis, osteomyelitis or

metastatic foci• Empirical therapy includes antimicrobial agent

• with activity against gram-positive bacteria[oxacillin, vancomycin] • effective against gram-negative bacteria, including Pseudomonas

species[ceftazidime or cefepime]• with or without an aminoglycoside.

• If MRSA is prevalent, vancomycin is used

Specific pathogens :

• Coagulase negative staph. Aureus• Present with fever or infection of the catheter exit site• Treatment without removal of the catheter is tried with long course of

10 – 14 days of antibiotic especially in neonates• If persistence of symptoms or culture positivity, removal of catheter

is warranted

• Fungal infection• Fungal infection of the catheters is best managed by removal of the

catheter and amphotericin B or fluconazole for at least 14 days• SCREENING for persistent infections also to be done to rule out fungal

ball uropathy, renal infiltration, abcess and endocarditis

• Staph aureus• Severe infections like endocarditis and deep tissue infection occurs• Echocardiography should be considered in prolonged bacteremia• Treatment include prompt removal of the catheter and antibiotics

acc to sensitivity for at least 14 days

• Gram neg bacilli• Catheter removal has been shown to be beneficial• Antibiotics given for 10 – 14 days after the culture becomes sterile

IN NEONATES

AGENDA

• DEVICES• EPIDEMIOLOGY• PATHOGENESIS• DIAGNOSIS• TREATMENT• PREVENTION

PREVENTION OF CATHETER RELATED INFECTIONS

PREVENTION OF CATHETER RELATED INFECTIONS

• THE MOST IMPORTANT STEP TO PREVENT CATHETER RELATED INFECTION IS ????

AVOID UNNECESSARY CATHETERIZATION !!!

and To remove unnecessary catheters as early as possible

Before putting a line

• A check list for inserting CVCs should be available

• A catheter kit should be available

• All health care personnel should go though an educational programme

• Indication for any central line should be clear cut

Inserting a central line

• Subclavian route is associated with least infection in some studies esp in adults• In children no site is preferable over the other, femoral

route is mostly used• Use of ultrasound guidance can help in easy insertion• Maximal sterile precaution • Skin preparation

• Povidone iodine in <2 months• 2% gluteraldehyde in > 2 months

Type of catheter

• Polyurethane catheters are widely used because of less chance of infection compared to polyvinyl and polyethylene catheters

• Catheters impregnated with chlorhexidine silverdiazine or minocycline-rifampicin reduce infection rates.• Effective only upto a max of 30 days • Cost benefit ratio is less

• As the number of lumens increases, higher the chances of infection

Management after insertion

• Accesing a CVCs with sterile precaution

• Clean all ports with 70% alcohol wipes before and after accessing them

• Cap all stopcocks and sterile hubs when not in use

• CVCs should not replace a peripheral canula as most bolus injection can be given via peripheral line

• Transparent dressing is preffered as it allows inspection of the insertion site

Management (contd.)

• Gauze dressing should be changed every 2 days and polyurethane dressing every 7 days

• All visibly soiled dressing should be changed

• Infusion sets that are continuously used should be changed no more frequently than 96 hours and no less frequently than every 7 days

• If blood or lipid products are transfused it should be changed every 24 hours or less

Management (contd.)

• Single dose vials should be discarded ideally after removing the necessary dose ideally as usage of leftover for the next dose is a source of infection

• Use of antibiotic lock solution in the hub like vancomycin has been shown to reduce the catheter hub related infection

Surveillance of CVC

• Catheter sites should be monitored daily by palpation or by visually inspecting the site

• Dressing should be completely removed and examined compleletly if we are suspecting any CLABSI manifested by fever without any focus, etc

• CVCs should be replaced only if it is malfunctioning or suspected to cause CLABSI

ARTERIAL LINES

• Infection rate for arterial line is lower than CVCs

• In pediatric population, radial, posterior tibial and dorsalis pedis are used

• Infective complications are high associated with reusable pressure transducer system associated with arterial lines

• Arterial lines should be removed as soon as possible and should be replaced only if malfunctioning

UMBILICAL LINES

• Unique to neonatal practice• Full barrier precaution should be maintined• Should be treated as any other CVC • Low dose heparin should be added to UACs to avoid thrombotic

complication• While using UAC lower limb should be monitored for vascular

complication• UAC max for 5 days• UVC max for 7 – 10 days

The Central Line Bundle*

…is a group of interventions related to patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.

*Bundle: Grouping of best practices

Central Line Bundle Elements

1. Hand hygiene2. Maximal barrier precautions3. Chlorhexidine skin antisepsis4. Optimal catheter site selection, with subclavian vein as

the preferred site for non-tunneled catheters in adults5. Daily review of line necessity with prompt removal of

unnecessary lines

COMPLICATIONS

SEPTIC THROMBOIS1. Remove the Central line

2. Systemic antibiotics for 4-6 weeks or more

3. Remove the infected vein if patient clinically not improving

4. Systemic anticoagulation [UROKINASE] is also highly recommended.

SEPTIC THROMBOPHLEBITIS

COMPLICATIONS

• Sepsis syndrome

• Endocarditis

• Metastatic infection with seeding to bone, kidney and other organs

RECENT STUDIES

• Recent study by Marik PE et al with regards to infection rate comparing femoral venous catheter and internal jugular or subclavian catheters shows no significant difference in the rates of CRBSI

• A Recent study by Maki ,et al showed reduced incidence of CRBSI with chlorhexidine- silverdiazine impregnated catheter

Recent studies( contd..)

• A recent study by Garland JS showed prophylactic use of vancomycin- heparin lock solution markedly reduced the incidence of CRBSI in high risk neonates

• A recent study by Marcos et al showed a changing trend of epidemiology of CRBSI with an increasing trend of gram negative organisms

TAKE HOME MESSAGES

• CRBSI are an important cause of hospital acquired infection esp in ICU settings

• Gram positive organism and fungi are the prominent pathogens presently

• Skin contaminants and catheter hub constitute major source of infection

• Treatment without removal by antibiotics can be tried in pediatric patients unless removal is absolutely warranted

• Prevention is better than cure by following the central line bundle of hand hygiene, strict asepsis, optimal site selection with proper surveillance and removal of unnecessary catheters

REFERENCES

• Long .s. sarah, principles and practices of pediatric infectious diseases, 3rd edition

• A . Parthasarathy, textbook of pediatric infectious diseases, IAP

• Remington & klein , infectious diseases of fetuses and newborn infant, 7th edition

• Fuhrman & Zimmerman, pediatric critical care, 4th edition

• Joshua Wolf and Patricia, nelson textbook of pediatrics, first south Asian edition

• Cathryn Murfy, Guide to the elimination of catheter related infections, 2009

• David.g. Nichols, rogers textbook of pediatric intensive care

• http://www.ncbi.nlm.nih.gov/pubmed