Intravascular Catheter-Related Infections

Chapter: Intravascular Catheter-Related Infections
McMaster Section Editor(s): Mark Loeb
Section Editor(s) in Interna Szczeklika: Piotr Zaborowski, Jerzy Stefaniak, Miłosz Parczewski, Weronika Rymer, Agnieszka Wroczyńska
McMaster Author(s): Diana Whellams, Dominik Mertz
Author(s) in Interna Szczeklika: Tomasz Ozorowski, Waleria Hryniewicz
Additional Information

Definition, Etiology, PathogenesisTop

Intravascular catheter-related infections may present as: (1) catheter-related bloodstream infections; or (2) infections localized to the catheter exit site (or subcutaneous tissue along tunneled central venous catheters [central lines]). Localized exit-site infections may eventually result in bloodstream infections.

Etiologic agent: Skin flora that migrates along the catheter or enter the bloodstream through the port during drug infusion or injection. Most frequently, the etiologic pathogens are coagulase-negative staphylococci, Staphylococcus aureus, Enterococcus spp, Candida spp, and gram-negative bacilli.

Clinical Features and Natural HistoryTop

1. Catheter-related bloodstream infection (CRBSI): Manifestations may range from fever alone to features of sepsis. CRBSI should be suspected in every patient with a vascular catheter and unexplained fever. A simultaneous exit-site infection is found in <30% of patients.

2. Exit-site infection: Erythema, pain, edema, warmth of the skin, sometimes with purulent drainage.

DiagnosisTop

Cultures:

1) CRBSI: Simultaneously obtain ≥2 blood samples for culture: draw one from a peripheral venipuncture site and the other via the catheter. If the catheter has multiple ports, consider drawing cultures from each port. A CRBSI is diagnosed if the same microorganism is cultured from both the peripheral blood and the catheter with a time-to-positivity ≥2 hours earlier in the sample drawn via the catheter.

In cases where blood cultures are inconclusive, catheter-associated infection is still suspected, and catheter removal is an option, consider catheter-tip culture. After removal, cut off the tip of the catheter and send it to the microbiology laboratory for semiquantitative or quantitative culture. Isolation of the same pathogen from blood and the catheter tip confirms a catheter-related infection.

2) Exit-site infection: If purulent drainage is present at the catheter exit site, consider sending a swab of the drainage for additional cultures. Interpret the results in the context of blood and catheter-tip cultures.

TreatmentTop

1. Antimicrobial treatment: Collect blood cultures, as possible and feasible, before starting antimicrobial therapy. De-escalate treatment based on cultures and susceptibility testing as results become available (Table. Organism-based treatment of catheter-related bloodstream…).

For empiric therapy, administer the following:

1) Vancomycin. Alternatively, an antibiotic active against methicillin-susceptible Staphylococcus spp (intravenous cloxacillin or cefazolin) could be considered if the facility has a low prevalence of methicillin-resistant S aureus (MRSA), if the patient is not MRSA-colonized, if the patient has no recent history of intensive care unit stay or long-term hospitalization, and if the patient is not severely sick from the infection.

2) Add empiric gram-negative (including antipseudomonal) coverage in severe infections, in immunocompromised patients (particularly those with neutropenia), and in patients with femoral catheters. If a patient is known to be colonized with a multidrug resistant gram-negative species, consider including empiric coverage for that pathogen.

3) Add empiric antifungal coverage for patients with sepsis who are immunocompromised, who are receiving total parenteral nutrition, who have femoral catheters, or who have been on prolonged broad-spectrum antibiotics. Use an echinocandin (such as caspofungin or anidulafungin); alternatively, consider fluconazole if the patient has had no exposure to azoles in the previous 3 months and in settings where the risk of Candida krusei or Candida glabrata infection is very low.

2. Catheter removal is ideally performed in all cases of CRBSI, but especially in the following situations:

1) When the source of infection is a short-term central venous catheter or arterial catheter. In exceptional cases, salvaging the catheter may be considered if the pathogen is coagulase-negative staphylococci (other than Staphylococcus lugdunensis). In the case of exit-site infection, remove the catheter.

2) When the source of infection is a long-term line, tunneled line, or a totally implantable device and the infection is complicated by an abscess, septic thrombophlebitis, or metastatic infection (eg, endocarditis, septic arthritis, septic emboli); persistent bacteremia is present after 72 hours of appropriate antibiotic treatment; or when the patient’s condition is critical. Additionally, routine catheter removal is recommended in cases where infection is caused by S aureus, Pseudomonas aeruginosa, and CandidaEvidence 1Strong recommendation (benefits clearly outweigh downsides; right action for all or almost all patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to the observational study design but increased due to the large potential effect size. Nguyen MH, Peacock JE Jr, Tanner DC, et al. Therapeutic approaches in patients with candidemia. Evaluation in a multicenter, prospective, observational study. Arch Intern Med. 1995 Dec 11-25;155(22):2429-35. PubMed PMID: 7503601. or other fungi. In cases of attempted catheter salvage, consider antibiotic lock therapy in conjunction with systemic antibiotics.

3. Duration of treatment:

1) If the catheter has been removed:

a) Coagulase-negative staphylococci (other than S lugdunensis): 5 to 7 days.

b) Enterococci or gram-negative bacilli: 7 to 14 days.

c) S aureus: 14 days (consider 4-6 weeks in patients with diabetes mellitus, immunodeficiency, intravascular devices, endocarditis, thrombophlebitis, or if fever and bacteremia fail to resolve within 72 hours of appropriate antibiotic treatment). If available, consider infectious disease consultation in cases of S aureus bloodstream infection.

d) Candida: ≥14 days. Exclude endophthalmitis with an ophthalmologic examination. Consider infectious disease consultation when possible.

2) If the catheter has been salvaged, in the absence of complications: Coagulase-negative staphylococci for 10 to 14 days (in combination with antibiotic lock therapy).

PreventionTop

1. Maintain good hand hygiene prior to establishing new vascular access and while changing dressings.

2. Disinfect the skin with alcoholic chlorhexidine (>0.5%) in preparation for peripheral catheter insertion and during dressing changes.Evidence 2Strong recommendation (benefits clearly outweigh downsides; right action for all or almost all patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to indirectness (peripheral vs central catheters and outcome being contamination). Mimoz O, Karim A, Mercat A, et al. Chlorhexidine compared with povidone-iodine as skin preparation before blood culture. A randomized, controlled trial. Ann Intern Med. 1999 Dec 7;131(11):834-7. PubMed PMID: 10610628. Mimoz O, Lucet JC, Kerforne T, et al; CLEAN trial investigators. Skin antisepsis with chlorhexidine-alcohol versus povidone iodine-alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two factorial trial. Lancet. 2015 Nov 21;386(10008):2069-2077. doi: 10.1016/S0140-6736(15)00244-5. Epub 2015 Sep 18. PubMed PMID: 26388532. In patients with contraindications to chlorhexidine, use iodine, iodophor, or 70% alcohol.

3. During insertion or exchange of central venous catheters, maintain aseptic technique and use maximal sterile barrier precautions, including a cap, mask, sterile gown, sterile gloves, and sterile full-body drape. If possible, use ultrasound guidance for central line insertion.

4. Avoid using the femoral vein for central venous catheters when possible.

5. While inserting a peripheral catheter, clean disposable gloves can be used instead of sterile gloves as long as the insertion site is not touched after skin disinfection.

6. Protect all catheter insertion sites with a sterile dressing. Replace dressings when wet, damaged, detached, or soiled.

7. For central venous catheters, routinely replace gauze dressings every 48 hours and transparent/semipermeable dressings every 7 days.

8. Before accessing catheter ports for injection or infusion, disinfect them with 70% alcohol.

9. Do not routinely replace central venous catheters or long-term lines. Avoid routinely replacing peripheral catheters more than every 3 to 4 days.

10. Remove all catheters promptly when no longer needed.

TablesTop

Table. Organism-based treatment of catheter-related bloodstream infectionsa

Pathogen

Antibiotic and routine dosage

Alternative antibiotics

Staphylococcus aureus and methicillin-susceptible coagulase-negative staphylococci

Cloxacillin 2 g IV every 4 h

Cefazolin 2 g IV every 8 h

Vancomycin

MRSA and methicillin-resistant coagulase-negative staphylococci

Vancomycin 15-20 mg/kg every 12 hb

Daptomycin (use for MRSA if vancomycin MIC ≥2 microg/mL)

Ampicillin-sensitive Enterococcus spp

Ampicillin 2 g IV every 6 h

Vancomycin

Ampicillin-resistant Enterococcus spp

Vancomycin (as above)

 

Daptomycin

VRE

Linezolid 600 mg IV every 12 h

Daptomycin

Pseudomonas aeruginosa

Ceftazidime 2 g IV every 8 h or piperacillin/tazobactam 4.5 g IV every 6-8 h, or

Ciprofloxacin 400 mg IV every 8 h

Aminoglycosides

Imipenem

Meropenem

Cefepime

“SPICE” organisms (Serratia spp, Providencia spp, Proteus vulgaris, Citrobacter spp [non-koseri], Enterobacter spp), ESBL-producing organisms

Ertapenem 1 g IV daily

Meropenem

Imipenem

 

Other gram-negative organisms (eg, Escherichia coli, Klebsiella spp)

Based on susceptibilities, eg, ceftriaxone 2 g IV every 24 hours

 

Candida spp

Anidulafungin 200 mg IV on day 1 then 100 mg IV daily

Caspofungin 70 mg IV on day 1 then 50 mg IV daily

 

Fluconazolec

Amphotericin

a Recommendations should be further guided by susceptibility testing as available. Doses indicated assume normal renal function and body mass.

b Serum trough levels suggested with first trough prethird or prefourth dose: levels should be 15-20 microg/mL for S aureus infection and 10-20 microg/mL for other pathogens.

c Fluconazole is suboptimal therapy in Candida krusei and Candida glabrata; use an echinocandin instead. For Candida parapsilosis, use fluconazole instead of an echinocandin.

ESBL, extended-spectrum beta-lactamase; IV, intravenous; MIC, minimum inhibitory concentration; MRSA, methicillin-resistant Staphylococcus aureus; VRE, vancomycin-resistant enterococci.

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