Intravascular Catheter–Related Infections

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 central 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 1).

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. Janum S, Afshari A. Central venous catheter (CVC) removal for patients of all ages with candidaemia. Cochrane Database Syst Rev. 2016 Jul 11;7(7):CD011195. doi: 10.1002/14651858.CD011195.pub2. PMID: 27398809; PMCID: PMC6457908. 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). Perform echocardiography to exclude endocarditis. If available, consider infectious disease consultation.

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 bias. Lai NM, Lai NA, O’Riordan E, Chaiyakunapruk N, Taylor JE, Tan K. Skin antisepsis for reducing central venous catheter-related infections. Cochrane Database Syst Rev. 2016. https://doi.org/10.1002/14651858.CD010140.pub2. PMID: 27410189; PMCID: PMC6457952. 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 if possible.Evidence 3Weak recommendation (downsides likely outweigh benefits, but the balance is close or uncertain; an alternative course of action may be better for some patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to heterogeneity and indirectness. Ge X, Cavallazzi R, Li C, Pan SM, Wang YW, Wang FL. Central venous access sites for the prevention of venous thrombosis, stenosis and infection. Cochrane Database Syst Rev. 2012 Mar 14;(3):CD004084. doi: 10.1002/14651858.CD004084.pub3. Review. PubMed PMID: 22419292; PubMed Central PMCID: PMC6516884. Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012 Aug;40(8):2479-85. doi: 10.1097/CCM.0b013e318255d9bc. Review. PubMed PMID: 22809915. Arvaniti K, Lathyris D, Blot S, Apostolidou-Kiouti F, Koulenti D, Haidich AB. Cumulative Evidence of Randomized Controlled and Observational Studies on Catheter-Related Infection Risk of Central Venous Catheter Insertion Site in ICU Patients: A Pairwise and Network Meta-Analysis. Crit Care Med. 2017 Apr;45(4):e437-e448. doi: 10.1097/CCM.0000000000002092. Review. PubMed PMID: 27632678.

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. For adults with short-term, nontunneled central venous catheters, use chlorhexidine-impregnated dressings.Evidence 4Strong recommendation (benefits clearly outweigh downsides; right action for all or almost all patients). High Quality of Evidence (high confidence that we know true effects of the intervention). Centers for Disease Control and Prevention. 2017 Recommendations on use of chlorhexidine-impregnated dressings for prevention of intravascular catheter-related infections: An update to the 2011 guidelines for the prevention of intravascular catheter-related infections from the Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality and Promotion. https://www.cdc.gov/infectioncontrol/pdf/guidelines/c-i-dressings-H.pdf. Updated July 17, 2017. Accessed May 29, 2019. 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. Consider the routine use of antimicrobial lock to prevent catheter-related infections, especially in patients on hemodialysis with tunneled central venous catheters or in patients with a history of multiple catheter-related infections.Evidence 5Weak recommendation (benefits likely outweigh downsides, but the balance is close or uncertain; an alternative course of action may be better for some patients). Low Quality of Evidence (low confidence that we know true effects of the intervention). Quality of Evidence lowered due to the risk of bias. Dang FP, Li HJ, Wang RJ, et al. Comparative efficacy of various antimicrobial lock solutions for preventing catheter-related bloodstream infections: A network meta-analysis of 9099 patients from 52 randomized controlled trials. Int J Infect Dis. 2019;87:154-165. doi: 10.1016/j.ijid.2019.08.017. PMID: 31442627. Arechabala MC, Catoni MI, Claro JC, et al. Antimicrobial lock solutions for preventing catheter-related infections in haemodialysis. Cochrane Database Syst Rev. 2018 Apr 3;4:CD010597. doi: 10.1002/14651858.CD010597.pub2. Review. PubMed PMID: 29611180; PubMed Central PMCID: PMC6513408. Zhao T, Liu H, Han J. Ethanol lock is effective on reducing the incidence of tunneled catheter-related bloodstream infections in hemodialysis patients: a systematic review and meta-analysis. Int Urol Nephrol. 2018 Sep;50(9):1643-1652. doi: 10.1007/s11255-018-1855-4. Epub 2018 Apr 17. Review. PubMed PMID: 29667048.

10. Do not routinely replace central venous catheters or long-term lines. There is no need to routinely replace peripheral catheters to reduce infection risk, but removal may be required for other reasons (eg, blockage, damage, phlebitis).

11. Remove all catheters promptly when no longer needed.

TablesTop