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, draw cultures from each port. A CRBSI is likely 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.

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 cultures.

TreatmentTop

1. Antimicrobial treatment: Collect blood cultures, whenever possible and feasible, before starting antimicrobial therapy. De-escalate treatment based on cultures and susceptibility testing as results become available (Table 10.7-1).

For empiric therapy, administer the following:

1) Vancomycin. Alternatively, an antibiotic active against methicillin-susceptible Staphylococcus spp (IV 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) Consider empiric antifungal coverage for patients with sepsis who are immunocompromised, are receiving total parenteral nutrition, have femoral catheters, or have been on a prolonged broad-spectrum antibiotic therapy. 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 for pathogens with low pathogenicity such as coagulase-negative staphylococci (other than Staphylococcus lugdunensis). Always remove the catheter in the case of exit-site infection.

2) When the source of infection is a long-term tunneled or nontunneled 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 the infection is caused by S aureus and Candida spp.Evidence 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. Lee YM, Kim DY, Kim YJ, Park KH, Lee MS. Clinical impacts of delayed central venous catheter removal according to the severity of comorbidities in patients with candidaemia. J Hosp Infect. 2019 Dec;103(4):420-427. doi: 10.1016/j.jhin.2019.08.018. Epub 2019 Sep 4. PMID: 31493475. 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 10 days.

c) S aureus: 14 days; consider 4 to 6 weeks in patients with risk factors for intravascular complications such as those with intravascular devices, implanted cardiac devices, endocarditis, thrombophlebitis, metastatic foci of infection, 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 from the first negative blood culture. Exclude endophthalmitis with an ophthalmologic examination. Consider infectious disease consultation when possible.

2) If the catheter has been salvaged, in the absence of complications: Typically 10 to 14 days (if possible in combination with antibiotic or ethanol lock therapy).

PreventioNTop

1. The use of “prevention bundles” has been shown to be effective, sustainable, and cost effective.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). Low-cost intervention with no relevant safety concerns and recommended in major guidelines. Main body of evidence consists of quasi-experimental studies, and there is significant heterogeneity in the findings across studies. Ista E, van der Hoven B, Kornelisse RF, et al. Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. Lancet Infect Dis. 2016 Jun;16(6):724-734. doi: 10.1016/S1473-3099(15)00409-0. Epub 2016 Feb 18. PMID: 26907734.

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

3. Disinfect the skin with alcoholic chlorhexidine (>0.5%) in preparation for peripheral catheter insertion and during dressing changes. In patients with contraindications to chlorhexidine, use iodine, iodophor, or 70% alcohol.

4. The subclavian vein is the preferred site for central venous catheters. The internal jugular vein is the next best alternative, while the use of the femoral vein is discouraged.Evidence 3Weak 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 (operator dependent) and heterogeneity of outcomes. 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. PMID: 22419292; PMCID: PMC6516884. 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. PMID: 27632678.

5. 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.

6. 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.

7. 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). Consistent benefit across multiple randomized clinical trials with no evidence of harm. Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol. 2022 May;43(5):553-569. doi: 10.1017/ice.2022.87. Epub 2022 Apr 19. PMID: 35437133; PMCID: PMC9096710. Centers for Disease Control and Prevention. 2017 Updated Recommendations on the Use of Chlorhexidine-Impregnated Dressings for Prevention of Intravascular Catheter-Related Infections. Centers for Disease Control and Prevention, National Center for Zoonotic and Emerging  Infectious Diseases, Division of Healthcare Quality Promotion. Updated April 12, 2024. Accessed December 18, 2024. https://www.cdc.gov/infection-control/hcp/c-i-dressings/index.html Replace dressings when wet, damaged, detached, or soiled.

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

9. Use chlorhexidine preparations for daily baths of intensive care unit patients.Evidence 5Weak recommendation (benefits likely outweigh downsides, but the balance is close or uncertain; an alternative course of action may be acceptable. Moderate  Quality of Evidence (moderate  confidence that we know true effects of the intervention). Quality of Evidence lowered due to imprecision and heterogeneity of outcomes (including cost). Milstone AM, Elward A, Song X, et al Pediatric SCRUB Trial Study Group. Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial. Lancet. 2013 Mar 30;381(9872):1099-106. doi: 10.1016/S0140-6736(12)61687-0. Epub 2013 Jan 28. PMID: 23363666; PMCID: PMC4128170. Climo MW, Yokoe DS, Warren DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013 Feb 7;368(6):533-42. doi: 10.1056/NEJMoa1113849. Erratum in: N Engl J Med. 2013 Jun 13;368(24):2341. PMID: 23388005; PMCID: PMC5703051. Noto MJ, Domenico HJ, Byrne DW, et al. Chlorhexidine bathing and health care-associated infections: a randomized clinical trial. JAMA. 2015 Jan 27;313(4):369-78. doi: 10.1001/jama.2014.18400. PMID: 25602496; PMCID: PMC4383133. Afonso E, Blot K, Blot S. Prevention of hospital-acquired bloodstream infections through chlorhexidine gluconate-impregnated washcloth bathing in intensive care units: a systematic review and meta-analysis of randomised crossover trials. Euro Surveill. 2016 Nov 17;21(46):30400. doi: 10.2807/1560-7917.ES.2016.21.46.30400. PMID: 27918269; PMCID: PMC5144946. Of note, some authorities issue a strong recommendation here.

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

11. Consider routine use of antiseptic- or antimicrobial-impregnated central line catheters if infection rates are above the institutional goals or based on individual patient risks.

12. Consider 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.

13. 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).

14. Remove all catheters promptly when no longer needed.

TablesTop