Dr mohammed abdelgawad crbsi

transcript

Catheter Related Blood Stream Infection (CRBSI)

Diagnosis & Management Step-Wise Practical Approach in HD Patients

Mohammed Abdel GawadNephrology Specialist

Kidney & Urology Center (KUC)

Alexandria – EGY

drgawad@gmail.com

1st Annual Interventional Nephrology Meeting – ESNTMansoura, 26-27/Oct/2017

Talk Outline

• Diagnosis

• Management

• Prevention

Talk Outline

• Diagnosis

• Management

• Prevention

Paired Blood Cultures

Peripheral vein

From the catheter

Culture of the catheter tip (distal 5 cm)

Paired Blood Cultures

When a peripheral blood sample cannot be obtained

From the catheter

From Dialysis circuit

2 quantitative blood cultures of samples obtained through

2 catheter lumens

Culture Results

Results Diagnosis

Same organism from both samples CRBSI Confirmed

Both negative CRBSI Unlikely

Negative peripheral blood cultureBUT

Positive central blood culture

Probably contamination (don’t treat EXCEPT if

Staph. Aureus)

Talk Outline

• Diagnosis

• Management

• Prevention

Talk Outline

• Diagnosis

• Management

• Prevention

Pathway 1: Catheter Salvage

Start Empirical Antibiotics + Antibiotic Lock Therapy

Reassess after 2-3 days: Clinically (fever) & Lab (WBC, CRP)

Improving?

Continue antibotics, then:

Pathway 3: Surveillance

Pathway 4: Catheter removal

Empirical Antibiotics Antibiotic To cover Condition

Vancomycin MRSA for institutions in with preponderance of MRSA

Gentamycin(if absolutely

contraindicated use Quinolones)

Gram –ve---------------------

Meropenem, Imipenemor Etrapenem

or Piperacillin/Tazobactamin community with low incidence of antibiotic

resistance

MDR Gram –ve In neutropenic patients, severely ill patients with sepsis, or patients

known to be colonized with such pathogens

Fluconazole or Echinocandin

Candidemia total parenteral nutrition, prolonged use ofbroad-spectrum antibiotics, hematologic

malignancy, receipt of bone marrow or solid-organ transplant, femoral catheterization,or colonization due to Candida species at

multiple sites

Alternatives to vancomycin as a first choice broad spectrum

Condition Alternative

the preponderance of MRSA isolates have vancomycin

minimum inhibitory concentration (MIC) values 12

Daptomycin

Antibiotic Doses: VANCOMYCIN

Antibiotic Doses: GENTAMICIN

Dialyziability & Residual Renal Function Effect

• Vancomycin is not removed by HD; gentamicin is.

• Measure gent levels daily (levels will decrease sooner in patients with significant residual function).

• Monitor predialysis trough levels if possible

Antibiotic Doses: MEROPENEM

Antibiotic Doses: IMIPENEM

Antibiotic Doses: ERTAPENEM

Antibiotic Doses: PIPERACILLIN/TAZOBACTAM

Antifungal Doses: FLUCONAZOL

Improving?

Continue antibiotics, then:

Improving?

Continue antibiotics, then:

Duration of Systemic and

Antibiotic Lock

Duration of Systemic and Antibiotic Lock

If catheter is retained for a patient with S. aureus CRBSI

Continue systemic and antibiotic

lock therapy for 4 weeks

If catheter is retained for a patient with any other organism

No clear data for systemic and antibiotic lock therapy salvage

duration

Antibiotic Lock Special Situation

Multiple positive catheter blood culture BUT concurrent negative peripheral

blood cultures

Antibiotic lock therapy without systemic therapy for 10–14 days

guide wire

Start Empirical Antibiotics as in salvage pathway

Improving?

Exchange on guide wire

Continue antibiotics

Pathway 2: Exchange on guide wire

Duration of Systemic and

Antibiotic Lock

If catheter is exchanged for a patient with any organism

No clear data for systemic and antibiotic lock therapy salvage

duration

Pathway 2: Exchange on guide wire

bloodstream infection that continuesdespite >72 h of antimicrobial therapy

to which the infecting microbes are susceptible

2 sets of blood cultures obtained on a given day

Pathway 3: Surveillance If the catheter has been retained

Surveillance blood cultures 1 week after completion of an antibiotic course

If blood cultures +ve → the catheter should be removed

New, long term dialysis catheter after additional –ve blood cultures

Remove catheter and culture tip (5 cm)

Start empirical antibiotics as in salvage pathway

Is access is needed urgently for dialysis?

Insert temporary catheter in

another site for short

period of time

Continue antibiotics

Insert long term catheter ONLY if:

1- afebrile for 48-72 hours

2- CRP is normal

3- Blood cultures are -ve

Duration?

Persistent fungemia or bacteremia >72 h after catheter

removal

4 to 6 weeks of antibiotic therapy

should be administered

Additional TEE should be obtained

Catheter Removal Special Situation (1)

Catheter Removal Special Situation (2)

Catheter tip grows S. aureus

Initial peripheral blood cultures -ve

5–7-day course of antibiotics

Close monitoring for signs and symptoms of ongoing infection, including additional blood cultures, as indicated

Talk Outline

• Diagnosis

• Management

• Prevention

Talk Outline

• Diagnosis

• Management

• Prevention

Prevention - Catheter

• Strict aseptic circumstances.

• Avoid as much as possible:

– using non-tunneled catheters.

– using femoral

• Monitor the catheter:

– visually when changing the dressing

– or by palpation through an intact dressing on aregular basis.

Prevention – Exit Site

• Application of antibiotic ointment at the exitsite until the insertion site has healed

• The catheter exit site should be covered by adressing as long as the catheter remains inplace.

Prevention – Antimicrobial Lock

• Its use is debated.

• Its use may be saved to patients with:– history of multiple CRBSI – those with high risk of severe sequelae (patients

with pacemakers, prosthetic valve or IV devices).

• Citrate locks have, for the time being, most extensively been studied. (The 4% solution seems to offer at present the best benefit/risk ratio).

Prevention – Staphylococcus

• Eradication of Staphylococcus carriage (nasal mupirocin cream).

• Consider IV antibiotics at insertion for patients with Staphylococcal skin colonisation.

Always re-evaluate for alternative access

(AVF or AVG).

References

Thank You

Dr mohammed abdelgawad crbsi

Health & Medicine