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LEARNING OBJECTIVES

1. Differentiate types of infection associated with vascular access

2. Formulate appropriate empiric therapy based on patient specific risk factors

3. Recite indications for antibiotic lock therapy

4. Prescribe appropriate antibiotic therapy based on culture results

INTRODUCTION

>150,000 devices purchased annually by US hospitals

>100,000 deaths $6.5 billion cost Result in average LOS of 12 days longer

in hospital

PATHOPHYSIOLOGY

How do these infections happen?1. Migration of skin flora from insertion site

2. Direct contamination of catheter

3. Hematogenous seeding

4. Contaminated infusate

RISK FACTORSRisk varies based on:

Type of device Midline catheters 0.2% PIV 0.5% PICC 1.1% Tunneled cvc 1.6% Noncuffed cvc 1.7/2.7% PA catheters 3.7%

Use of device

Insertion site (femoral>IJ>SC)

RISK FACTORS Risk varies based on:

Duration of catheter PIV 3-5 days CVC >6 days PA catheter >3-4 days

Frequency of accesses

Use of prevention strategies

Experience and skill of individual

Patient factors

ASK 3 MAIN QUESTIONS

1. What is the nature of the infection?

2. What type of catheter is infected?

3. What is the organism?

What is a CRBSI? Growth of same

organism from percutaneous blood culture and catheter

What is not a CRBSI?Catheter colonizationPhlebitisExit site infectionTunnel InfectionPocket infection

DEFINITIONSWHAT IS A CATHETER RELATED BLOODSTREAM INFECTION (CRBSI)?

MORE DEFINITIONS

Catheter colonization-growth of organism from tip, hub or sq segment of catheter

Phlebitis-redness, warmth, tenderness along tract of catheterized vein

Exit site infection-redness, tenderness or exudate with growth at exit site

Pocket infection-infected fluid in pocket of totally implanted device

Tunnel infection-pain, redness, >2cm from catheter exit site along sq tract of tunneled catheter

Complicated Infection-metastatic foci of bloodstream infection

ASK 3 MAIN QUESTIONS

1. What is the nature of the infection?

2. What type of catheter is infected?

3. What is the organism?

TYPES OF CATHETERS

P E R I P H E R A L I V M I D L I N E C A T H E T E R

TYPES OF CATHETERS

S H O R T T E R M C V C P A C A T H E T E R

TYPES OF CATHETERS

P I C C

TYPES OF CATHETERS

T O T A L LY I M P L A N T A B L E D E V I C E

L O N G T E R M C V C

ASK 3 MAIN QUESTIONS

1. What is the nature of the infection?

2. What type of catheter is infected?

3. What is the organism?

EMPIRIC TREATMENTCOVERAGE FOR BACTERIA

Empiric treatment with vanc or dapto depending on hospitals mrsa mic data

Do not use linezolid empirically

Empiric GNR coverage should be based on severity of disease and presence of femoral line

Use cefepime, carbapenem, or zosyn if warranted

Only empirically double cover MDR GNR if pt is one of the following

neutropenic severely septic colonized/recently infected with mdr gnr

Add aminoglycoside if warranted

EMPIRIC TREATMENTCOVERAGE FOR CANDIDAOnly empirically cover candida if pt is

septic AND one of the followingTPNprolonged broad spectrum abxhematologic malignancytransplant ptfemoral sitept colonized with candida at multiple sites

Use echinocandin OR fluconazole if pt has had no azole exposure in past 3 months

MICROBE SPECIFIC TREATMENTCOAG NEGATIVE STAPHNafcillin/oxacillin for msse

Vancomycin for mrse

Treat for 5-7 days with antibiotics if catheter removed

Treat 10-14 days with abx lock if catheter is salvaged

Some say ok to not treat if catheter is removed, pt has no hardware, and blood cx negative after catheter removal

MICROBE SPECIFIC TREATMENTSTAPH AUREUSAlways remove catheter

Nafcillin/oxacillin for mssa

Vanco/dapto for mrsa

Default duration of therapy is 4-6 weeks

Treat 14 days if all following apply

pt not immunosuppressed

catheter is removed

no intravascular devices or grafts

tee negative

no evidence of metastatic infx

bacteremia resolves after 72 hours on abx

Treat 5-7 days for tip cx positive/perc blood cx negative situations

MICROBE SPECIFIC TREATMENTENTEROCOCCUS

Ampicillin is drug of choice if susceptible

Vanco if resistant to amp

Double coverage with aminoglycoside is controversial

7-14 course of therapy recommended

Only tee if other signs and symptoms of endocarditis

MICROBE SPECIFIC TREATMENTGRAM NEGATIVE BACILLI

Carbapenem ok for all following ESBL + ecoli/klebsiella enterobacter serratia acinetobacter

ESBL – e. coli/klebsiella-use 3rd gen cephalosporin

Psuedomonas-4th gen cephalosporin, carbapenem, zosyn, +/- aminoglycoside

Stenotrophomonas- bactrim 3-5mg/kg q8hr

De-escalate asap

Duration of therapy 7-14 days

MICROBE SPECIFIC TREATMENTCANDIDA

Always remove catheter (tunneled hd catheter can be exchanged over wire)

C. Glabrata and C. krusei use echinocandins

C. Albicans use fluconazole 400mg qd

ANTIBIOTIC LOCK THERAPYWHAT IS IT AND WHO CAN GET IT?

ANTIBIOTIC LOCK THERAPYWHAT IS IT AND WHO CAN GET IT?

For pts with long term cvc’s and uncomplicated

crbsi

Always use with systemic abx

If abx lock not available, give systemic abx through the lumen of the infected catheter

Not for candida or staph aureus crbsi Not for complicated crbsi, exit site or tunnel infx, or

infx with persistent + blood cx after >72 hours of appropriate abx therapy

PEARLS AND PITFALLS

PEARLS AND PITFALLS

Only culture if infection is suspected

Culture before starting abx

The first day cultures are negative is day one of

abx If unable to obtain percutaneous blood cultures,

drawn cultures from 2 lumens of line

Arterial lines follow the same rules as

temporary cvc’s

PEARLS AND PITFALLS

Do not remove catheters based on fever alone Do not change over guidewire routinely to

prevent infection If you exchange a catheter over a guide wire

and the tip and perc blood cx come back +, you must remove catheter and do fresh stick

When removing the line for suspected crbsi, culture the tip, not the sq segment

For PA catheters culture the introducer tip

PREVENTION

Only place line if necessary, use least risky line in the least risky place that will accomplish your goals

Use full body drape and aseptic technique

Prophylactic systemic abx are not indicated

For pts with hx of crbsi abx lock may be indicated for

prevention

Education, education, education

Checklists

TREATMENT ALGORITHMSUSPECTED CRBSI

TREATMENT ALGORITHMDOCUMENTED CRBSI IN SHORT-TERM CVC

TREATMENT ALGORITHMDOCUMENTED CRBSI IN LONG TERM CVC

TREATMENT ALOGRITHMSUSPECTED TUNNELED HD CATHETER INFX