catheter related blood stream infection

1. Catheter related
blood stream
infection (CRBSI)

2. 2
Central line-associated bloodstream infection: a laboratory-
confirmed bloodstream infection not related to an infection
at another site that develops within 48 hours of a central
line placement.
CLABSI

3. CRBSI
Catheter-related bloodstream infection: a bloodstream infection
attributed to an intravascular catheter by quantitative culture of
the catheter tip or by differences in growth between catheter and
peripheral venipuncture blood culture specimens.
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4. Risk factors:
Host factors that increase the risk of CLABSI are chronic illnesses,
immune compromised states, malnutrition, total parenteral nutrition,
extremes of age, loss of skin integrity (burns), prolonged
hospitalization before line insertion, catheter type, catheter location,
conditions of insertion, catheter site care, and skill of the catheter
inserter
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5. × Fever
× Inflammation or
purulence (at insertion
site)
× Hemodynamically
instability
Clinical
manifestations:
× s/s of sepsis
× Complications related to
bloodstream infection*
× Catheter dysfunction
× AMS
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6. Diagnosis
Cultures of blood & catheter should be
taken in the setting of clinical suspicion
for CRBSI
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7. Culture
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• Paired blood samples drawn from the catheter and a
peripheral vein should be obtained prior to initiation of
antibiotic therapy.
• The same volume of blood should be inoculated for
each culture.

8. Diagnostic Criteria
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Culture of the same organism from both the catheter tip and at least
one percutaneous blood culture.
Culture of the same organism from at least two blood samples
meeting criteria for quantitative blood cultures or differential time to
positivity.

9. × Quantitative blood cultures demonstrating a colony count from the
catheter hub sample ≥3-fold higher than the colony count from the
peripheral vein sample (or a second lumen).
× Semi-quantitative cultures demonstrating >15 colony forming units
(CFU)/mL of the same microbe from the insertion site, hub site, and
peripheral blood culture.
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10. 10
Differential time to positivity
(DTP) refers to growth
detected from the catheter
hub sample at least two
hours before growth
detected from the
peripheral vein sample.

11. Treatment:
Cases where systemic AB is not rcd:
× Positive catheter tip culture in the absence of clinical signs
of infection.
× Positive blood cultures obtained through a catheter with
negative cultures through a peripheral vein.
× Phlebitis in the absence of infection.
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12. 12
Catheter Management: salvage, exchange, removal
Indications to remove Catheter:
 Severe sepsis.
 Hemodynamic instability.
 Endocarditis or evidence of metastatic infection.
 Erythema or exudate due to thrombophlebitis.
 Persistent bacteremia after 72 hours of antimicrobial therapy to which the
organism is susceptible.

13. • Short-term catheters (indwelling <14 days) removed if
S.aureus, enterococci, gram-negative bacilli, fungi, and
mycobacteria.
• Long-term catheters (indwelling ≥14 days) removed if S.
aureus, P.aeruginosa, fungi, or mycobacteria.
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Catheter removal in terms of
pathogen:

14. 14
Catheter Salvage
• Catheter salvage may be attempted in the setting
of uncomplicated CRBSI involving long-term
catheters due to pathogens other than S. aureus,
P. aeruginosa, fungi, or mycobacteria.
• If salvage is attempted, both systemic and
antimicrobial lock therapy may be administered
through the colonized catheter for the duration of
therapy, depending upon the microorganism.
• Two sets of blood cultures
should be obtained after
72 hours of appropriate
antimicrobial therapy (for
neonates, one set is
acceptable); positive
cultures should prompt
catheter removal.

15. 15
• For circumstances in which catheter removal is
necessary for suspected catheter related infection
and the risk for mechanical complications or
bleeding during catheter reinsertion is high,
guidewire exchange of the catheter is acceptable
(except in the setting of sepsis).
Catheter removal
The tip of the removed
catheter should be sent for
culture; if the results are
positive or if there is
evidence of phlebitis,
thrombosis, or purulence,
the newly inserted catheter
should be relocated to a
new site.

16. Abx- empiric
therapy
 The severity of illness.
 The risk factors for infection.
 The likely pathogens associated with the
specific intravascular device.
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17. × CNST is the most common cause of infection  Vancomycin
× Daptomycin*
× Additional agents with activity against CNS and MRSA
include daptomycin, linezolid, tedizolid, telavancin,
dalbavancin, oritavancin, ceftaroline, and quinupristin-
dalfopristin.**
× In certain circumstances w/ certain pts we should cover G-
ve in empiric treatment
× In case of sepsis or NF: empiric antibiotic therapy for gram-
negative bacilli (including Pseudomonas) is appropriate .
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18. Candida is suspected:
Septic patients with the following risk factors:
× Total parenteral nutrition
× Prolonged use of broad-spectrum antibiotics
× Hematologic malignancy
× Bone marrow or solid organ transplant
× Femoral catheterization
× Colonization due to Candida species at multiple sites
Should be given:
× Appropriate agents: echinocandin or azole drugs
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19. Tailored therapy- CNST
 Coagulase-negative staphylococci are the most common
cause & the most common blood culture contaminant.
 This makes it difficult to interpret blood cultures positive
with S. epidermidis.
 Best indicator for true CRBSI is positive blood cultures
drawn from both peripherally and through the suspected
catheter.
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20. × Treatment with antibiotics following catheter removal (5-7 days).
× However, such infections may resolve with removal of the catheter in the
absence of antibiotic therapy
× If no endovascular hardware, no abx therapy is warranted unless fever and/or
bacteremia persist after catheter withdrawal.
× Patients with endovascular hardware should have the catheter removed and
more prolonged therapy is warranted. (4-6wks)
× If infective endocarditis is excluded, three weeks of therapy is appropriate.
× If catheter salvage is necessary, antibiotic therapy is warranted (systemically as
well as via antibiotic lock therapy [ALT] in some cases) for 10 t o 14 days.
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21. Staphylococcus aureus:
× Catheter removal and systemic antibiotic therapy. (A new
catheter may be placed if additional blood cultures
demonstrate no growth at 72 hours).
× Treatment with vancomycin should be initiated. If CRBSI is
2/2 MSSA, switch to nafcillin or oxacillin.
× Transesophageal echocardiogram (TEE) should be pursued
in the setting of S. aureus bacteremia to rule out IE (5-7)
days after the onset of bacteremia.
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22. × Risk factors for hematogenous complications:
 Community-acquired infection (suggesting
longer duration of bacteremia)
 Prosthetic intravascular device.
 Co-morbid immunocompromising conditions.
 Valvular abnormality predisposing to
endocarditis.
 Dialysis dependence.
 suppurative thrombophlebitis.
 Delay in catheter removal.
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23. × No hematogenous complications -> ≥14 days.
× Hematogenous complications -> 4-6 weeks.
× If pt have 1 positive and 1 negative culture then 2
cultures are repeated (catheter and blood). If both
repeat cultures are positive, treatment for CRBSI is
warranted.
× Clinical signs of infection should prompt catheter
removal.
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24. Antibiotic lock therapy
× ALT is to achieve sufficient therapeutic concentrations to kill
microbes growing in a biofilm.
× Its used as adjunct therapy for intraluminal infections 2/2
CNST or gram-negative organisms when the catheter cannot be
removed.
× ALT should not be used for extraluminal infections nor for
management of infections due to S. aureus, P. aeruginosa, drug-
resistant gram-negative bacilli, or Candida.
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