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Infections Caused by Percutaneous Intravascular Devices Jane J. Suaco, M.D. 1.11.20
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CLABSI Most costly health-care associated infection Occur as sporadic cases and as case clusters caused by the same organism Complications of intravascular therapy: Local cellulitis Septic thrombophlebitis Device-associated bacteremia Abscess formation Endocarditis
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PATHOGENESIS Microorganisms gain access to extra- or intraluminal surface of the device Adherence and incorporation into biofilms Infection Hematogeneous dissemination
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POINTS OF ACCESS Most important portal of entry! INFUSATE
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CONTAMINATION OF THE INFUSATE Rare cause of bacteremia Enterobacter, Citrobacter, and Serratia predominate Extrinsic cause: In-use contamination of infusate Intrinsic cause: Manufacture-related Suboptimal quality control standards Composition of the fluid: No infusate is entirely free of risk! Not isotonic At nonphysiologic pH Contains particulates
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CONTAMINATION OF THE CATHETER HUB AND LUMEN Intraluminal source Most frequent cause of bacteremias associated with long-term catheters Biofilm-producing microbes = CONS The hub and the hub-tubing junction are common portals of entry for bacteria Needleless connector access must be disinfected with minimum of 5 seconds of scrubbing
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CONTAMINATION OF SKIN AT THE DEVICE INSERTION SITE Extraluminal source Major portal of entry Cutaneous microflora Most frequently associated with bacteremias occurring with short-term noncuffed central catheters Average duration of < 8 days
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EPIDEMIOLOGY Intravenous device–related bacteremia rates are influenced by: Patient-related parameters Catheter-related parameters Hospital-related parameters
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PATIENT-RELATED PARAMETERS Alteration of the patient’s skin microbiota Result of antimicrobial therapy Loss of skin integrity (burns, psoriasis) Hand hygiene by hospital personnel Intrinsic host defense mechanisms Granulocytopenia, hematologic malignancy, chemotherapy, underlying illness, active infection at other site Contaminated ointment or cream
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↑thrombogenicity = ↑infection CATHETER-RELATED PARAMETERS Catheter composition/construction: Flexibility/stiffness Thrombogenicity Microbial adherence and biofilm production Size of catheter Number of catheter lumens Catheter function/use ↑stiffness = ↑thrombogenicity Fibrin sheath = thrombogenic Polyvinyl chloride Staphylococci Candida spp. Silicon: S. aureus EDTA with Sodium citrate Ethanol locks ↑size = ↑infection ↑lumen = ↑infection PA catheter = ↑infection
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CATHETER-RELATED PARAMETERS Catheter management Skill of venipuncturist Number of entries into the system Type of catheter: plastic > steel Location of catheter: Central > peripheral Jugular > femoral > subclavian Lower extremity sites > upper extremity sites
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CATHETER-RELATED PARAMETERS Duration of placement Biofilm formation within 72 hours after insertion Predominant extraluminally if < 10 days Predominant intraluminally if ≥ 30 days Type of placement Cutdown > percutaneous Emergent > elective Type/use of catheter Balloon-tipped, flow-directed > percutaneous Central venous > implanted central venous
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HOSPITAL-RELATED PARAMETERS Nursing staffing variables Nurse-to-patient ratio Level of training Permanent assignment to unit Lower regular registered nurse-to-patient ratio Higher float pool registered nurse-to-patient ratio
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MICROBIOLOGY CONS Staphylococcus aureus Enterococcus spp. Serratia marcescens Candida albicans Candida tropicalis Pseudomonas aeruginosa Klebsiella spp. Enterobacter spp. Citrobacter freundii Corynebacterium (esp C. jeikeium) Acinetobacter (esp A. baumannii) Burkholderia cepacia complex Most common Frequent with contaminated infusate Most often with TPN; usually along the catheter path, occ as a result of contaminated infusate From infusate or cutaneous colonization Frequent with contaminated infusate From infusate or cutaneous colonization Severely immunosuppressed patient With life support, multiple antibiotics
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DIAGNOSIS Factors Differentiating Device-Associated Bacteremia From Other Septic Syndromes Local phlebitis, inflammation, or both at catheter insertion site Lack of other source for bacteremia Sepsis occurring in a patient not otherwise at high risk for bacteremia Localized embolic disease distal to cannulated artery Hematogenous Candida endophthalmitis in patients receiving TPN Presence of ≥ 15 colonies of bacteria on semiquantitative culture of the catheter tip Sepsis apparently refractory to “appropriate” antimicrobial therapy Resolution of febrile syndrome after device removal Typical (Staphylococcus aureus, Staphylococcus epidermidis, or other CONS) or unusual (Burkholderia cepacia complex, Pantoea [Enterobacter] agglomerans, Enterobacter cloacae) microbiology Clustered infections caused by infusion-related organisms
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DIAGNOSIS 2009 IDSA Guideline on intravascular catheter-related infection The same organism growing from a percutaneous blood culture and a catheter tip culture A catheter draw-back culture and a peripheral culture that have the same organism, with the catheter blood culture becoming positive 2 hours earlier or having a quantitative blood culture that is threefold higher; or Blood cultures drawn through different catheter lumens that differ threefold in quantitative cultures.
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DIAGNOSIS Catheter tip CS? Variable and limited value Should not be performed for subcutaneous venous ports; culture of material inside the port reservoir is more sensitive Cutoff point of ≥15 colonies per catheter on semiquantitative culture Increased sensitivity if plated at the bedside False negative results for newer catheters with antimicrobial coating
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DIAGNOSIS Most accurate diagnostic methods Short-term central catheters: quantitative or semiquantitative culture of the catheter, combined with two blood cultures (one peripheral and one through the catheter) Long-term devices (tunneled and totally implanted): Paired quantitative blood culture Vascular catheters should not be cultured if no signs of infection are present
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DIAGNOSIS Differential time to positivity Speed with which bacterial isolates can be detected may distinguish catheter-associated from non–catheter-associated infection Blood cultures drawn through an infected CVC > blood cultures drawn peripherally 2 hours earlier Comparable sensitivity
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DIAGNOSIS Alternative techniques Acridine orange leukocyte cytospin testing Rapid diagnosis Endoluminal brush method
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PERIPHERAL INTRAVENOUS CANNULIZATION Lower infection risks than central catheters Should be replaced every 72 to 96 hours Adults: To prevent phlebitis and increased risk of colonization and bloodstream infection Children: Not recommended to be routinely replaced ↑ risk: lower extremities, cutdown, emergent placement
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CENTRAL VENOUS CATHETERS SHORT TERM ISSUES ↑risk of complications and infection Placement in the great veins Heavy colonization of the insertion site Contamination of a catheter hub >7 days catheter duration Insertion technique: Pneumothorax Routine replacement is not necessary
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CENTRAL VENOUS CATHETERS SHORT TERM ISSUES Use of guidewire: Controversial ↓ mechanical complications but ↑ BSI May be preferred if catheter change is due to some reasons other than suspected infection If used for catheter exchange, must culture blood prior to removal and send old/removed catheter tip for culture If positive: remove replacement catheter
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CENTRAL VENOUS CATHETERS PARENTERAL NUTRITION ISSUES Infusate supports growth of microorganism ↑ parenteral caloric intake = Independent risk factor for bacteremia Catheters are required to remain in place much longer Hypertonicity of solution irritates vascular intima  thrombosis  infection ↑ risk for bacteremia: people who require TPN are oftentimes critically ill
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CENTRAL VENOUS CATHETERS PARENTERAL NUTRITION ISSUES Mechanisms for decreasing infections: Bonding heparin or a heparin-like substance to the catheter or infusing heparin with the infusate Constructing the catheter of a more flexible substance Tunneling the catheter under the skin
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CENTRAL VENOUS CATHETERS LONG TERM ISSUES Fewer infections and other complications with totally implantable access ports “Pocket infections”: Spread of infection into the subcutaneous pocket of a totally implanted intravascular device, Absolute indication for device removal Poor response to antimicrobial therapy by bacteria inside the biofilms on the port inner surface
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PERIPHERALLY INSERTED CENTRAL VENOUS CATHETERS May be inserted at bedside for chemo, antimicrobials and parenteral nutrition Prone to mechanical malfunction and have a shorter survival time than CVCs Higher thrombophlebitis rates Studies suggested catheter replacement within 7 days as a strategy to prevent CLABSIs
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CARE AND MAINTENANCE OF IMPLANTED CVC Issues Should a dressing be placed over the exit site, and if so, what dressing materials should be used and how frequently should the dressing be changed? Should the system be routinely flushed, and if so, how frequently and with what? Are blood cultures obtained through the catheter reliable indicators of catheter contamination? What are the indications for catheter removal, and can either or both local infection and bacteremia be treated with the catheter in place?
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CARE AND MAINTENANCE OF IMPLANTED CVC Issues Should a dressing be placed over the exit site, and if so, what dressing materials should be used and how frequently should the dressing be changed? A semipermeable membrane is kept in place over the exit site Dressings are changed at least weekly Disruption of catheter dressings is an important risk factor for catheter-related infections Well-healed exit sites might not require dressings.
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CARE AND MAINTENANCE OF IMPLANTED CVC Issues Should the system be routinely flushed, and if so, how frequently and with what? Every-other-day heparin flush (5 mL of 100 units/mL) to attempt to keep the catheters patent Newer, valved catheters do not require heparin and are locked with saline after use
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CARE AND MAINTENANCE OF IMPLANTED CVC Issues Are blood cultures obtained through the catheter reliable indicators of catheter contamination? What are the indications for catheter removal, and can either or both local infection and bacteremia be treated with the catheter in place? Repeated isolation of the same organism from cultures drawn through the catheter indicates a need for therapy Individual positive cultures and sporadic positive cultures are difficult to interpret in the absence of clinical or laboratory correlates Quantitative cultures may prove particularly helpful in establishing a diagnosis in this setting
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PULMONARY ARTERY CATHETERS High rate of contamination, with occasional episodes of catheter-related sepsis and nosocomial endocarditis Catheters may traumatize the right-sided heart valves and the right-sided endocardium Cardiac surgery studies: should limit the duration to no more than 4 days CDC guideline: every 7 days Changing these catheters over a guidewire is a major risk factor for infection
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ARTERIAL LINES, TRANSDUCERS, AND TRANSDUCER DOMES Similar infectious risks with short-term CVCs Factors associated with increased risk for infection: Duration of catheterization (especially longer than 96 hours) Placement by cutdown rather than percutaneously Clinical signs of local inflammation Improper sterilization of reusable transducer domes
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ARTERIAL LINES, TRANSDUCERS, AND TRANSDUCER DOMES Must replace transducers, tubing, and continuous-flow devices every 96 hours Must not routinely replace peripheral arterial catheters to prevent infection CDC guidelines: Recommend against routine replacement of arterial catheters and for replacement only with clinical indication
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MANAGEMENT Alternative: Daptomycin
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MANAGEMENT Antibiotic lock therapy is NOT for: S. aureus Candidemia Mycobacteremia GNB with biofilms: Klebsiella, Pseudomonas, and Acinetobacter species Long-term catheters with exit site, tunnel, or a pocket infection
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PREVENTION
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PREVENTION
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PREVENTION
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QUIZ What is the most important portal of entry for central line associated bloodstream infections?
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QUIZ What are the 3 microorganisms that predominate among CLABSI secondary to contaminated infusate?
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QUIZ What is the point of access of bacteremias frequently associated with long-term catheters?
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QUIZ At what location has the highest frequency of CLABSI?
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QUIZ At what duration is biofilm formation almost universal?
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QUIZ What microorganism is implicated among severely immunosuppressed patients?
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QUIZ What microorganisms, when isolated, are indicated to have the catheter removed?
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QUIZ What is the most accurate diagnostic method for short term central catheters?
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QUIZ What is an independent risk factor for bacteremia for TPN?
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QUIZ What is an alternative to vancomycin for treatment of CONS CLABSI?