LINE IN

FECTIONS

DIAGNOSIS AND TREAT

MENT

H O S P I TA L M

E D I CI N

E CU R R I C

U LU M

PA M E L A PR I D

E MD , F

H M

M E D I CA L U

N I VE R S I T

Y OF S

O U T H CA R O L I N

A

M AY 21 , 2

0 1 3

LEARNING OBJECTIVES1. Differentiate types of infection

associated with vascular access2. Formulate appropriate empiric therapy

based on patient specific risk factors3. Recite indications for antibiotic lock

therapy4. 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

PATHOPHYSIOLOGYHow do these infections happen?1. Migration of skin flora from insertion site2. Direct contamination of catheter3. Hematogenous seeding4. 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 deviceInsertion 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 accessesUse of prevention strategiesExperience and skill of individualPatient factors

ASK 3 MAIN QUESTIONS1. 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 DEFINITIONSCatheter 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 QUESTIONS1. 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 CATHETERST O T A L L Y 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 QUESTIONS1. What is the nature of the

infection?2. What type of catheter is

infected?3. What is the organism?

EMPIRIC TREATMENTCOVERAGE FOR BACTERIAEmpiric treatment with vanc or dapto depending

on hospitals mrsa mic data

Do not use linezolid empiricallyEmpiric GNR coverage should be based on severity

of disease and presence of femoral line

Use cefepime, carbapenem, or zosyn if warrantedOnly 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 msseVancomycin for mrseTreat for 5-7 days with antibiotics if catheter

removedTreat 10-14 days with abx lock if catheter is

salvagedSome 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 catheterNafcillin/oxacillin for mssaVanco/dapto for mrsaDefault duration of therapy is 4-6 weeksTreat 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 abxTreat 5-7 days for tip cx positive/perc blood cx negative situations

MICROBE SPECIFIC TREATMENTENTEROCOCCUSAmpicillin is drug of choice if susceptibleVanco if resistant to ampDouble coverage with aminoglycoside is controversial7-14 course of therapy recommendedOnly tee if other signs and symptoms of endocarditis

MICROBE SPECIFIC TREATMENTGRAM NEGATIVE BACILLICarbapenem ok for all following

ESBL + ecoli/klebsiella enterobacter serratia acinetobacter

ESBL – e. coli/klebsiella-use 3rd gen cephalosporinPsuedomonas-4th gen cephalosporin, carbapenem, zosyn, +/-

aminoglycosideStenotrophomonas- bactrim 3-5mg/kg q8hrDe-escalate asapDuration of therapy 7-14 days

MICROBE SPECIFIC TREATMENTCANDIDAAlways remove catheter (tunneled hd catheter can be

exchanged over wire)C. Glabrata and C. krusei use echinocandinsC. 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