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INDEX

  • Line-Related Infections
  • Context
  • Diagnostic Approach
  • Management
  • Empiric Antibiotic Therapy
  • Quality Of Evidence?
  • Other Relevant Information
  • Related Information

Line-Related Infections

Hematological / Oncological

Last Reviewed on Jan 19, 2022
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By Joseph Chong,Tracy Huynh

Context

  • Despite advances in prevention of catheter-related infections, tens of thousands of patients continue to experience bloodstream infections (BSI) every year.
    • Results in prolonged hospitalization, increased morbidity and mortality, healthcare cost.
  • Definition:
    • Catheter-related bloodstream infection (CRBSI): clinical definition that requires microbiologic data (e.g., catheter tip culture, quantitative blood cultures, differential time to positivity [DTP]).
    • Central-line associated bloodstream infection (CLABSI): surveillance definition that identifies patients with a central venous catheter who experiences a BSI not attributable to another source.
      • Overestimates true incidence of CRBSI since some BSIs are due to sources other than the catheter.
  •  Risk factors:
    • Host factors:
      • Immunosuppression
      • Bone marrow transplantation
      • Malnutrition
      • Total parenteral nutrition
      • Previous BSI
      • Extremes of age
      • Loss of skin integrity, as with burns
    • Catheter factors:
      • Extrinsic factors:
        • Duration and type of catheter
        • Catheter-site care
      • Comparatively elevated risk in the following circumstances:
        • Femoral or internal jugular vein compared with subclavian vein
        • Use for hemodialysis compared with other indications
        • Multiple-lumen compared with single-lumen PICCs

Diagnostic Approach

  • Clinical presentation:
    • Local catheter infections are characterized by inflammatory manifestations:
      • Induration, erythema, warmth, and pain or tenderness at or around catheter exit site.
      • High specificity but very low sensitivity for CRBSI.
    • Systemic catheter infections (CRBSI) should be considered when a patient with a CVC presents with bacteremia or fungemia in the presence of signs and symptoms of systemic infection:
      • Fevers, chills, hypotension, altered mental status.
      • Fever/chills is most sensitive clinical finding, but has poor specificity.
  •  Complications: suspect in patients with CRBSI and persistent bacteremia after >72 hours of appropriate antibiotic therapy.
    • Septic thrombophlebitis: venous thrombosis associated with inflammation in setting of bacteremia.
    • Infective endocarditis.
    • Metastatic MSK infections: septic arthritis, osteomyelitis, orthopedic hardware infection.
  • Investigations:
    • CBC
    • Lactate
    • CRP
    • Blood cultures x 2: if positive for S. aureus, coagulase-negative staphylococci, or Candida species, in absence of other identifiable sources of infection, should increase suspicion for CRBSI.
    • There is NO role for routine catheter culture at time of catheter removal as positive culture is not diagnostic of CRBSI.
  • Approach:
    • Patients with fevers, chills, or hypotension in setting of catheter placed at least 48 hours prior to symptoms: suspect CRBSI.
    • Two sets of blood cultures from separate peripheral sites should be obtained, preferably prior to antimicrobial therapy.
    • If not possible, one blood culture set may be drawn from the catheter, while the other set is drawn peripherally.
    • Exception: frequently not feasible to obtain a peripheral blood sample from patients receiving hemodialysis.
      • Blood samples may be drawn during hemodialysis from bloodlines connected to the CVC.
    • Following results may be attributable to CRBSI:
      • 1 or more blood culture bottles positive for: S.aureus, Enterococci, Enterobacteriaceae, Pseudomonas, Candida.
      • 2 or more blood culture bottles positive for Coag Neg Staph (CoNS), Cutibacterium, Viridans group streptococci.

Management

  • In general, management consists of catheter removal and systemic antibiotic therapy.

Catheter Management

  • Indications for catheter removal:
    • Sepsis
    • Hemodynamic instability
    • Presence of concomitant endocarditis, septic thrombophlebitis, metastatic MSK infection.
    • Persistent bacteremia after 72 hours of appropriate antibiotic therapy.
    • Subcutaneously tunneled CVC, tunnel tract infection, or subcutaneous port reservoir infection.
    • CRBSI due to the following pathogens: S.aureus, P.aeruginosa, drug-resistant gram-negative bacilli, Candida.
  • Indications for catheter salvage:
    • No alternative access site or sites are limited.
    • Patient has bleeding diathesis (thrombocytopenia).
    • Patient declines removal.
    • Quality of life takes priority over need for catheter reinsertion.
    • In absence of complications, catheter salvage is reasonable in setting of CRBSI due to CoNS and drug-susceptible Enterobacteriaceae.
    • In patients with CRBSI due to Enterococcus, catheter removal is preferred but salvage may be attempted if not feasible.
  • Hemodialysis patients:
    • For patients whose symptoms resolve after 2-3 days of IV antibiotic therapy and who do not have complications, guidewire exchange of catheter is associated with cure rates comparable to those associated with immediate removal.
    • If CRBSI due to gram-negative pathogens or CoNS, catheter may be retained and treated with adjunctive antibiotic lock therapy.

Empiric Antibiotic Therapy

  • Empiric therapy should cover gram-positive organisms: typically IV vancomycin.
  • Indications for gram-negative bacilli coverage:
    • Critical illness
    • Neutropenia
    • Hemodynamic instability
    • Severe burns
    • Femoral catheter-related BSI
    • Choice of agent for Gram-negative bacilli: antipseudomoal beta-lactam such as Ceftazidime, Cefepime, Piperacillin-Tazobactam, Imipenem, Meropenem.
  • Indications for Candida coverage:
    • Critical illness
    • Prolonged exposure to broad-spectrum antibiotics
    • Recent GI surgery
    • Femoral catheter-related BSI
    • Hematologic malignancies
    • Hematopoietic stem cell transplantation
    • Solid organ transplantation
    • Patients on TPN
    • Presence of candida colonization at multiple body sites
    • Choice of agent for Candida: Echinocandins or Fluconazole
  • Hemodialysis patients:
    • Antibiotic selection should be made on basis of pharmacokinetic characteristics that permit dosing after each dialysis session (vancomycin, ceftazidime, cefazolin) or antibiotics that are unaffected by dialysis (ceftriaxone).
  • If patients have persistent bacteremia or fungemia after catheter removal (>72 hr), duration of therapy should be extended to 4-6 weeks and consider TTE to rule out infective endocarditis if appropriate.

Quality Of Evidence?

Justification

Majority of articles are guidelines and there are no randomized control studies.

Low-Moderate

Other Relevant Information

Related Information

Reference List

  1. Buetti N, Timsit J-F. Management and Prevention of Central Venous Catheter-Related Infections in the ICU. Semin Respir Crit Car Med. 2019; 40: 508-523.


  2. Calderwood MS, Harris A, Kaplan S, Hall KK. Intravascular non-hemodialysis catheter-related infection: Clinical manifestations and diagnosis. UpToDate. Retrieved January 8, 2022, from uptodate.com


  3. Calderwood MS, Harris A, Kaplan S, Hall KK. Intravascular non-hemodialysis catheter-related infection: Treatment. UpToDate. Retrieved January 8, 2022, from uptodate.com


  4. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2009; 49(1): 1-45.


  5. Raad I, Hanna H, Maki D. Intravascular catheter-related infections: advances in diagnosis, prevention, and management. Lancet Infect Dis. 2007; 7: 645-57.


  6. Rupp ME, Karnatak R. Intravascular Catheter-Related Bloodstream Infections. Infect Dis Clin N Am. 2018; 32: 765-787


  7. Shah H, Bosch W, Thompson KM, Hellinger WC. Intravascular Catheter-Related Bloodstream Infection. The Neurohospitalist. 2013; 3(3): 144-151.


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