Catheter Related Bloodstream Infections Flashcards by Kirsten Gerrand

Which patients generally have central catheters inserted?

ICU patients
Haemodialysis
Chemotherapy

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What are some of the catheter related blood stream infections?

catheter colonization
phlebitis
exit site infection (microbiological / clinical)
tunnel infection
pocket infections
bloodstream infection (infusate / catheter related)

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How many patients in ICU have catheters inserted?

Catheters are an important “feature” of patients in ICU settings - 48% of patients in ICU have central catheters

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What are the effects of catheter related bloodstream infections?

Increase morbidity
High mortality (mortality associated with CRBSI = approx. 20%)
Increase hospital stay by approx. 7 days
Costly

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What is the most common organism associated with catheter related bloodstream infections?

Coagulase Negative Staphylococci (CNS)

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What are the three groups of organisms commonly implicated in catheter related bloodstream infections?

Gram positive organisms
Gram negative organisms
Fungi

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What are the gram positive organisms commonly implicated in catheter related bloodstream infections?

CNS
Staphylococcus aureus
Enterococcus faecalis / enterococcus faecium

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What are the gram negative organisms commonly implicated in catheter related bloodstream infections?

Enterobactericae (E. coli, K. pneumoniae, E. cloacae
Acinetobacter baumannii
Pseudomonas Aeruginosa
Burkholderia cepacia complex

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What are the fungal organisms commonly implicated in catheter related bloodstream infections?

Candida species (including C. albicans, C. parapsilosis, C. krusei, C. glabrata)

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What is the most common portal of entry in catheter related bloodstream infections?

Skin, during catheter insertion

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What is the second most common portal of entry in catheter related bloodstream infections?

Contamination of the catheter during manipulation by medical staff

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What are other portals of entry in catheter related bloodstream infections?

Haematogenous dissemination from a distal infected focus
Administration of infected infusates
Contaminated transducer kits, disinfectants and infusion lines

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Explain the pathogenesis of biofilm formation in catheter related bloodstream infections.

Catheter insertion - fibrin sheath develops around the catheter which promotes adherence of pathogens = biofilm

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Explain the pathogenesis of bloodstream infection in catheter related bloodstream infections.

Skin organisms migrate along the external surface of the catheter - colonize the distal intravascular tip - bloodstream infection.

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What is the most common cause of contamination of the device / catheter prior to insertion?

Extrinsic&raquo_space; Manufacturer

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What is considered a catheter related bloodstream infection in a patient?

Bacteraemia / fungaemia
In a patient who has an intravascular device
> 1 positive blood culture result obtained from the peripheral vein
Clinical manifestations of infection (e.g. fever, chills and / or hypotension)
NO apparent source for bloodstream infection (with the exception of the catheter)

One of the following three criteria must be met for the diagnosis of catheter related bloodstream infection to be made:

A positive result of semiquantitative or quantitative catheter culture + same organism (species) is isolated from from a catheter segment and a peripheral blood culture
Simultaneous quantitative cultures of blood with ratio of >3:1 cfu/ml blood (catheter vs. peripheral blood)
Differential time to positivity (growth in a culture of blood obtained through a catheter hub is detected by an automated system at least 2 hours earlier than a culture of simultaneously drawn blood of equal volume)

What does a semiquantitative catheter culture mean?

Pathogens only taken from outside not inside of catheter. (roll-plate)

What does a quantitative catheter culture mean?

Pathogens taken from outside and inside of catheter (broth)

How are bloodstream infections differentiated from catheter colonization?

Higher from peripherally collected blood = bloodstream infection
Higher from catheter collected blood = colonization of the catheter

How is catheter colonization defined?

Growth of >15 cfu from a 5-cm segment of the catheter tip by semiquantitative culture
Growth of 10^2 cfu from catheter by quantitative (sonication) broth culture

What should be taken into consideration when deciding on the management of catheter related bloodstream infections?

Type of catheter
Severity of the illness
Complications present?
Likely pathogens associated with the infection

What is generally done for initial management of catheter related bloodstream infections?

Antibiotics may be started empirically in severely ill patients - changed once catheter culture results are available

What are special considerations in the management of CNS catheter related bloodstream infections: for uncomplicated infections?

Removal of catheter with close observation

What are special considerations in the management of CNS catheter related bloodstream infections: for complicated infections / if there is presence of prosthetic material ?

Remove and treat for 5-7 days

How long should a patient with A. Aureus catheter related bloodstream infection be treated for?

``` 14 days of therapy if: - no evidence of endocarditis - non-diabetic - not immunocompromised - infected catheter removed - no prosthetic material - resolution of bacteremia and fever after 72 hours on antimicrobial therapy - no evidence of metastatic infection If any of the above apply, then 4-6 weeks of treatment ```

What are special considerations in the management of gram negative bacteria catheter related bloodstream infections?

Remove catheter | Treat empirically

What are special considerations in the management of candida catheter related bloodstream infections?

Prompt removal of catheter Appropriate antifungal therapy Dilated eye examination (retinitis)

What are some of the potential complications of catheter related bloodstream infections?

1. Sepsis 2. Suppurative thrombophlebitis 3. Endocarditis 4. Persistent bloodstream infection 5. Osteomyelitis 6. Local catheter site infection 7. Metastatic infections

What are some of the strategies that can be used to prevent catheter related bloodstream infections?

1. Hand hygiene 2. Aseptic technique 3. Barrier precautions (cap, mask, sterile gown, full body drape for insertion CVC - subclavian and jugular > femoral) 4. Skin preparations with antiseptic prior to catheter insertion 5. Catheter care 'bundles' 6. Removal or replacement of catheters

What is the definition of catheter colonization?

Significant growth of >1 microorganism in a quantitative or semiquantitative culture of the catheter tip, subcutaneous catheter segment, or catheter hub

What is the definition of phlebitis?

Induration or erythema, warmth, and pain or tenderness along the tract of a catheterized or recently catheterized vein.

What is the definition of microbiological exit site infection?

Exudate at catheter exit site yields a microorganism with or without concomitant bloodstream infection.

What is the definition of clinical exit site infection?

Erythema, induration, and / or tenderness within 2 cm of the catheter exit site; may be associated with other signs and symptoms of infection e.g. fever, purulent drainage emerging from the exit site, with or without concomitant bloodstream infection.

What is the definition of tunnel infection?

Tenderness, erythema and / or induration >2 cm from the catheter exit site, along the subcutaneous tract of a tunnel catheter (e.g. Hickman or Broviac catheter), with or without concomitant bloodstream infection.

What is the definition of pocket infection?

Infected fluid in the subcutaneous pocket of a totally implanted intravascular device; often associated with tenderness, erythema, and / or induration over the pocket; spontaneous rupture and drainage, or necrosis of the overlying skin with or without bloodstream infection

What is the definition of infusate related bloodstream infection?

Concordant growth of a microorganism from infusate and cultures of percutaneously obtained blood cultures with no other identifiable source of infection.

What is the definition of catheter related bloodstream infection?

Bacteraemia or fungemia in a patient who has an intravascular device and >1 positive blood culture result obtained from the peripheral vein, clinical manifestations of infection and no apparent source for bloodstream infection (apart from the catheter). 1 of the 3 criteria described previously should be met.