Management of Intravascular Catheter related infection

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Management of Intravascular Catheter related
infection

• Intern ???
• Supervisor VS ???Ref Clinical Infectious
  Diseases 2001321249-72

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Types of intravascular devices
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Epidemiology and pathogens

• 200000 nosocominal bloodstream infection
  /5million CVC placement annually in U.S. (4)
• Case-fatality rate 14, 19 of these death can
  be attribute to catheter related infection.
• Coagulase negative staphylococci, S. aureus,
  aerobic gram negative bacilli, C. albicans.
• Mortality rate of catheter related bacteremia
  varies from species to species
• Eg S. aureus (8.2) v. CNS (0.7)

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Specific culture methodology

• Roll plate (Semi-quantitave)
• Vortex or Sonication (Quantitative)
• Sensitivity 80 v. 60 (roll plate) v. 40-50
  (flush culture).
• Quantitative culture of CVC blood sample.
• Useful in diagnose the tunneled catheter related
  blood stream infection.
• Differential time to positivity for CVC versus
  peripheral blood culture
• Useful in hospital which do not have quantitative
  culture methods.

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Diagnosis

• One positive result of culture of blood samples
  obtained from the peripheral vein
• Clinical manifestations of infection.
• No apparent source for bloodstream infection
• One of the following should be present
• a positive result of semiquantitative (15 cfu per
  catheter segment) or quantitative (102 cfu per
  catheter segment) catheter culture
• same organism (species and antibiogram)
• simultaneous quantitative cultures of blood
  samples with a ratio of 51 (CVC vs. peripheral)
  
• CVC sample differential time to positivity 2 h
  earlier than peripheral blood)

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Diagnosis of non tunneled CVC infection
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Diagnosis of tunneled CVC infection
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Complication Septic Thrombosis

• Continued positive blood culture results after
  catheter withdrawal.
• S. aureus is the most common pathogen.
• Use of thrombolytic agents in addition to
  antimicrobial agents is not recommended.
• Heparin should be used in the treatment of septic
  thrombosis of the great central veins and
  arteries.
• Surgical exploration is needed when infection
  extends beyond the vein into surrounding tissue.

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Complication Persistent bloodstream infection
and IE

• Empirical therapy in this situation must include
  coverage for staphylococci.
• Remove the CVC
• 4 weeks of antimicrobial therapy in most cases
  and with surgical intervention when indicated.
• Exception Uncomplicated tricuspid valve
  endocarditis due to staphylococci in injection
  drug users, a 2-week duration of antimicrobial
  therapy appears to be effective.

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Management

• Remove the central venous catheter / implantable
  device or not?
• Depending on the complications and specific
  microorgainsm.
• What antibiotics and the duration of treatment?
• Depending on whether the device is salvaged, the
  complications and specific microorgainsm. From no
  antibiotics usage to 8 weeks.
• Is antibiotics lock therapy useful?
• In most GPC intraluminal infection, YES.

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Antibiotics lock therapy

• Antibiotic in a concentration of 15 mg/mL are
  usually mixed with 50100 U heparin to fill the
  catheter lumen and are installed or locked into
  the catheter lumen during periods when the
  catheter is not being used (e.g., for a 12-h
  period each night).
• Several open trials of antibiotic lock therapy of
  tunneled catheter related bacteremia, have
  reported catheter salvage without relapse in 138
  (82.6) of 167 episodes, compared to 342 (66.5)
  of 514 episodes which use standard parenteral
  therapy.

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Specific pathogen CNS

• Coagulase-negative staphylococci, such as S.
  epidermidis, are the most common cause of
  catheter-related infections.
• Catheter-related infections due to CNS
  staphylococci predominantly manifest with fever
  alone or fever with inflammation at the catheter
  exit site.
• Vancomycin empirical therapy is appropriate
  before culture data to be obtained.

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Specific pathogen S. aureus

• TEE should be done to r/o endocarditis.
• Vancomycin should not be used when theres
  infection with b-lactam susceptible S. aureus.
• excessive vancomycin use selects
  vancomycin-resistant organisms
• vancomycin has higher failure rates than do
  either oxacillin or nafcillin
• slower clearance of bacteremia among patients
  with S.aureus endocarditis

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Specific pathogen C. albicans

• All patients with candidemia should be treated
• Amphotericin B is recommended for hemodynamically
  unstable patients or who have received prolonged
  fluconazole therapy
• Salvage therapy for infected tunneled CVCs or IDs
  is not recommended for routine use
• Salvage rates with systemic fungal therapy and
  antibiotic lock therapy for Candida species have
  been about 30.

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Management of removable CVC infection
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Management of tunneled CVC infection
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Summery

• Paired quantitative blood culture is recommended
  especially in tunneled CVD/ID to confirm
  diagnosis.
• TEE should be done to rule out vegetations in S.
  aureus bloodstream infection.
• For complicated infections, the CVC/ID should be
  removed.
• For uncomplicated intraluminal bacterial
  infection in the absence of tunnel or pocket
  infection, 2 weeks systemic therapy with
  antibiotic lock therapy add chance to salvage
  the CVC/ ID.

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Areas of further research.

• Do patients with positive results of catheter
  cultures but with negative blood culture results
  and no other obvious site of infection need to be
  treated with antibiotics?
• Prospective, randomized studies for the optimum
  duration of treatment when the catheters are left
  in place.
• Prospective, randomized studies to determine the
  efficacy of combined systemic and antibiotics
  lock therapy in specific pathogen.

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Thanks for your attention