Catheter Related Infections

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Catheter Related Infections
Dr Todd Fraser Intensive Care Unit The Geelong
Hospital
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Issues

• Incidence
• Importance
• Pathophysiology
• Microbiology
• Diagnosis
• Approach to management
• Prevention

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Incidence

• 5.3 CRI per 1000 catheter days in Intensive Care
• Mortality rate 12-25
• US 25 000 / infection
• Centers for Disease Control and Prevention.
  National Nosocomial Infections Surveillance
  (NNIS) System report 1998. Am J Infect Control.
  199826522-533.
• Kluger DM, Maki DG. The relative risk of
  intravascular device related bloodstream
  infections in adults. September 26-29, 1999 San
  Francisco, California. Abstract 514.

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Importance

• Mortality
• Morbidity
• Financial

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Pathophysiology

• 4 routes of contamination
• Skin site
• Hubs / connectors etc
• Haematogenous spread
• Contaminated infusate
• Short term lines
• Long term lines

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Biofilm
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Pathogens
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Complications

• Metastasis
• Endocarditis
• Septic thrombosis
• Tunnel infection
• Sepsis

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Diagnosis

• Clinical
• Maki criteria
• Concept of threshold
• Additional techniques
• Differential blood cultures

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Maki Criteria

• Colonisation
• Semiquantitative culture method
• gt15 CFU
• Exit site infection
• Catheter-related bacteraemia
• Catheter-related sepsis
• Probable catheter-related infection

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Maki Criteria

• gt15 CFU 100 sensitive for bacteraemia

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Other diagnostic methods

• Quantitative culture
• Cleriflush
• Vortex
• Sonication
• Line-sampled blood cultures
• Differential cultures
• Microscopy

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Management

• Removal of line
• Appropriate antibiotic cover
• Surveillance for complications

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Antibiotics

• Vancomycin
• Enteric G- cover
• Pseudomonas cover
• Antifungals?
• Duration
• Lock therapy

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Surveillance of complications

• TOE

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Challenging cases

• Positive tip, negative B/C
• Tunnelled lines
• Hard to place lines

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Prevention

• Insertion issues
• Surveillance
• Maintenance issues
• Catheter types

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Insertion issues

• Patient selection
• Skin preparation
• Dressing
• Site

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Catheter types

• Number of lumens
• Tunnelled
• Cuffed
• Impregnated
• Types

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What is available?

• Chlorhexidine-Silver sulphadiazine
• External (half life 3 days)
• 2nd generation
• Minocycline-rifampicin
• Internal and external
• Half life 25 days

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What is available?

• Platinum / silver
• Silver impregnated cuffs
• Little evidence of effect, even in long term use
• Heparin bonded
• Other

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What is the evidence?

• Maki 1997
• 158 pts chlorhex v standard
• 1.0 vrs 4.7 CRI/100 catheter days (p0.03)
• Chlorhexidine-Silver sulphadiazine
• 2 metanalyses, short term catheter use
• Both favour use
• Veenstra 2001 OR 0.56 (95 CI, 0.37-0.84
  P.005).
• Cost effective (Veenstra) - 68-391/catheter
• Maki 1997 3.3 CRI/1000 CVC-days

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What is the evidence?

• Darouiche 1999 NEJM
• Head to head, lt30 days
• 0.3 v 3.4 (p0.002)
• Effect evident only gt6 days
• No resistance to R-M catheters noted
• In vivo evidence of resistance
• No comparative studies with 2nd generation CH-SS
  catheters

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What is the evidence?
Cost-Benefit of the Use of Antibiotic Impregnated
CV lines to Prevent Catheter Related
Bacteraemia I.J.Wilkinson, I.Blight, M.Chapman,
S.Creed, and M.Pradhan.
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What is recommended?

• IDSA recommend impregnated catheters if
• CVC required gt5 days
• High risk
• CRI rate gt benchmark despite other control
  measures
• Category 1b recommendation

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Surveillance

• Pull out when no longer needed
• Daily observation

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Maintenance issues

• Aseptic method of access
• Infusion sets
• Line changes
• Inline filters

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Unexplained fever with CVC

• See rello eur j clin nicro infect dis 11
  1192-3
• Up to 71 of lines may in fact be sterile
• Remove only if severe or local signs
• ? Role for guidewire exchange

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Febrile patients

• Balance of risk
• Decontamination
• Guidewire exchanges
• Tunnelled lines

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Further reading

• CDC
• IDSA