CATHETER RELATED NON HEMODIALYSIS INFECTION

CATHETER RELATED INFECTION

1. Intravascular non-hemodialysis catheter-related infection: Treatment Dr. Mohammad Zaro Supervisor : Dr. Amjed Alnatsheh

2. central line catheters (Central Venous Access Device ) Types of central lines : By site : Percutaneous central venous catheter (CVC ) Peripherally inserted central catheters (PICC ) Subcutaneous or tunnelled central venous catheter Implanted central venous catheter (ICVC, port a cath ) Catheter types : Triple-lumen catheter Hemodialysis catheter Introducer sheaths

3. MANAGEMENT OF CATHETER-RELATED BLOODSTREAM INFECTION In general, management of CRBSI consists of : catheter removal systemic antibiotic therapy Indications for ID consultation : Infection due to  Staphylococcus aureus ,  Pseudomonas aeruginosa , drug-resistant gram-negative bacilli, or  Candida   spp Patients who are unable to undergo catheter removal Patients with endovascular implant or orthopedic hardware Patients with complications of bloodstream infection such as infective endocarditis (IE), septic thrombophlebitis, metastatic musculoskeletal infection, mycotic aneurysm, or vascular graft infection

4. Empiric antibiotic therapy   The initial choice of empiric antibiotic therapy for treatment of ( CRBSI) depends on the severity of illness , the risk factors for infection , and the likely pathogens Empiric antibiotic therapy for treatment of CRBSI should be guided by Gram stain results : For CRBSI due to gram-positive organisms , empiric therapy consists of  vancomycin . In institutions with high rates of infection due to  (MRSA) isolates with vancomycin minimum inhibitory concentration >2 mcg/mL, an alternative agent such as  daptomycin  should be used .   Linezolid  is not an appropriate agent for empiric therapy of CRBSI Additional agents with activity against CoNS and MRSA include   : ceftaroline ,  tedizolid ,  telavancin ,  dalbavancin ,  oritavancin , and  quinupristin-dalfopristin . Clinical data regarding efficacy of these agents for treatment of CRBSI are limited

5. For CRBSI due to gram-negative bacilli , empiric therapy should be guided by clinical circumstances : In patients with neutropenia or severe burns , monotherapy with an antipseudomonal beta-lactam antibiotic is appropriate; examples include  ceftazidime ,  cefepime ,  piperacillin- tazobactam ,  imipenem , and  meropenem . For patients with hemodynamic instability and in health care settings where local resistance suggests < 90% susceptibility to antipseudomonal beta-lactams, administration of an additional antipseudomonal agent (such as an aminoglycoside or  ciprofloxacin ) is appropriate while awaiting culture results; once susceptibilities are known, monotherapy may be administered In the absence of neutropenia, severe burns, or hemodynamic instability , monotherapy with  ceftriaxone  or another agent with activity against gram-negative organisms is reasonable; antipseudomonal coverage is not necessary Patients known to be colonized with drug-resistant organisms should receive empiric antibiotic therapy selected accordingly

6. Selecting a catheter management strategy If catheter removal is not feasible ( eg , there is no alternative access site or sites are limited , the patient has a bleeding diathesis , patient declines removal , or quality of life issues take priority over the need for catheter reinsertion at another site ), a decision regarding catheter salvage or guidewire exchange must be made REMOVAL SALVAGE GUIDEWIRE EXCHANGE

7. Removal :  

8. In patients with CRBSI due to  S. aureus , catheter retention has been associated with a low success rate; most patients eventually relapse and require removal of the catheter. Early catheter removal (within three days of bacteremia onset ) has been associated with lower relapse rates and lower rates of hematogenous complications.  In a prospective study including 324 patients  with CRBSI due to  S.   aureus , failure to pursue catheter removal was associated with increased risk for hematogenous complications. Similarly, in a retrospective study including 304 episodes of CRBSI due to  S. aureus , a higher relapse rate was observed among patients whose catheter was retained beyond three days after bacteremia onset than among those whose catheter was removed or exchanged within the first three days of bacteremia onset In patients with CRBSI due to drug-resistant gram-negative bacteria, delayed catheter removal has been associated with increased mortality In a retrospective study including more than 70 patients with CRBSI due to a gram-negative organism, delayed catheter removal in the setting of drug-resistant infection was associated with increased 30-day mortality

9. In patients with CRBSI due to  Enterococcus   spp , catheter removal is preferred ; in patients for whom catheter removal is not readily feasible, catheter salvage may be attempted. In a retrospective study including 111 patients with CRBSI due to  Enterococcus  (of whom 74 percent underwent catheter removal), catheter retention was an independent predictor of mortality In another study including 64 patients with dialysis catheters and CRBSI due to  Enterococcus , catheter salvage was successful in 61 percent of cases In patients with CRBSI due to organisms of relatively low virulence that are difficult to eradicate (such as  Bacillus   spp ,  Micrococcus  spp , or  Cutibacterium   spp [formerly  Propionibacterium   spp ]), catheter removal may be warranted if bacteremia persists and blood culture contamination has been ruled out ( eg , based on multiple positive culture results with at least one sample drawn from a peripheral vein ). However, catheter salvage with antibiotic lock therapy (ALT) may be feasible in some cases Catheter removal based on the above pathogen-related considerations must be weighed against the clinical indication for the catheter and the risks associated with removal and replacement of a catheter at another site. Catheter removal is not necessary for patients with unexplained fever who are hemodynamically stable in the absence of documented bloodstream infection

10. Salvage :   Catheter salvage refers to retention of the catheter while treating the CRBSI ; we typically suggest ALT in addition to systemic antimicrobial therapy if catheter salvage is attempted  Catheter salvage should not be attempted in patients with a condition warranting catheter removal. In the absence of complications, catheter salvage is reasonable in the setting of CRBSI due to CoNS and drug-susceptible Enterobacteriaceae ( eg ,  Escherichia coli ,  Klebsiella  species,   Enterobacter  species ) In patients with CRBSI due to   Enterococcus   spp , catheter removal is preferred ; however, catheter salvage may be attempted in patients for whom catheter removal is not readily feasible Circumstances precluding catheter salvage include septic thrombophlebitis , endocarditis , metastatic musculoskeletal infection , and inability to draw back and/or flush the catheter For children with CRBSI, some pediatricians favor attempting catheter salvage when feasible, given greater difficulty with vascular access among children than among adults

11. Guidewire exchange : Guidewire exchange of the catheter should not be performed in patients with a condition warranting catheter removal For situations in which catheter removal is not readily feasible, catheter salvage is preferable to guidewire exchange Guidewire exchange of the catheter is a management approach of last resort ( eg , only in patients for whom continued access is essential and alternative vascular access is absolutely impossible due to high risk for mechanical complications or bleeding during catheter reinsertion). These caveats are important since the new catheter is inserted into a likely infected tract, and removing the old catheter will seed the tract if not yet infected. Most studies describing successful management of CRBSI via guidewire exchange have been small. Patients who undergo guidewire exchange should receive systemic antimicrobial therapy and ALT; the clinical approach is the same as for catheter salvage

12. Subsequent management : Catheter removed : Directed systemic antibiotic therapy and duration: Coagulase-negative Staphylococcus   : Antimicrobial agents for treatment of CRBSI due to staphylococci are summarized in the table. The optimal duration of antibiotic therapy for CRBSI due to CoNS is uncertain, our approach is as follows: For patients with no endovascular implant or orthopedic hardware and uncomplicated CRBSI due to CoNS who undergo catheter removal with rapid clearance of bacteremia, we favor systemic antimicrobial therapy for 5-7 days For patients with endovascular implant or orthopedic hardware (in the absence of evidence for IE or orthopedic hardware infection) and uncomplicated CRBSI due to CoNS who undergo catheter removal with rapid clearance of bacteremia, we favor systemic antimicrobial therapy for 14 days. We extend the course empirically to account for the possibility of foreign material seeding CRBSI due to  Staphylococcus lugdunensis   should be managed as for  S. aureus  

13. Staphylococcus aureus : For adults with uncomplicated CRBSI due to  S. aureus  who undergo catheter removal, we favor systemic antimicrobial therapy for 14 days . In children, the duration of therapy is ≥7 days . Enterococcus   : For patients with uncomplicated CRBSI due to  Enterococcus   spp who undergo catheter removal, we favor systemic antimicrobial therapy for 7 to 14 days   Gram-negative bacilli : For patients with uncomplicated CRBSI due to gram-negative bacilli who undergo catheter removal, we favor systemic antimicrobial therapy for 7 to 14 days

14. Catheter salvaged : refers to retention of the catheter while treating the CRBSI; we typically suggest ALT in addition to systemic antimicrobial therapy if catheter salvage is attempted. Coagulase-negative Staphylococcus : For patients with no endovascular implant or orthopedic hardware and uncomplicated CRBSI due to CoNS who are unable to undergo catheter removal, we favor systemic antimicrobial therapy and ALT for 10 to 14 days For patients with endovascular implant or orthopedic hardware (in the absence of evidence for IE, endovascular infection, or orthopedic hardware infection) and uncomplicated CRBSI due to CoNS who are unable to undergo catheter removal, we favor systemic antimicrobial therapy and ALT for 14 to 21 days “ “  This approach should be limited to situations in which symptoms of bacteremia were of short duration before antibiotics were started (≤2 days), with resolution of bacteremia within 48 hours after starting antibiotics ; such patients should have repeat transthoracic echocardiogram before antibiotics are discontinued. If these criteria are not met and catheter removal is not feasible, we favor extending the duration of treatment to 4-6 weeks

15. Staphylococcus aureus : For adults with uncomplicated CRBSI due to  S. aureus  who are unable to undergo catheter removal, we favor systemic antimicrobial therapy and ALT for 28 days . In children, the duration of therapy is ≥14 days Enterococcus   : For patients with uncomplicated CRBSI due to  Enterococcus   spp who are unable to undergo catheter removal, we favor systemic antimicrobial therapy and ALT for 14 days Gram-negative bacilli : For patients with uncomplicated CRBSI due to gram-negative bacilli are unable to undergo catheter removal, we favor systemic antimicrobial therapy and ALT 14 days

16. Antibiotic lock therapy refers to instillation of a concentrated antibiotic solution into the catheter lumen with the intention of achieving a drug level high enough to kill bacteria within the biofilm of the catheter ALT is a useful adjunctive therapy (administered together with systemic antibiotic therapy) for treatment of CRBSI for circumstances in which the catheter cannot be removed. It is most commonly used for management of CRBSI due to CoNS and drug-susceptible Enterobacteriaceae . For patients on total  parenteral nutrition  or other continuous infusions, ALT may not be feasible because there is insufficient time for the antibiotic solution to dwell within the line. For multilumen catheters, ALT may be rotated between lumens, although this practice has not been studied formally

17. Monitoring and indications for catheter removal : Patients with CRBSI must be monitored closely for relapse or signs of metastatic infection. Surveillance blood cultures should be drawn following initiation of antibiotic therapy to demonstrate clearance of bacteremia . Presence of persistent symptoms and/or persistently positive blood cultures 72 hours after initiation of appropriate antibiotic therapy should prompt catheter removal. In addition, evaluation for complications of CRBSI (including suppurative thrombophlebitis, endocarditis, and metastatic foci of infection) should be pursued Catheter exchanged over a guidewire : Patients who undergo guidewire exchange should receive systemic antimicrobial therapy and ALT; the clinical approach is the same as for catheter salvage

18. MANAGEMENT OF CATHETER COLONIZATION : In the setting of a single positive catheter-drawn blood culture positive for coagulase-negative staphylococci or other potential skin contaminant, with concomitant negative peripheral-drawn blood cultures, the findings may be attributable to colonization of the catheter hub, rather than catheter infection In such circumstances, there may be increased risk for subsequent development of catheter-related bloodstream infection (CRBSI), especially if the catheter is left in place. We favor following the patient closely for clinical manifestations of CRBSI and obtaining additional peripheral percutaneous blood cultures. Alternative approaches include catheter removal (if feasible) or administration of antibiotic lock therapy (without systemic therapy ) Blood cultures growing  S. aureus  should be considered clinically significant

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