CATHETER RELATED BLOOD STREAM INFECTION

CATHETER RELATED
BLOOD STREAM
INFECTIONS
Dr. Anil Kumar.K.M
2nd year M.D. student
Dept. of pediatrics
Goa medical college

AGENDA
• DEVICES AND INDICATIONS
• EPIDEMIOLOGY
• PATHOGENESIS
• DIAGNOSIS
• TREATMENT
• PREVENTION

IV DEVICES
• PERIPHERAL
• ARTERIAL
• VENOUS
• CENTRAL VENOUS CATHETERS
• TUNNELLED
• NON- TUNNELED
• PICC
• IMPLANTED PORTS

TUNNELED CVCs
• Used for long term therapy
• Needs surgical intervention or
intervention radiology
• Does not need dressing

Non-Tunneled CVCs
• Used for short term therapy
• Inserted in
• Subclavian
• Jugular
• Femoral vein

IMPLANTABLE PORT
• Used for long term therapy
• Surgically implanted
• Metal/plastic housing with
silicone septum
• Catheter placed in superior
vena cava

Peripherally inserted central catheters[PICC]
• Used for short/ long therapies
• Inserted percutaneously via
• Basilic vein
• Cephalic vein
• Brachial vein
• Saphenous vein

OTHER DEVICES
PERITONEAL CATHETER
URINARY CATHETER

INDICATIONS OF CENTRAL LINE
• Poor venous access [ most common]
• Prolonged venous access required
• CVP monitoring
• Volume resuscitation
• Total parentral nutrition
• Cardio pulmonary resuscitation
• Medications like vasoactive substances
• Frequent blood sampling
• For certain extracorporeal support modality like CRRT.

AGENDA
• DEVICES
• EPIDEMIOLOGY
• PATHOGENESIS
• DIAGNOSIS
• TREATMENT
• PREVENTION

CRBSI AND CLABSI
• Catheter related blood stream infection[CRBSI]
• requires rigorous clinical definition, defined by precise laboratory findings that
identify the CVC as the source of the BSI.
• Culturing the CVC segment/ tips is essential
• Used for research purpose
• Central line associated blood stream infection [CLABSI]
• is a primary (i.e., no apparent infection at another site) BSI in a patient that
had a central line within the 48-hour period before the development of the BSI.
• The culture of the catheter tip is not a criterion for CLABSI.
• Used for surveillance purpose

EPIDEMIOLOGY
• CLABSI incidence has been between 3.5 – 11.5/1000 catheter days
according to various studies.
• In cancer patients the incidence has been as high as 25% according
to indian studies

BIRTH WEIGHT UMBILICAL CA BSI /1000 CATH.
DAYS
NON UMBILICAL CA BSI/1000
CATH. DAYS
<= 750 4 3.7
751 - 1000 2.6 3.3
1001 - 1500 1.9 2.6
1501 - 2500 0.9 2.4
>2500 1 1
IN NEONATES

ORGANISMS
• MOST COMMON
• Coagulase-negative staphylococci[20% - 50%]
• COMMON
• Enterobacter spp.
• Escherichia coli 20%
• Klebsiella spp.
• Pseudomonas aeruginosa
• Staphylococcus aureus[10%]
• Enterococcus spp.
• Candida spp.[10%]

CONTAMINATED
HUBS
CONTAMINATE
D INFUSATE
HEMATOGENOUS

BIOFILM FORMATION
• Strains like CONS and some candida species especially in
presence of glucose can produce “BIO FILM”
• Protective barrier against host defense and antibiotics

RISK FACTORS FOR CRBSI
• CATHETER RELATED:
• SITE OF INSERTION
• REPEATED MANIPULATION
• DURATION OF CATHEREIZATION
• LUMENS, STOPCOCKS OR MONITORING DEVICES
• ANTI SEPTIC / ANTIBIOTIC COATED OR NOT
• TUNNELED OR NOT; IMPLANTED OR NOT

•CATHETER RELATED:

• Groin and jugular are more colonized than upper extremity and chest

• Biofilm formation increases the chances of colonization with time

RISK FACTORS contd..
• Type of infusate
• Parentral nutrirtion more chance of candida spp. Infection
• Lipid formulation ---- CONS
• Host factors
• Skin integrity
• Skin flora
• Immunocompetence

• Exit site infection
• Erythema or induration within
2 cm of the catheter insertion
site

• Tunnel infection
• Tenderness, erythema or
induration over the
subcutaneous tunnel around 2
cm from the exit site

• Pocket infection
• Accompanied by subcutaneous
purulent material with
overlying erythema,
tenderness or skin necrosis

Diagnosis of CRBSI
• Positive simultaneous blood cultures from the central venous catheter and
peripheral vein yielding the same organism in the presence of at least one
of the following:
Simultaneous quantitative blood cultures in which the number of cfu s isolated from
blood drawn through the central catheter is at least fivefold greater than the number
isolated from blood drawn peripherally
Positive semi quantitative (≥ 15 cfu/catheter segment) or quantitative (≥ 100
cfu/catheter segment) catheter tip cultures
 Simultaneous blood cultures in which the central blood culture has growth in an
automated system ≥ 2 hours earlier than the peripheral blood culture

Diagnosis of CRBSI contd..
• Practical difficulty in removing the catheter for diagnosis
especially in pediatric patients where vascular acesss is difficult
• Multiple samples in different time frame – may be required due to
intermittent bacteriemia
• Ideal blood to broth ratio of 1:5 or 1:10

AGENDA
• DEVICES
• EPIDEMIOLOGY
• PATHOGENESIS
• DIAGNOSIS
• MANAGEMENT
• PREVENTION

Management of catheter
• In children, removal of a catheter not always feasible because of
the potential for complications associated with reinsertion and
limited vascular access sites.
• Therefore, treatment of CVC BSI without removal of the catheter
is often attempted.

Indications of removal
• Exit site infection, if:
• No longer required
• Alternate site exists
• Patient critically ill (e.g., hypotension)
• Infection due to Pseudomonas aeruginosa or fungi
• Pocket infection
• Tunnel infection

• In CRBSI , removal is indicated in :
• No longer required
• Infection caused by Staphylococcus aureus, Candida species, or
mycobacteria
• Patient critically ill
• Failure to clear bacteremia in 48–72 hours
• Persistent symptoms of bloodstream infection beyond 48–72 hours
• Noninfectious valvular heart disease (increased risk of endocarditis)
• Endocarditis
• Metastatic infection
• Septic thrombophlebitis

Antibiotic therapy for CRBSI
• Depends on:
• Specific pathogen
• Whether catheter is removed or not
• Whether associated with thrombosis, endocarditis, osteomyelitis or metastatic foci
• Empirical therapy includes antimicrobial agent
• with activity against gram-positive bacteria[oxacillin, vancomycin]
• effective against gram-negative bacteria, including Pseudomonas species[ceftazidime
or cefepime]
• with or without an aminoglycoside.
• If MRSA is prevalent, vancomycin is used

Specific pathogens :
• Coagulase negative staph. Aureus
• Present with fever or infection of the catheter exit site
• Treatment without removal of the catheter is tried with long course of 10 –
14 days of antibiotic especially in neonates
• If persistence of symptoms or culture positivity, removal of catheter is
warranted
• Fungal infection
• Fungal infection of the catheters is best managed by removal of the
catheter and amphotericin B or fluconazole for at least 14 days
• SCREENING for persistent infections also to be done to rule out fungal ball
uropathy, renal infiltration, abcess and endocarditis

• Staph aureus
• Severe infections like endocarditis and deep tissue infection occurs
• Echocardiography should be considered in prolonged bacteremia
• Treatment include prompt removal of the catheter and antibiotics acc to
sensitivity for at least 14 days
• Gram neg bacilli
• Catheter removal has been shown to be beneficial
• Antibiotics given for 10 – 14 days after the culture becomes sterile

PREVENTION OF CATHETER RELATED
INFECTIONS

PREVENTION OF CATHETER RELATED
INFECTIONS
• THE MOST IMPORTANT STEP TO PREVENT CATHETER RELATED INFECTION
IS ????
AVOID UNNECESSARY CATHETERIZATION !!!
and
To remove unnecessary catheters as early as possible

Before putting a line
• A check list for inserting CVCs should be available
• A catheter kit should be available
• All health care personnel should go though an educational
programme
• Indication for any central line should be clear cut

Inserting a central line
• Subclavian route is associated with least infection in some studies
esp in adults
• In children no site is preferable over the other, femoral route is
mostly used
• Use of ultrasound guidance can help in easy insertion
• Maximal sterile precaution
• Skin preparation
• Povidone iodine in <2 months
• 2% gluteraldehyde in > 2 months

Type of catheter
• Polyurethane catheters are widely used because of less chance of
infection compared to polyvinyl and polyethylene catheters
• Catheters impregnated with chlorhexidine silverdiazine or
minocycline-rifampicin reduce infection rates.
• Effective only upto a max of 30 days
• Cost benefit ratio is less
• As the number of lumens increases, higher the chances of
infection

Management after insertion
• Accesing a CVCs with sterile precaution
• Clean all ports with 70% alcohol wipes before and after accessing them
• Cap all stopcocks and sterile hubs when not in use
• CVCs should not replace a peripheral canula as most bolus injection can
be given via peripheral line
• Transparent dressing is preffered as it allows inspection of the insertion
site

Management (contd.)
• Gauze dressing should be changed every 2 days and polyurethane
dressing every 7 days
• All visibly soiled dressing should be changed
• Infusion sets that are continuously used should be changed no more
frequently than 96 hours and no less frequently than every 7 days
• If blood or lipid products are transfused it should be changed every 24
hours or less

Management (contd.)
• Single dose vials should be discarded ideally after removing the
necessary dose ideally as usage of leftover for the next dose is a
source of infection
• Use of antibiotic lock solution in the hub like vancomycin has been
shown to reduce the catheter hub related infection

Surveillance of CVC
• Catheter sites should be monitored daily by palpation or by visually
inspecting the site
• Dressing should be completely removed and examined compleletly if we
are suspecting any CLABSI manifested by fever without any focus, etc
• CVCs should be replaced only if it is malfunctioning or suspected to
cause CLABSI

ARTERIAL LINES
• Infection rate for arterial line is lower than CVCs
• In pediatric population, radial, posterior tibial and dorsalis pedis are
used
• Infective complications are high associated with reusable pressure
transducer system associated with arterial lines
• Arterial lines should be removed as soon as possible and should be
replaced only if malfunctioning

UMBILICAL LINES
• Unique to neonatal practice
• Full barrier precaution should be maintined
• Should be treated as any other CVC
• Low dose heparin should be added to UACs to avoid thrombotic
complication
• While using UAC lower limb should be monitored for vascular
complication
• UAC max for 5 days
• UVC max for 7 – 10 days

The Central Line Bundle*
…is a group of interventions related to patients with intravascular
central catheters that, when implemented together, result in
better outcomes than when implemented individually.
*Bundle: Grouping of best practices

Central Line Bundle Elements
1. Hand hygiene
2. Maximal barrier precautions
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection, with subclavian vein as the
preferred site for non-tunneled catheters in adults
5. Daily review of line necessity with prompt removal of
unnecessary lines

COMPLICATIONS
SEPTIC THROMBOIS
1. Remove the Central line
2. Systemic antibiotics for 4-6 weeks or more
3. Remove the infected vein if patient clinically not improving
4. Systemic anticoagulation [UROKINASE] is also highly recommended.

COMPLICATIONS
• Sepsis syndrome
• Endocarditis
• Metastatic infection with seeding to bone, kidney and other organs

RECENT STUDIES
• Recent study by Marik PE et al with regards to infection rate
comparing femoral venous catheter and internal jugular or
subclavian catheters shows no significant difference in the rates of
CRBSI
• A Recent study by Maki ,et al showed reduced incidence of CRBSI
with chlorhexidine- silverdiazine impregnated catheter

Recent studies( contd..)
• A recent study by Garland JS showed prophylactic use of
vancomycin- heparin lock solution markedly reduced the incidence
of CRBSI in high risk neonates
• A recent study by Marcos et al showed a changing trend of
epidemiology of CRBSI with an increasing trend of gram negative
organisms

TAKE HOME MESSAGES
• CRBSI are an important cause of hospital acquired infection esp in ICU settings
• Gram positive organism and fungi are the prominent pathogens presently
• Skin contaminants and catheter hub constitute major source of infection
• Treatment without removal by antibiotics can be tried in pediatric patients
unless removal is absolutely warranted
• Prevention is better than cure by following the central line bundle of hand
hygiene, strict asepsis, optimal site selection with proper surveillance and
removal of unnecessary catheters

REFERENCES
• Long .s. sarah, principles and practices of pediatric infectious diseases, 3rd edition
• A . Parthasarathy, textbook of pediatric infectious diseases, IAP
• Remington & klein , infectious diseases of fetuses and newborn infant, 7th edition
• Fuhrman & Zimmerman, pediatric critical care, 4th edition
• Joshua Wolf and Patricia, nelson textbook of pediatrics, first south Asian edition
• Cathryn Murfy, Guide to the elimination of catheter related infections, 2009
• David.g. Nichols, rogers textbook of pediatric intensive care
• http://www.ncbi.nlm.nih.gov/pubmed

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