Crbsi kamran
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Central venous catheters are an important part of critical care but can lead to bloodstream infections in 5-20% of hospitalized patients. The most common causes are coagulase-negative staphylococci and S. aureus. Prevention strategies focus on catheter design, careful insertion and maintenance, and using antimicrobial coatings or locks. Treatment involves removing and replacing the catheter along with systemic antibiotics.
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Crbsi kamran
- 1. CENTRAL VENOUS CATHETER-RELATED BLOODSTREAM INFECTIONS DR KAMRAN AFZAL DEPARTMENT OF PATHOLOGY
- 2. CENTRAL VENOUS CATHETER-RELATED BLOODSTREAM INFECTIONS CVC an important part of critical care medicine CR-BSI occur in 5 – 20% of hospitalized catheterized patients Attributable mortality rate: 10 – 20% More than 90% of nosocomial BSI are associated with CVC
- 3. CENTRAL VENOUS CATHETERS (CVC) PERCUTANEOUS – NTCVC SHORT TERM – PICC SUBCUTANEOUS – TCVC TOTALLY IMPLANTED – TID
- 4. USES Fluids Blood products Drugs Parenteral nutrition Infusion therapy Pressure monitoring
- 5. RISK FACTORS Frequent manipulations Prolonged use Repeated use Violation of asepsis Site of insertion Insertion / maintenance by inexperienced staff Immunocompromised state
- 6. ETIOLOGIC AGENTS Coagulase negative Staphylococcus Staphylococcus aureus Enterococcus spp Pseudomonas spp Acinetobacter spp Escherichia coli Klebsiella spp Enterobacter spp Corynaebacterium spp Candida spp
- 7. CASE DEFINITIONS- I CATHETER CONTAMINATION < 103 CFU / ml (catheter tip) Organisms reach, adhere, multiply CATHETER COLONIZATION > 103 CFU / ml (catheter tip) Blood culture negative for same organism / 24 hrs
- 8. CASE DEFINITIONS- II LOCAL INFECTION > 103 CFU / ml (catheter tip) Local signs and symptoms within 2 cm of skin CATHETER-RELATED BLOODSTREAM INFECTION > 103 CFU / ml (catheter tip) Blood culture positive for same organism / 24 hrs Defervescence on removal of catheter
- 9. PATHOGENESIS- I • Adherence of microorganisms • Formation of thrombin biofilm
- 10. PATHOGENESIS- II MATERIAL Teflon, Polyurethane, Silicone ADHERENCE PROPERTIES Coagulase negative Staphylococcus Slime: glycocalyx formation on polymer surface Staphylococcus aureus Host protein: fibronectin, coagulase production Candida albicans Surface receptors: thrombin biofilm
- 11. PATHOGENESIS- III ROUTES OF INFECTION SHORT TERM Extra-luminal <14 days Intra-luminal Skin microorganisms Haematogenous Cutaneous tract Extra-luminal colonization Infusates LONG TERM >14 days Contamination of catheter hub Intra-luminal colonization
- 12. COMPLICATIONS OF CVC FAULTY INSERTION THROMBOSIS Pneumothorax Local Haemothorax CV thrombosis Arterial puncture Air embolism INFECTION Thoracic duct laceration Exit site Brachial plexus injury Bacteraemia Catheter malposition Septicaemia MECHANICAL METASTASIS Kinking Osteomyelitis Cracking Pneumonia Displacement Endocarditis
- 13. LAB DIAGNOSIS QUANTITATIVE CULTURE PAIRED QUANTITATIVE Accurate CULTURE High sensitivity and Accurate specificity 10 : 1 CFU / ml > 103 CFU / ml between CVC and Sonication peripheral blood Ultra-sonication Vortex DIFFERENTIAL TIME TO POSITIVITY Surface and lumen Cut off: 120 minutes SEMI-QUANTITATIVE CULTURE GRAM STAIN AND AOLC Simplest and commonly Rapid used Simple > 15 CFU Inexpensive External surface High sensitivity and specificity
- 14. SPECIMEN COLLECTION- I INSERTION Aseptic procedure CVC: In OT under GA CVP: In ward under LA REMOVAL Suspicion of infection (local / systemic) No longer required Aseptic procedure COLLECTION Sterile container
- 15. SPECIMEN COLLECTION- II BLOOD CULTURE At the time of catheter insertion and then at removal Fever >1010 F, chills, shock PUS / PUS SWAB Site of insertion Local signs and symptoms
- 16. BACTERIAL CULTURE CATHETER TIP Cleri’s quantitative culture method Blood and MacConkey agar at 370 C aerobically for 24 - 48 hrs BLOOD BHI broth at 370 C aerobically for up to 7 days Sub-culture on days 1, 2, 4 and 7 on Blood and MacConkey agar PUS / PUS SWAB Blood and MacConkey agar at 370 C aerobically for 24 - 48 hrs
- 17. FUNGAL CULTURE CATHETER TIP Sabouraud’s agar at 220 C aerobically for up to 14 days BLOOD CULTURE Trypticase soy broth at 220 C aerobically for up to 14 days PUS / PUS SWAB Sabouraud’s agar at 220 C aerobically for up to 14 days
- 18. IDENTIFICATION BACTERIAL ISOLATES Colony morphology Gram’s stain Biochemical tests Serology API galleries FUNGAL ISOLATES Colony morphology Gram’s stain Lactophenol blue stain Biochemical tests API Candida
- 19. ANTIMICROBIAL SUSCEPTIBILITY TESTING BACTERIAL ISOLATES Modified Kirby-Bauer disk diffusion method CLSI FUNGAL ISOLATES MICs by Etest
- 20. PREVENTION APPROACH EFFECT CATHETER DESIGN • Smooth topography Discourages thrombus formation, microbial adherence, colonization • Antibiotic coating Reduces microbial adherence CARE OF INSERTION SITE • Skin preparation and antisepsis Reduces possibility of catheter contamination • Application of antimicrobials Reduces skin microbial load (mupirocin) at insertion site • Use of (silver-impregnated) Prevents migration of organisms antimicrobial cuff at insertion site down the external surface of catheter • Use of antibiotic-heparin flush soln Discourages fibrin collection / biofilm • Regular use of antiseptics on hub Reduces hub contamination • Use of prophylactic antibiotics Reduces catheter-related infections
- 21. TREATMENT Glycopeptides with / without gram negative coverage Substitution of catheter with / without replacing it at an alternate site Guide-wire exchange Systemic antimicrobial therapy without removing catheter Antibiotic-lock technique Antibiotic and heparin lock solution
- 22. INCIDENCE OF CR-BSI INCIDENCE TYPE OF YEAR REFERENCE CATHETER 16.8% CVC 2003 AFIP study 19.8% CVC / 1999 Souweine et al Peripheral 17.6% CVC / 2000 Petrosillo et al Peripheral 15.1% Peripheral 2001 Hafeez et al 12.0% CVC 2001 Nicastri et al 10.1% CVC / 2000 Kinkelstein et al Peripheral 8.9% CVC 1999 Timsit et al 3.3% CVC 2000 Sherertz et al
- 23. CONCLUSIONS • Central venous catheter is an important source of bloodstream infection in catheterized patients • A glycopeptide and a carbapenem, or pipracillin- tazobactam, or cefoperazone-sulbactam are recommended to be included in the empirical regimen in high risk cases • There is a need to implement more effective infection control measures and more advanced technologies in an effort to reduce this high incidence