guideline update for the management of intravenous catheter related infections
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ACPE accredited presentationTRANSCRIPT
Guideline Update for the Management of Intravascular Catheter-Related Infections
Sarah Nelson, Pharm.D.Critical Care Pharmacy Resident
October 21 & 22, 2009
Objectives Identify common microorganisms associated with
intravascular catheter-related infections
Analyze treatment options for infections associated with short-term catheters
Analyze treatment regimens for infections associated with long-term and dialysis catheters
Recognize appropriate utilization of antibiotic lock therapy
Summarize pathogen-specific treatment recommendations for select microorganisms
Background
Epidemiology 300 million catheters are used in the United
States each year
Functions of intravascular catheters include Administration of fluids and medications Administration of blood products Administration of total parenteral nutrition Monitor hemodynamic status Provide hemodialysis
Mermel LA, Allon M, Bouza E, et a. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the IDSA. Clin Infect Disease. 2009;49:1-45
Epidemiology Nosocomial CRBSI > Community-acquired CRBSI
21.6 cases of CRBSI per 1,000 hospital admissions
Estimated case fatality rate of 20.6%
ICU LOS increases by 9 to 11 daysEdgeworth, J. J Hosp Infect. 2009;10:1-8Al-Rawajfah OM, Stetzer F, Hweitt JB. Infect Control Hosp Epidemiol. 2009;30:000Ramritu P, Halton K, Collignon P, et al. An J Infect Control. 2008;36:104-17
Types of Intravascular DevicesType FunctionPeripheral venous catheter Short-term intravascular administration
Peripheral arterial catheter Monitor hemodynamics & blood gas
Short-term central venous catheter (CVC)
Short-term intravascular administration
Pulmonary artery catheter Advanced hemodynamic monitoring
Peripherally inserted central catheter (PICC)
Short-term intravascular administration(alternative to a CVC)
Long-term CVC Long-term tunneled vascular access
Totally implantable device Long-term subcutaneous port/reservoir with needle access
Mermel LA, Allon M, Bouza E, et al. Clin Infect Disease. 2009;49:1-45
Central Venous Catheters
http://microbix.com
Risk Factors for CRBSIs Type of intravascular device Intended use for catheter Insertion site Experience & education of installer Duration of catheter placement Characteristics of catheterized patient Utilization of preventative strategies
Mermel LA, Allon M, Bouza E, et a. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the IDSA. Clin Infect Disease. 2009;49:1-45
Diagnosis of CRBSI Catheter tip culture + blood culture
Sonification of catheter
Simultaneous quantitative blood cultures
Differential time to positivity (DTP)
Edgeworth, J. Intravascular catheter infections. J Hosp Infect. 2009;10:1-8
Common Pathogens Percutaneous Catheters
Coagulase-negative staphlococci (CNS)
Staphlococcus aureus
Candida species
Enteric gram-negative bacilli
Surgically Implanted & Peripheral Catheters
CNS
Enteric gram-negative bacilli
Staphlococcus aureus
Pseudomonas aeurginosa
Mermel LA, Allon M, Bouza E, et a. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the IDSA. Clin Infect Disease. 2009;49:1-45
Lorente et al Design: prospective cohort
Patient population: Medical/Surgical ICU pts with either a CVC or arterial catheter
Outcome: assess proportion of CRBSI due to gram – rods and yeast according to catheter site
Lorente L, Jimenez A, Santana M et al. Microorganisms responsible for intravascular catheter related bloodstream infection according to catheter site. Crit Care Med. 2007;35:2424-27
Lorente et al.
Lorente L, Jimenez A, Santana M et al. Microorganisms responsible for intravascular catheter related bloodstream infection according to catheter site. Crit Care Med. 2007;35:2424-27
Femoral site n=36 Other site n=52
Gm + bacteria 16 47CNS 8 29MRSA 2 7E. faecalis 4 2Other 2 9Gram – bacteria 14 4E. coli 10 1P. aeurginosa 1 2Candida albicans 6 1
Antibiotic Selection
Empiric Antibiotic Selection Are antibiotics indicated?
Signs/symptoms of infection Patient characteristics
Where is the catheter located?
Can/should the catheter be removed?
Catheter Removal Short-term CVC
Not necessary unless: pt is severely ill, no other sources of fever identified, pt has secondary infections
Long-term CVC/Port Not necessary unless complicated infection is
apparent (tunnel infection, port abscess, secondary infections present)
Mermel LA, Allon M, Bouza E, et a. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the IDSA. Clin Infect Disease. 2009;49:1-45Rijnders BJ, Peetermans WE, Verwaest C et al. Watchful waiting vs. immediate catheter removal in ICU patients with suspected CRI: a randomized trial. Inten Care Med. 2004;30:1073-80
Empiric Antibiotic Therapy Gram + pathogen:
Vancomycin is recommended Daptomycin if MRSA MIC consistently > 2 mcg/mL
Gram – pathogen: Not always necessary Choice based off antibiogram and severity of
illness Single agent vs. double coverage of P. aeurginosa
Double coverage should be used if pt is neutropenic, severely ill with sepsis, or colonized with P. aeurginosa
Mermel LA, Allon M, Bouza E, et a. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the IDSA. Clin Infect Disease. 2009;49:1-45
Empiric Antifungals Not necessary unless patient is septic AND
has any of the following: TPN Prolonged use of broad-spectrum antibiotics Malignancy Transplant recipient Femoral catheter in place Multi-site Candida colonizaton
Mermel LA, Allon M, Bouza E, et a. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the IDSA. Clin Infect Disease. 2009;49:1-45
Tailored Antibiotic Therapy Detailed summary of preferred antibiotics
listed in guidelines
Local antibiogram helps dictate tailored therapy
Duration of therapy dictated by site of infection and pathogen isolated Day 1 of treatment is the first day on which a
negative blood culture is obtained
Mermel LA, Allon M, Bouza E, et a. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the IDSA. Clin Infect Disease. 2009;49:1-45
Guideline Algorithms
Patient with a short term CVC or arterial line with acute febrile illness
Mild or moderately ill (no hypotension or organ failure)
Seriously ill (hypotension, hypoperfusion, s/sx organ dysfunction)
Consider antimicrobial
therapy
Blood cultures (2 sets, 1 peripheral)
If no other source of fever, remove CVC or AC and culture tip, replace or exchange CVC
Blood cultures (2 sets, 1 peripheral), remove CVC or AC
and culture tip, replace or
exchange CVC
Initiate appropriate
antimicrobial therapy
Blood culture (-) & catheter not cultured
Blood culture (-) & catheter culture (-)
Blood culture (-) & catheter culture ≥15 CFU
Blood culture (+) & catheter culture ≥15 CFU
Continued fever & no other source found,
remove & culture CVC or AC
Look for other source of infection
See figure 2For S. aureus, treat for 5-7 days. For all other microbes, monitor for s/sx
infection and send repeat blood cultures appropriately
Short-term CVC or AC-related bloodstream infection
Complicated Uncomplicated (infection and fever resolved within 72 hours, no
hardware, evidence of endocarditis or suppurative thrombophlebitis, & if S.
aureus, no active malignancy or immunosuppression)
Suppurative thrombophlebi
tis, endocarditis, osteomyelitis,
etc
S. aureus Enterococcus Gram - bacilli Candida spCNS
Remove catheter & treat 4-6
weeks, 6-8 weeks for
osteomyleitis
Remove catheter and treat
with systemic
Abx for 5-7 days
If catheter is retained, add ALT for 10-14 days
Remove catheter and treat
with systemic Abx for ≥ 14 days
Remove catheter and treat
with systemic
Abx for 7-14 days
Remove catheter and treat
with systemic
Abx for 7-14 days
Remove catheter and treat
with systemic Abx for ≥ 14 days after 1st negative culture
Long-term CVC or port-related bacteremia or fungemia
UncomplicatedComplicated
Tunnel infection/
port abscess
Suppurative thrombophlebitis,
endocarditis, osteomyelitis
S. aureus Enterococcus Gram - bacilli Candida spCNS
Remove CVC/P
and treat with
systemic Abx for 7-10 days
Remove CVC/P and treat with
systemic Abx for 4-6 weeks, 6-8 weeks for osteomyelitis
Retain CVC/P and treat with systemic
Abx + ALT for 10-14
days
Remove CVC/P and treat with
systemic Abx for 4-6 weeks
Retain CVC/P and treat with systemic Abx + ALT for 7-14
days
Remove catheter and treat
with systemic Abx for ≥ 14 days after 1st negative culture
Remove and treat with systemic Abx 7-14
daysOR
Retain and treat with systemic + ALT for 10-
14 days
Remove CVC/P if there is clinical deterioration, persisting bacteremia or signs of complicated infection
Tunneled HD catheter with suspected CRBSI
Empiric Abx + ALT
Negative blood cultures Persistent bacteremia/fungemia and fever
Resolution of bacteremia/fungemia and fever in 2-3 days
Stop Antibiotics CNS Gram - bacilli S. aureus C. albicans Remove CVC and administer
antibiotics
Antibiotic tx for 10-14 days, retain CVC
and continue ALT OR replace CVC
Remove CVC & treat with
systemic Abx for 3 weeks if TEE-
Replace catheter and treat with
systemic Abx for ≥ 14 days after 1st negative culture
Systemic Abx 4-6 weeks and look for signs
of complicated infection
Persistent bacteremia/fungemia and fever
Remove CVC and administer
antibiotics
Systemic Abx 4-6 weeks and look for signs
of complicated infection
Guideline Changes
Changes to the 2009 Guidelines Short-term CVC
Addition of arterial line infection Alteration of treatment duration Inclusion of antibiotic lock therapy Inclusion of specific therapy for Enterococcus sp.
Long-term CVC Distinguishes hemodialysis catheter infection vs. long-
term CVC and port infection Alteration of treatment duration Inclusion of antibiotic lock therapy Inclusion of specific therapy for Enterococcus sp.
Mermel LA, Allon M, Bouza E, et a. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the IDSA. Clin Infect Disease. 2009;49:1-45
Coagulase-negative staphylococcus Most common contaminant AND cause of
CRBSI
Benign clinical course Rarely leads to sepsis
Little evidence to drive treatment recommendations Remove catheter & DO NOT treat Treat systemically and/or ABL
Mermel LA, Allon M, Bouza E, et a. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the IDSA. Clin Infect Disease. 2009;49:1-45
S. aureus Important to determine uncomplicated from
complicated infection to determine treatment duration
Infective endocarditis commonly associated with S. aureus bacteremia TEE should be completed 5-7 days after onset of bacteremia
Risk factors associated with complicated S. aureus bacteremia: + blood cultures >72 hours after initiation of Abx Community-acquired infection Skin changes consistent with septic emboli
Mermel LA, Allon M, Bouza E, et a. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the IDSA. Clin Infect Disease. 2009;49:1-45
S. aureus Wilcox et al
Design: randomized, double-blind, non-inferiority Intervention:
Vancomyin (weight-based dosing) Linezolid 600 mg every 12 hours
Endpoint: Microbiological and clinical cure Outcome:
Microbiological cure: 86% for vancomycin vs. 81% for linezolid
Clinical cure: 76% for vancomcyin vs. 79% for linezolid
Wilcox MH, Tack KJ, Bouza E et al. Complicated skin and skin-structure infections and catheter-related bloodstreaminfections: non-inferiority of linezolid in a phase 3 study. Clin Infect Dis. 2009;48:203-12
Enterococcus sp. New addition to the guidelines Account for 10% of all nosocomial
bloodstream infections 60% of E. faecalis was resistant to vancomycin
No good data to support Role of combination therapy Duration of treatment
Jones Rn, Marshall SA, Pfaller MA et al. Nosocomial enterococcal blood stream infections in the SCOPE program. Diagn Microbiol Infect Dis. 2004;39:309-17
Gram - bacilli Rate of gram – bacilli associated CRBSI is
decreasing
Resistance to gram – bacilli increasing
Role of double antibiotic coverage for CRBSI
Wilcox MH, Tack KJ, Bouza E et al. Complicated skin and skin-structure infections and catheter-related bloodstreaminfections: non-inferiority of linezolid in a phase 3 study. Clin Infect Dis. 2009;48:203-12
Gram - bacilli Safdar N et al.
Design: meta-analysis Outcome: mortality in monotherapy vs.
combination therapy in gram – bacteremia Results:
Combination therapy for P. aeurginosa demonstrated a significant mortality benefit (OR 0.5, 95% CI 0.3-0.79)
Mortality not reduced with utilization of combination therapy for other gram - bacilli
Safdar N, Handelsman J, Maki D. Does combination antimicrobial therapy reduce mortality in gram-negative bacteremia? Lancet Infect Dis. 2004;4:519-27
Antibiotic Lock Therapy
Antibiotic Lock Therapy (ALT) Attempt to salvage current intravascular
catheter
Small amount of antibiotic is retained in the catheter lumen to eradicate colonized microorganisms
Used in combination with systemic antibiotics for 7-14 days
Segara-Newnham M, Martin-Cooper EM. Antibiotic Lock Technique: a review of the literature. Annals of Pharmacotherapy. 2005;39:311-8
Advantages of ALT Negligible risk of adverse effects
Increased local concentration of antibiotic
Ease of administration
Ability to administer in an outpatient setting
Decreases need for catheter replacement
Cost-saving measure
Segara-Newnham M, Martin-Cooper EM. Antibiotic Lock Technique: a review of the literature. Annals of Pharmacotherapy. 2005;39:311-8
Types of ALT Antibiotics
Cefazolin, 5mg/mL Vancomycin, 5mg/mL Ampicillin, 10 mg/mL Ceftazidime, 0.5 mg/mL Ciprofloxacin, 0.2 mg/mL Gentamicin, 1 mg/mL
Ethanol 70%
Mermel LA, Allon M, Bouza E, et a. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the IDSA. Clin Infect Disease. 2009;49:1-45
Fernandez-Hidalgo et al. Design: retrospective/prospective Intervention
Gram + organism: vancomycin 2 mg/mL Gram - organism: ciprofloxacin 2mg/mL OR amikacin 2
mg/mL Treatment duration: 10-14 days
Outcomes Cure: negative cultures at 1 month Treatment failure: positive cultures or presence of fever
>72 hours after start of ALT or expansion of infection Relapse: new episode of infection with same
microorganism within 30 days of treatment completionFernandez-Hidalgo N, Almirante B, Calleja R, et al. Antibiotic lock therapy for long-term intravascular catheter-related bacteremia: results of an open, non-comparative study. J Antimicro Chemotherapy. 2006:57:1172-80
Fernandez-Hidalgo et al.Organism No. of isolatesGram + organisms 80CNS 56S. aureus 20E. faecalis 2other 3Gram – organisms 26E. coli 11P. aeurginosa 5other 10Polymicrobial infection 8
Fernandez-Hidalgo N, Almirante B, Calleja R, et al. Antibiotic lock therapy for long-term intravascular catheter-related bacteremia: results of an open, non-comparative study. J Antimicro Chemotherapy. 2006:57:1172-80
Fernandez-Hidalgo et al. Treatment success occurred in 93 cases (82%)
Gram + infection cure rate: 78% Gram - infection cure rate: 92% By treatment day 7, all cultures were negative
Unsuccessful outcomes occurred in 21 cases Treatment failure: 13 cases Relapses: 7 cases Death: 1 case
Mean catheter salvage duration: 163 daysFernandez-Hidalgo N, Almirante B, Calleja R, et al. Antibiotic lock therapy for long-term intravascular catheter-related bacteremia: results of an open, non-comparative study. J Antimicro Chemotherapy. 2006:57:1172-80
Fortun et al. Design: prospective, randomized Intervention
Systemic therapy alone Systemic therapy + ALT
Gram + organism: vancomycin 2 mg/mL Gram - organism: ciprofloxacin 2mg/mL OR gentamicin 2 mg/mL
Treatment duration: 14 days
Outcomes Cure: negative cultures 2-5 days after completion of
treatment and no colonization present Treatment failure: catheter removal, persistence of
colonization, relapse of bacteremiaFortun J, Grill F, Martin-Davis, P. et al. Treatment of long-term intravascular catheter-related bacteremia with antibiotic lock therapy. J Antimricob Chemotherapy. 2006;58:816-821
Fortun et al.
Organism ALT + systemic therapy
N=19
Systemic therapy onlyN=29
CNS 14 19
S. aureus 3 4
Gram - bacteria
2 6
Fortun J, Grill F, Martin-Davis, P. et al. Treatment of long-term intravascular catheter-related bacteremia with antibiotic lock therapy. J Antimricob Chemotherapy. 2006;58:816-821
Fortun et al.
Fortun J, Grill F, Martin-Davis, P. et al. Treatment of long-term intravascular catheter-related bacteremia with antibiotic lock therapy. J Antimricob Chemotherapy. 2006;58:816-821
Ethanol Locks Antiseptic agent, bactericidal Active against gram + and gram – organisms
and fungi Non-toxic in doses administered Advantageous in patients with multi-drug
resistant pathogens May be best option for PREVENTION of CRBSI
and catheter colonization
Broom J, Woods M, Allworth A. Ethanol lock therapy to treat tunnelled central venous catheter associated blood stream infections: results from a prospective trial. Scandinavian Journal of Infect Disesase. 2008;40:399-406
Prevention of CRBSI
Preventative Strategies Hand hygiene
Sterile precautions during insertion
Skin antisepsis (chlorhexidine, iodine)
Daily inspection and documentation of exit site
Avoidance of femoral site utilization
Removal of device as soon as it is no longer required
Utilization of antimicrobial impregnated cathetersEdgeworth, J. Intravascular catheter infections. J Hosp Infect. 2009;10:1-8
Antimicrobial Impregnated CVCs Coating of catheters with antimicrobial compounds
External coating with chlorhexidine and silver sulfadiazine (CH-SS)
Silver, platinum, or carbon coating Antimicrobial coatings
minocycline + rifampin (MR) vancomycin cefazolin
Only externally coated CH-SS and MR coated catheters reduced the risk of CRBSI as compared to uncoated catheters
Ramritu P, Halton K, Collignon P, et al. A systematic review comparing the relative effectivenessof antimicrobial-coated catheters in intensive care units. An J Infect Control. 2008;36:104-17
Take Home Points CRBSI are common and can happen with a variety of
intravascular devices
CNS is the predominant pathogen causing CRBSI Pt characteristics may predispose them to other pathogens
Catheter removal is not always necessary ‘Watch and wait’ method or antibiotic lock therapy may help avoid
catheter replacement Antibiotic lock therapy plays a larger role in current guidelines
Guidelines demonstrate proper treatment for short-term, long-term, tunneled, and port infections
Prevention of CRBSI should not be forgotten
Questions?