line infections diagnosis and treatment
DESCRIPTION
Line Infections diagnosis and treatment. Hospital medicine curriculum Pamela pride md,fhm Medical University of South Carolina May 21, 2013. Learning objectives. Differentiate types of infection associated with vascular access - PowerPoint PPT PresentationTRANSCRIPT
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LINE IN
FECTIONS
DIAGNOSIS AND TREAT
MENT
H O S P I TA L M
E D I CI N
E CU R R I C
U LU M
PA M E L A PR I D
E MD , F
H M
M E D I CA L U
N I VE R S I T
Y OF S
O U T H CA R O L I N
A
M AY 21 , 2
0 1 3
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LEARNING OBJECTIVES1. Differentiate types of infection
associated with vascular access2. Formulate appropriate empiric therapy
based on patient specific risk factors3. Recite indications for antibiotic lock
therapy4. Prescribe appropriate antibiotic
therapy based on culture results
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KEY MESSAGES1. Catheter related bloodstream infection
(CRBSI) is defined as growth of the same microorganism in blood drawn from a percutaneous stick and from an intravenous catheter.
2. The treatment of line infections depends on type of catheter and microorganism.
3. Antibiotic lock therapy is used to salvage long term catheters infected in certain circumstances.
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INTRODUCTION >150,000 devices purchased annually
by US hospitals >100,000 deaths $6.5 billion cost Result in average LOS of 12 days longer
in hospital
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PATHOPHYSIOLOGYHow do these infections happen?1. Migration of skin flora from insertion site2. Direct contamination of catheter3. Hematogenous seeding4. Contaminated infusate
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RISK FACTORSRisk varies based on:Type of device Midline catheters 0.2% PIV 0.5% PICC 1.1% Tunneled cvc 1.6% Noncuffed cvc 1.7/2.7% PA catheters 3.7%Use of deviceInsertion site (femoral>IJ>SC)
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RISK FACTORS Risk varies based on:Duration of catheter PIV 3-5 days CVC >6 days PA catheter >3-4 days Frequency of accessesUse of prevention strategiesExperience and skill of individualPatient factors
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ASK 3 MAIN QUESTIONS1. What is the nature of the
infection?2. What type of catheter is
infected?3. What is the organism?
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What is a CRBSI? Growth of same
organism from percutaneous blood culture and catheter
What is not a CRBSI?Catheter colonizationPhlebitisExit site infectionTunnel InfectionPocket infection
DEFINITIONSWHAT IS A CATHETER RELATED BLOODSTREAM INFECTION (CRBSI)?
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MORE DEFINITIONSCatheter colonization-growth of organism from tip, hub or sq segment of
catheter
Phlebitis-redness, warmth, tenderness along tract of catheterized vein
Exit site infection-redness, tenderness or exudate with growth at exit site
Pocket infection-infected fluid in pocket of totally implanted device
Tunnel infection-pain, redness, >2cm from catheter exit site along sq tract of tunneled catheter
Complicated Infection-metastatic foci of bloodstream infection
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ASK 3 MAIN QUESTIONS1. What is the nature of the
infection?2. What type of catheter is
infected?3. What is the organism?
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TYPES OF CATHETERS
P E R I P H E R A L I V M I D L I N E C A T H E T E R
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TYPES OF CATHETERS
S H O R T T E R M C V C P A C A T H E T E R
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TYPES OF CATHETERS
P I C C
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TYPES OF CATHETERST O T A L L Y I M P L A N T A B L E D E V I C E
L O N G T E R M C V C
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ASK 3 MAIN QUESTIONS1. What is the nature of the
infection?2. What type of catheter is
infected?3. What is the organism?
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EMPIRIC TREATMENTCOVERAGE FOR BACTERIAEmpiric treatment with vanc or dapto depending
on hospitals mrsa mic data
Do not use linezolid empiricallyEmpiric GNR coverage should be based on severity
of disease and presence of femoral line
Use cefepime, carbapenem, or zosyn if warrantedOnly empirically double cover MDR GNR if pt is
one of the following neutropenic severely septic colonized/recently infected with mdr gnr
Add aminoglycoside if warranted
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EMPIRIC TREATMENTCOVERAGE FOR CANDIDAOnly empirically cover candida if pt is
septic AND one of the followingTPNprolonged broad spectrum abxhematologic malignancytransplant ptfemoral sitept colonized with candida at multiple sites
Use echinocandin OR fluconazole if pt has had no azole exposure in past 3 months
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MICROBE SPECIFIC TREATMENTCOAG NEGATIVE STAPHNafcillin/oxacillin for msseVancomycin for mrseTreat for 5-7 days with antibiotics if catheter
removedTreat 10-14 days with abx lock if catheter is
salvagedSome say ok to not treat if catheter is
removed, pt has no hardware, and blood cx negative after catheter removal
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MICROBE SPECIFIC TREATMENTSTAPH AUREUSAlways remove catheterNafcillin/oxacillin for mssaVanco/dapto for mrsaDefault duration of therapy is 4-6 weeksTreat 14 days if all following apply pt not immunosuppressed catheter is removed no intravascular devices or grafts tee negative no evidence of metastatic infx bacteremia resolves after 72 hours on abxTreat 5-7 days for tip cx positive/perc blood cx negative situations
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MICROBE SPECIFIC TREATMENTENTEROCOCCUSAmpicillin is drug of choice if susceptibleVanco if resistant to ampDouble coverage with aminoglycoside is controversial7-14 course of therapy recommendedOnly tee if other signs and symptoms of endocarditis
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MICROBE SPECIFIC TREATMENTGRAM NEGATIVE BACILLICarbapenem ok for all following
ESBL + ecoli/klebsiella enterobacter serratia acinetobacter
ESBL – e. coli/klebsiella-use 3rd gen cephalosporinPsuedomonas-4th gen cephalosporin, carbapenem, zosyn, +/-
aminoglycosideStenotrophomonas- bactrim 3-5mg/kg q8hrDe-escalate asapDuration of therapy 7-14 days
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MICROBE SPECIFIC TREATMENTCANDIDAAlways remove catheter (tunneled hd catheter can be
exchanged over wire)C. Glabrata and C. krusei use echinocandinsC. Albicans use fluconazole 400mg qd
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ANTIBIOTIC LOCK THERAPYWHAT IS IT AND WHO CAN GET IT?
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ANTIBIOTIC LOCK THERAPYWHAT IS IT AND WHO CAN GET IT?
For pts with long term cvc’s and uncomplicated crbsi
Always use with systemic abx If abx lock not available, give systemic abx through
the lumen of the infected catheter
Not for candida or staph aureus crbsi Not for complicated crbsi, exit site or tunnel infx, or
infx with persistent + blood cx after >72 hours of appropriate abx therapy
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PEARLS AND PITFALLS
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PEARLS AND PITFALLS
Only culture if infection is suspected
Culture before starting abx
The first day cultures are negative is day one of
abx If unable to obtain percutaneous blood cultures,
drawn cultures from 2 lumens of line
Arterial lines follow the same rules as
temporary cvc’s
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PEARLS AND PITFALLS Do not remove catheters based on fever alone Do not change over guidewire routinely to
prevent infection If you exchange a catheter over a guide wire
and the tip and perc blood cx come back +, you must remove catheter and do fresh stick
When removing the line for suspected crbsi, culture the tip, not the sq segment
For PA catheters culture the introducer tip
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PREVENTION Only place line if necessary, use least risky line in the
least risky place that will accomplish your goals
Use full body drape and aseptic technique
Prophylactic systemic abx are not indicated
For pts with hx of crbsi abx lock may be indicated for
prevention
Education, education, education
Checklists
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TREATMENT ALGORITHMSUSPECTED CRBSI
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TREATMENT ALGORITHMDOCUMENTED CRBSI IN SHORT-TERM CVC
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TREATMENT ALGORITHMDOCUMENTED CRBSI IN LONG TERM CVC
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TREATMENT ALOGRITHMSUSPECTED TUNNELED HD CATHETER INFX
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REFERENCEMermel LA, Allon
M, et al. Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America. Accessed on line at: http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Management%20IV%20Cath.pdf