LEARNING OBJECTIVES
1. Differentiate types of infection associated with
vascular access
2. Formulate appropriate empiric therapy based on
patient specific risk factors
3. Recite indications for antibiotic lock therapy
4. Prescribe appropriate antibiotic therapy based on
culture results
KEY MESSAGES
1. 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.
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
PATHOPHYSIOLOGY
How do these infections happen?
1. Migration of skin flora from insertion site
2. Direct contamination of catheter
3. Hematogenous seeding
4. Contaminated infusate
RISK FACTORS
Risk 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 device
Insertion site (femoral>IJ>SC)
RISK FACTORS
Risk varies based on:
Duration of catheter
 PIV 3-5 days
 CVC >6 days
 PA catheter >3-4 days
Frequency of accesses
Use of prevention strategies
Experience and skill of individual
Patient factors
ASK 3 MAIN QUESTIONS
1. What is the nature of the infection?
2. What type of catheter is infected?
3. What is the organism?
DEFINITIONS
WHAT IS A CATHETER RELATED BLOODSTREAM
INFECTION (CRBSI)?
What is a CRBSI?
 Growth of same organism
from percutaneous blood
culture and catheter
What is not a CRBSI?
 Catheter colonization
 Phlebitis
 Exit site infection
 Tunnel Infection
 Pocket infection
MORE DEFINITIONS
Catheter 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
ASK 3 MAIN QUESTIONS
1. What is the nature of the infection?
2. What type of catheter is infected?
3. What is the organism?
TYPES OF CATHETERS
PERIPHERAL IV
M ID LIN E C AT HE T E R
TYPES OF CATHETERS
SHORT TERM CVC
PA C AT HE T E R
TYPES OF CATHETERS
PICC
TYPES OF CATHETERS
TOTA L LY I M P L A N TA B L E
DEVICE
LONG TERM CVC
ASK 3 MAIN QUESTIONS
1. What is the nature of the infection?
2. What type of catheter is infected?
3. What is the organism?
EMPIRIC TREATMENT
COVERAGE FOR BACTERIA
Empiric treatment with vanc or dapto depending on hospitals mrsa
mic data
Do not use linezolid empirically
Empiric GNR coverage should be based on severity of disease and
presence of femoral line
Use cefepime, carbapenem, or zosyn if warranted
Only 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
EMPIRIC TREATMENT
COVERAGE FOR CANDIDA
Only empirically cover candida if pt is septic AND one of
the following






TPN
prolonged broad spectrum abx
hematologic malignancy
transplant pt
femoral site
pt colonized with candida at multiple sites
Use echinocandin OR fluconazole if pt has had no azole exposure in
past 3 months
MICROBE SPECIFIC TREATMENT
COAG NEGATIVE STAPH
Nafcillin/oxacillin for msse
Vancomycin for mrse
Treat for 5-7 days with antibiotics if catheter removed
Treat 10-14 days with abx lock if catheter is salvaged
Some say ok to not treat if catheter is removed, pt has
no hardware, and blood cx negative after catheter
removal
MICROBE SPECIFIC TREATMENT
STAPH AUREUS
Always remove catheter
Nafcillin/oxacillin for mssa
Vanco/dapto for mrsa
Default duration of therapy is 4-6 weeks
Treat 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 abx
Treat 5-7 days for tip cx positive/perc blood cx negative situations
MICROBE SPECIFIC TREATMENT
ENTEROCOCCUS
Ampicillin is drug of choice if susceptible
Vanco if resistant to amp
Double coverage with aminoglycoside is controversial
7-14 course of therapy recommended
Only tee if other signs and symptoms of endocarditis
MICROBE SPECIFIC TREATMENT
GRAM NEGATIVE BACILLI
Carbapenem ok for all following
 ESBL + ecoli/klebsiella
 enterobacter
 serratia
 acinetobacter
ESBL – e. coli/klebsiella-use 3rd gen cephalosporin
Psuedomonas-4th gen cephalosporin, carbapenem, zosyn, +/- aminoglycoside
Stenotrophomonas- bactrim 3-5mg/kg q8hr
De-escalate asap
Duration of therapy 7-14 days
MICROBE SPECIFIC TREATMENT
CANDIDA
Always remove catheter (tunneled hd catheter can be exchanged over wire)
C. Glabrata and C. krusei use echinocandins
C. Albicans use fluconazole 400mg qd
ANTIBIOTIC LOCK THERAPY
WHAT IS IT AND WHO CAN GET IT?
ANTIBIOTIC LOCK THERAPY
WHAT 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
PEARLS AND PITFALLS
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
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
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
TREATMENT ALGORITHM
SUSPECTED CRBSI
TREATMENT ALGORITHM
DOCUMENTED CRBSI IN SHORT-TERM CVC
TREATMENT ALGORITHM
DOCUMENTED CRBSI IN LONG TERM CVC
TREATMENT ALOGRITHM
SUSPECTED TUNNELED HD CATHETER INFX
REFERENCE
Mermel 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/GuidelinesPatient_Care/PDF_Library/Management%20IV%20Cath.pdf