IV CATHETER-RELATED RELATED INFECTIONS Javier Garau Department of Medicine Universidad de Barcelona SPAIN
Scope of the problem Catheter types and terms Epidemiology and pathogenesis Diagnosis Etiology Local and systemic therapy Preventive measures
ACCESS TO THE VASCULAR TREE Administration of : Hydroelectrolitic solutions Drugs Hemodyalisis Blood derivatives parentheral nutrition Hemodinamic monitoring
CATHETER-RELATED RELATED SEPSIS CONSECUENCES Increased morbidity/mortality 2573 episodes* Mortality global: 14% attributable, 19% (2.7%) (S. aureus, 8.2%; Coag neg Staph, 0.7%) Increased LOS Increased costs *Byers et al. En Mermel LA et al. CID 2001
TYPES OF INTRAVASCULAR CATHETERS AND DEVICES Peripheral venous catheter Peripheral arterial catheter Middle sized venous catheter Central venous catheter (CVC) Pulmonary artery catheter Presure monitoring systems Central catheter with peripheral implantation Tunnelized CVC Subcutaneous device
TYPES OF INTRAVASCULAR CATHETERS Peripheral venous catheter. Usually in veins of the arm or hand; short duration; low incidence of infection Peripheral arterial catheter. Short duration. Measures hemodynamic status or blood gas analysis in critical patients; risk of infection similar to CVC Middle size venous catheter. Peripheral catheter in antecubital fossa (basilic, cephalic veins). Does not reach central veins; lesser risk than CVC Non tunnelized CVC. Yugular, subclavian veins.the commonest type in ICU; 90% of all catheter related sepsis. Yugular vein, higher risk than subclavian Central catheter with peripheral insertion. Usually from antecubital fossa to superior vena cava
TYPES OF INTRAVASCULAR DEVICES Tunnelized CVC. Surgically placed CVC ( Hickman, Broviac, Groshong, Quinton); for prolonged catheterization Totally Implantable device. A subcutaneous reservoir under the skin. Access through the skin with a needle; low incidence of infection
Estimated risk of catheter-related related bacteremia for different catheter types TYPE OF CATHETER BACTEREMIAS PER 1000 DAYS OF CATHETER Short, peripheral < 2 Arterial 10 Central Venous, multilumen 30 Swan-Ganz 10 Hemodyalisis 50 Long duration CVC, peripheral insertion Tunneled CVC Totally implantable device 2 2 < 1 Sheretz RJ. ASM, Washington 2000
INTRAVASCULAR DEVICES TERMINOLOGY Catheter colonización Significant growth of a microorganism in culture of catheter tip, subcutaneous segment or catheter hub Exit site infection CLINICAL: Erythema, induration and/or tenderness whithin 2 cm of catheter exit site; may be associated to other signs (pus) or symptoms of infection (fever) MICROBIOLOGAL: Exudate at catheter exit site yields a microorganism with or without concomitant blood stream infection
INTRAVASCULAR DEVICES TERMINOLOGY Tunnel infection Erythema, induration and/or tenderness along the subcutaneous track of a tunneled catheter (Hickman o Broviac) with or without concomitant bloodstream infection Pocket infection Infected fluid in the subcutaneous pocket of a totally implantable intravascular device. Often associated with local signs of infection;spontaneous rupture and drainage or necrosis of skin can occur
EPIDEMIOLOGY AND PATHOGENESIS. Each year, approximately > 27 millions of iv catheters and iv devices are sold in Spain for iv administration The majority are peripheral venous catheters, but there are at least 3 million CVC Risk factors for infection vary with the type of catheter, hospital size, Unit or Service, site of insertion and duration of catheterization
Maki DG et al. New Egl J Med 1977 Liñares J, Sitges-Serra A, Garau J et al. J Clin Microbiol 1985 Sitges-Serra A, Liñares J, Garau J et al. Surgery 1985
CATHETER RELATED SEPSIS I. Skin and extralumenal progression The traditional mechanism Historical importance of focal infection The most important cause of bacteremic catheter-related related infection Early infection
CATHETER RELATED SEPSIS II. Hub and intralumenal colonization Commonly associated with bacteremia Late infection 80% of sepsis in CVC for TPN Sources : Skin Orotracheal secretions Hands Infusate Cercenado et al 1990
CATHETER RELATED SEPSIS III. Contamination of infusate Uncommon Intralumenal colonization Hub frequently colonized Intrínsic TPN Intralípid Blood derivatives Tribe Klebsiellae Non fermenting GNB
CATHETER RELATED SEPSIS IV. Hematogenous seeding Exceptional Importance of fibrin cuff
Relative importance of the different routes of colonization of intravascular catheters* Reference Nº catheters Implantation days Episodes SRC Hub Skin Mixed Other A Cercenado et al De Cicco et al Salzman et al Liñares et al Fan et al Weightman et al Segura et al 139 109 113 135 156 42 400 D 8,6 18,2 23,9 20 15 114 23 53(30.8%) B 6(5.5%) 28(24.7%) 20(14.8%) 11(7.1%) 11(26.1%) 24(6%) 12 3 21 14 1 8 9 30 3 7 2 4-5 8 - - - 2-2 3 - - 4 4 3 C 8 BRC: catheter related bacteremia A Hematogenous seeding. B Positive culture of tip C Cultures not completed D Number of patients Sitges-Serra A et al. Nutrition, 1997;13:30s-35s
RATE (MEAN) OF CATHETER-RELATED RELATED BACTEREMIA. NNISS 1992-20012001 TYPE OF ICU Coronary Cardiothorathic Medical/surgical Neonatal < 1000 g 1001-15001500 1501-2500 > 2500 Pediatric Nº of ICUs Catheter days 102 64 123 138 136 132 133 74 252,325 419,674 579,704 438,261 213,351 163,697 231,573 291,831 Rate/1000 catheter days 4.5 2.9 5.3 11.3 6.9 4.0 3.8 7.6 Seguin J et al, Am J Perinatol 1994; Loisel DB et al, J Perinatol 1996; O Grady NP et al, Clin Infect Dis 2001
CATHETER RELATED SEPSIS Clinical diagnosis Rapid diagnosis Catheter cultures DIAGNOSIS Paired CVC and peripheral cultures (Quantitative cultures; Differences in growing time to positivity) Infusate contamination
DIAGNOSIS CLINICAL DIAGNOSIS Low sensitivity and specificity TECHNIQUES OF RAPID DIAGNOSIS Gram stain, useful in local infection, but low sensitivity In some studies, orange of acridine stain has a positive predictive value of 91% and a negative predictive value of 97%* *Kite P et al. Lancet 1999
CATHETER CULTURES Qualitative cultures of catheter tip Semiquantitative cultures of catheter tip (Maki et al, 1977) Quantitative cultures of the catheter tip - Cleri et al (1980) - Liñares et al (1985) - Brun-Buisson Buisson et al (1990) - Sheretz et al (1990)
Catheter related bacteremias-causative organisms Microorganism 1986-19891989 % 1992-19991999 % GRAM POSITIVE COCCI Cagulase negative staphylococci Staphylococcus aureus Enterococcus spp GRAM NEGATIVE BACILLI Escherichia coli Enterobacter spp Pseudomonas aeruginosa Klebsiella pneumoniae FUNGI Candida spp 27 16 8 6 5 4 4 8 37 13 13 2 5 4 3 8 CDC. Am J Infect Control 1999; Schaberg DR et al. Am J Med 1991
Main coagulase negative staphylococci of interest in human infetions S. epidermidis Most common pathogen; bacteremia, infection prothesis, wound, endoftalmitis S. saprophyticus Common pathogen; UTI S. haemolyticus S. lungdunensis S. auricularis, capitis, cohnii, hominis, simulans, warneri, saccharolyticus, schleiferi, xylosus Less common pathogens; bacteremia, endocarditis Rare pathogens; infection prosthesis
When to remove the catheter Clinical picture Presence of local signs of infection Type of catheter Microorganism Possibility of conservative treatment Change of catheter through a metallic wire serving as a guide can be an alternative to consider in cases where there is an extreme difficulty in finding a new vascular access
Indications of immediate withdrawal of IV catheter when infection is suspected Unnecessary catheters Catheters easy to replace Catheters in patients with persistent bacteremia despite adequate antibiotic treatment Tunnelized catheters with infection of subcutaneous track Catheters causing embolization Catheters as a cause of endocarditis Catheters infected with difficult to treat microorganisms without their removal