IV CATHETERIV CATHETER--RELATED RELATED INFECTIONSINFECTIONS

Javier GarauJavier Garau

Department of MedicineDepartment of Medicine

Universidad de BarcelonaUniversidad de Barcelona

SPAINSPAIN

Scope of the problemScope of the problem

Catheter types and termsCatheter types and terms

Epidemiology and pathogenesisEpidemiology and pathogenesis

DiagnosisDiagnosis

EtiologyEtiology

Local and systemic therapyLocal and systemic therapy

Preventive measuresPreventive measures

ACCESS TO THE VASCULAR ACCESS TO THE VASCULAR TREETREE

Administration of :Administration of :

Hydroelectrolitic solutionsHydroelectrolitic solutions

Drugs Drugs

Blood derivativesBlood derivatives

parentheral nutritionparentheral nutrition

HemodyalisisHemodyalisis

Hemodinamic monitoringHemodinamic monitoring

CATHETERCATHETER--RELATED SEPSIS RELATED SEPSIS CONSECUENCESCONSECUENCES

Increased morbidity/mortalityIncreased morbidity/mortality2573 episodes*2573 episodes*

Mortality global: 14%Mortality global: 14%attributable, 19% (2.7%)attributable, 19% (2.7%)

(S. aureus, 8.2%; Coag neg Staph, (S. aureus, 8.2%; Coag neg Staph, 0.7%)0.7%)Increased LOSIncreased LOSIncreased costsIncreased costs

*Byers et al. En Mermel LA et al. CID 2001

TYPES OF INTRAVASCULAR TYPES OF INTRAVASCULAR CATHETERS AND DEVICESCATHETERS AND DEVICES

Peripheral venous catheterPeripheral venous catheterPeripheral arterial catheterPeripheral arterial catheterMiddle sized venous catheterMiddle sized venous catheterCentral venous catheter (CVC)Central venous catheter (CVC)Pulmonary artery catheterPulmonary artery catheterPresure monitoring systemsPresure monitoring systemsCentral catheter with peripheral implantationCentral catheter with peripheral implantationTunnelized CVC Tunnelized CVC Subcutaneous deviceSubcutaneous device

TYPES OF INTRAVASCULAR CATHETERSTYPES OF INTRAVASCULAR CATHETERS

Peripheral venous catheterPeripheral venous catheter. Usually in veins of the . Usually in veins of the arm or hand; short duration; low incidence of infectionarm or hand; short duration; low incidence of infectionPeripheral arterial catheterPeripheral arterial catheter. Short duration. Measures . Short duration. Measures hemodynamic status or blood gas analysis in critical hemodynamic status or blood gas analysis in critical patients; risk of infection similar to CVCpatients; risk of infection similar to CVCMiddle size venous catheterMiddle size venous catheter. Peripheral catheter in . Peripheral catheter in antecubital fossa (basilic, cephalic veins). Does not antecubital fossa (basilic, cephalic veins). Does not reach central veins; lesser risk than CVCreach central veins; lesser risk than CVCNon tunnelized CVC. Non tunnelized CVC. Yugular, subclavian veins.The Yugular, subclavian veins.The commonest type in ICU; 90% of all catheter related commonest type in ICU; 90% of all catheter related sepsis. Yugular vein, higher risk than subclaviansepsis. Yugular vein, higher risk than subclavianCentral catheter with peripheral insertion. Central catheter with peripheral insertion. Usually Usually from antecubital fossa to superior vena cavafrom antecubital fossa to superior vena cava

TYPES OF INTRAVASCULAR TYPES OF INTRAVASCULAR DEVICESDEVICES

Tunnelized CVC Tunnelized CVC . Surgically placed CVC ( . Surgically placed CVC ( Hickman, Broviac, Groshong, Quinton); for Hickman, Broviac, Groshong, Quinton); for prolonged catheterizationprolonged catheterization

Totally Implantable device. Totally Implantable device.

A subcutaneous reservoir under the skin. A subcutaneous reservoir under the skin. Access through the skin with a needle; low Access through the skin with a needle; low incidence of infectionincidence of infection

Estimated risk of catheterEstimated risk of catheter--related bacteremia for related bacteremia for different catheter typesdifferent catheter types

TYPE OF CATHETERTYPE OF CATHETER BACTEREMIAS PER 1000 DAYS OF BACTEREMIAS PER 1000 DAYS OF CATHETERCATHETER

Short, peripheralShort, peripheral < 2< 2

ArterialArterial 1010

Central Venous, multilumenCentral Venous, multilumen 3030

SwanSwan--GanzGanz 1010

HemodyalisisHemodyalisis 5050

Long durationLong duration

CVC, peripheral insertionCVC, peripheral insertion

Tunneled CVCTunneled CVC

Totally implantable deviceTotally implantable device

22

22

< 1< 1

Sheretz RJ . ASM, Washington 2000

INTRAVASCULAR DEVICES INTRAVASCULAR DEVICES TERMINOLOGYTERMINOLOGY

Catheter colonización Catheter colonización Significant growth of a Significant growth of a microorganism in culture of catheter tip, microorganism in culture of catheter tip, subcutaneous segment or catheter hubsubcutaneous segment or catheter hub

Exit site infectionExit site infectionCLINICAL: Erythema, induration and/or CLINICAL: Erythema, induration and/or

tenderness whithin 2 cm of catheter exit site; tenderness whithin 2 cm of catheter exit site; may be associated to other signs (pus) or may be associated to other signs (pus) or symptoms of infection (fever)symptoms of infection (fever)

MICROBIOLOGAL: Exudate at catheter exit MICROBIOLOGAL: Exudate at catheter exit site yields a microorganism with or without site yields a microorganism with or without concomitant blood stream infectionconcomitant blood stream infection

INTRAVASCULAR DEVICES INTRAVASCULAR DEVICES TERMINOLOGY TERMINOLOGY

Tunnel infection Tunnel infection Erythema, induration and/or Erythema, induration and/or tenderness along the subcutaneous track of a tenderness along the subcutaneous track of a tunneled catheter (Hickman o Broviac) with or tunneled catheter (Hickman o Broviac) with or without concomitant bloodstream infectionwithout concomitant bloodstream infection

Pocket infection Pocket infection Infected fluid in the subcutaneous Infected fluid in the subcutaneous pocket of a totally implantable intravascular pocket of a totally implantable intravascular device. Often associated with local signs of device. Often associated with local signs of infection;spontaneous rupture and drainage or infection;spontaneous rupture and drainage or necrosis of skin can occurnecrosis of skin can occur

EPIDEMIOLOGY AND PATHOGENESIS. EPIDEMIOLOGY AND PATHOGENESIS.

Each year, approximately > 27 millions of iv catheters and Each year, approximately > 27 millions of iv catheters and iv devices are sold in Spain for iv administrationiv devices are sold in Spain for iv administration

The majority are peripheral venous catheters, but there The majority are peripheral venous catheters, but there are at least 3 million CVCare at least 3 million CVC

Risk factors for infection vary with the type of catheter, Risk factors for infection vary with the type of catheter, hospital size, Unit or Service , site of insertion and hospital size, Unit or Service , site of insertion and duration of catheterizationduration 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 CATHETER RELATED SEPSIS

I. Skin and extralumenal progressionI. Skin and extralumenal progression

The traditional mechanismThe traditional mechanism

Historical importance of focal infectionHistorical importance of focal infection

The most important cause of bacteremic The most important cause of bacteremic cathetercatheter--related infectionrelated infection

Early infectionEarly infection

CATHETER RELATED SEPSIS CATHETER RELATED SEPSIS

II. Hub and intralumenal colonizationII. Hub and intralumenal colonization

Commonly associated with bacteremiaCommonly associated with bacteremiaLate infectionLate infection≈≈80% of sepsis in CVC for TPN80% of sepsis in CVC for TPNSources : Sources : SkinSkin

Orotracheal secretionsOrotracheal secretionsHandsHandsInfusate Infusate

Cercenado et al 1990

CATHETER RELATED SEPSIS CATHETER RELATED SEPSIS

III. Contamination of infusateIII. Contamination of infusateUncommon Uncommon Intralumenal colonization Intralumenal colonization Hub frequently colonizedHub frequently colonizedIntrínsic Intrínsic

TPNTPNIntralípid Intralípid Blood derivatives Blood derivatives

Tribe Tribe Klebsiellae Klebsiellae Non fermenting GNBNon fermenting GNB

CATHETER RELATED SEPSIS CATHETER RELATED SEPSIS

IV. Hematogenous seedingIV. Hematogenous seeding

ExceptionalExceptional

Importance of fibrin cuffImportance of fibrin cuff

Relative importance of the different routes of Relative importance of the different routes of colonization of intravascular catheters*colonization of intravascular catheters*

ReferenceReference NºNºcatheterscatheters

Implantation Implantation daysdays

Episodes Episodes

SRCSRC

HubHub SkinSkin Mixed Mixed OtherOtherAA

Cercenado et alCercenado et al

De Cicco et alDe Cicco et al

Salzman et alSalzman et al

Liñares et alLiñares et al

Fan et alFan et al

Weightman et alWeightman et al

Segura et alSegura et al

139139

109109

113113

135135

156156

4242

400400DD

8,68,6

18,218,2

23,923,9

2020

1515

114114

2323

53(30.8%)53(30.8%)BB

6(5.5%)6(5.5%)

28(24.7%)28(24.7%)

20(14.8%)20(14.8%)

11(7.1%)11(7.1%)

11(26.1%)11(26.1%)

24(6%)24(6%)

1212

33

2121

1414

11

88

99

3030

33

77

22

44

--

55

88

--

--

--

22

--

22

33

--

--

44

44

33CC

88

BRC: catheter related bacteremiaA Hematogenous seeding.B Positive culture of tipC Cultures not completedD Number of patients Sitges-Serra A et al. Nutrition, 1997;13:30s-35s

RATE (MEAN) OF CATHETERRATE (MEAN) OF CATHETER--RELATED RELATED BACTEREMIA. NNISS 1992BACTEREMIA. NNISS 1992--20012001

TYPE OF ICUTYPE OF ICU Nº of ICUsNº of ICUs Catheter Catheter daysdays

Rate/1000 Rate/1000 catheter catheter

daysdays

CoronaryCoronary

CardiothorathicCardiothorathic

Medical/surgicalMedical/surgical

NeonatalNeonatal

< 1000 g< 1000 g

10011001--15001500

15011501--25002500

> 2500> 2500

PediatricPediatric

102102

6464

123123

138138

136136

132132

133133

7474

252,325252,325

419,674419,674

579,704579,704

438,261438,261

213,351213,351

163,697163,697

231,573231,573

291,831291,831

4.54.5

2.92.9

5.35.3

11.311.3

6.96.9

4.04.0

3.83.8

7.67.6Seguin 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 SEPSISCATHETER RELATED SEPSISDIAGNOSISDIAGNOSIS

Clinical diagnosisClinical diagnosis

Rapid diagnosisRapid diagnosis

Catheter culturesCatheter cultures

Paired CVC and peripheral culturesPaired CVC and peripheral cultures

(Quantitative cultures;(Quantitative cultures;

Differences in growing time to positivity) Differences in growing time to positivity)

Infusate contaminationInfusate contamination

DIAGNOSISDIAGNOSIS

CLINICAL DIAGNOSIS CLINICAL DIAGNOSIS

Low sensitivity and specificityLow sensitivity and specificity

TECHNIQUES OF RAPID DIAGNOSIS TECHNIQUES OF RAPID DIAGNOSIS

Gram stain, useful in local infection, but Gram stain, useful in local infection, but low sensitivitylow sensitivity

In some studies, orange of acridine stain In some studies, orange of acridine stain has a positive predictive value of 91% and has a positive predictive value of 91% and a negative predictive value of 97%*a negative predictive value of 97%*

*Kite P et al. Lancet 1999

CATHETER CULTURESCATHETER CULTURES

Qualitative cultures of catheter tipQualitative cultures of catheter tipSemiquantitative cultures of catheter tip Semiquantitative cultures of catheter tip (Maki et al, 1977)(Maki et al, 1977)Quantitative cultures of the catheter tipQuantitative cultures of the catheter tip

-- Cleri et al (1980)Cleri et al (1980)-- Liñares et al (1985)Liñares et al (1985)-- BrunBrun--Buisson et al (1990)Buisson et al (1990)-- Sheretz et al (1990)Sheretz et al (1990)

Catheter related bacteremiasCatheter related bacteremias--Causative Causative organismsorganisms

MicroorganismMicroorganism 19861986--19891989

%%

19921992--19991999

%%

GRAM POSITIVE COCCIGRAM POSITIVE COCCI

Cagulase negative staphylococciCagulase negative staphylococci

Staphylococcus aureusStaphylococcus aureus

Enterococcus sppEnterococcus spp

GRAM NEGATIVE BACILLIGRAM NEGATIVE BACILLI

Escherichia coliEscherichia coli

Enterobacter sppEnterobacter spp

Pseudomonas aeruginosaPseudomonas aeruginosa

Klebsiella pneumoniaeKlebsiella pneumoniae

FUNGIFUNGI

Candida sppCandida spp

2727

1616

88

66

55

44

44

88

3737

1313

1313

22

55

44

33

88

CDC. Am J Infect Control 1999; Schaberg DR et al. Am J Med 1991

Main coagulase negative staphylococci of Main coagulase negative staphylococci of interest in human infetionsinterest in human infetions

S. epidermidisS. epidermidis Most common pathogen; Most common pathogen; bacteremia, infection bacteremia, infection prothesis, wound, prothesis, wound, endoftalmitisendoftalmitis

S. saprophyticusS. saprophyticus Common pathogen;Common pathogen;

UTIUTI

S. haemolyticusS. haemolyticus

S. lungdunensisS. lungdunensis

Less common pathogens; Less common pathogens; bacteremia, endocarditisbacteremia, endocarditis

S. auricularis, capitis, cohnii, S. auricularis, capitis, cohnii, hominis, simulans, warneri, hominis, simulans, warneri, saccharolyticus, schleiferi, saccharolyticus, schleiferi, xylosusxylosus

Rare pathogens; infection Rare pathogens; infection prosthesisprosthesis

When to remove the catheterWhen to remove the catheter

Clinical pictureClinical picturePresence of local signs of infectionPresence of local signs of infectionType of catheterType of catheterMicroorganismMicroorganismPossibility of conservative treatmentPossibility of conservative treatment

Change of catheter through a metallic wire serving as a Change of catheter through a metallic wire serving as a guide can be an alternative to consider in cases where guide can be an alternative to consider in cases where there is an extreme difficulty in finding a new vascular there is an extreme difficulty in finding a new vascular accessaccess

Indications of immediate withdrawal of IV Indications of immediate withdrawal of IV catheter when infection is suspectedcatheter when infection is suspected

Unnecessary cathetersUnnecessary cathetersCatheters easy to replaceCatheters easy to replaceCatheters in patients with persistent bacteremia despite Catheters in patients with persistent bacteremia despite adequate antibiotic treatmentadequate antibiotic treatmentTunnelized catheters with infection of subcutaneous Tunnelized catheters with infection of subcutaneous tracktrackCatheters causing embolizationCatheters causing embolizationCatheters as a cause of endocarditisCatheters as a cause of endocarditisCatheters infected with difficult to treat microorganisms Catheters infected with difficult to treat microorganisms without their removalwithout their removal