Catheter related infections

Dr. Nadia Mohsen Abdu IbrahimSpecialist of Nephrology

New Mansoura General Hospital

DIALYSIS CATHETER–RELATED INFECTIONS

HD Catheter related Complications

Mchanical (Dysfunction)

Infectious

Dialysis catheter related infections Local site

infection

Exit , insertion site infection

Tunnel infection

CRBSI

non Cuffed, non Tunneled Catheters (Temporary)

Short.More ridgid.< 3wks for IJ.<5 days for femoralExit site= insertion siteNo tunnel

Cuffed Tunneled Catheters

(Permanent)• Softer• Sheath for insertion,

Dacron cuff.• 1 year –Indefinite• Exit site, insertion site,

tunnelN.B Up until 6 weeks following tunneled catheter placement the insertion site and exit site may be considered contiguous; after healing has completed they may be considered distinct.

Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375.2009.

Magnitude of the problem

The risk of bacteremia in dialysis patients with dialysis catheters has been estimated to be approximately 10 times higher than the risk of bacteremia in patients with AV fistulas

catheter-dependent hemodialysis patients have a

two- to threefold higher risk of infection-related hospitalization and infection-related death, as compared to patients undergoing dialysis via a fistula or graft .

Host factors

• Chronic illness (DM)• Immune deficiency

neutropenia• Malnutrition• Hypoalbuminemia• Extremes of age• Iron overload• Previous BSI

Catheter factors • Type (Nontunneled )• location (Femoral )• duration of catheterization

(Prolonged )• Barrier Precautions during

insertion (Submaximal; “mask, cap, sterile gloves, gown, large drape”

• Skill of the catheter inserter• Catheter- site care• thrombosis (increased

manipulation of the catheter • presence of septic foci

elsewhere .

Risk Factors

The deposition of biofilm (on external & internal surface of vascular catheters) is thought to play an important role in the colonization process. produced by a combination of host factors (eg,

fibrinogen and fibrin) and microbial products (eg, glycocalyx or "slime"), and can be present

24 hours following catheter insertion

From: Mermel L, Rhode Island Hospital

POTENTIAL ROUTES OF INFECTIONAll sources of infectionare potential targetsfor prevention

Routes of infection colonization from the skin

Skin of patient and hands of healthcare workers on insertion or manipulation

Migration from the skin along the outside of the catheter into the bloodstream.

skin commensals: Staphylococcus aureus and coagulase-negative staphylococci, are often isolated from colonized catheters and patients with CRBSIs

The Dacron cuff in tunneled catheters with fibrosis, in time may create a mechanical barrier to migration of bacteria from the skin along the outside of the catheter.

intraluminal or hub contamination

secondary seeding from a bloodstream infection Hematogenous seeding can occur during a

bloodstream infection originating from another focus of infection, often from a gastrointestinal site

The secondary seeding of CVCs may result in a relapse of the bloodstream infection due to the same organism.

contamination of the infusate or additives, such as a contaminated heparin flush (Rare, Epidemic)

Causative organismsOrganism

(1) Gram-positive cocci Staph. aureus coagulase negative staph Meticillin-resistant Staphylococcus aureus Enterococcus faecalis(3) Gram-negative bacilli Pseudomonas aeruginosa Enterobacter cloacae Escherichia coli Acinetobacter species Serratia marcesens Klebsiella pneumonia(3) Polymicrobial (4) Candida species

40 to 80 %

Non-staphylococc

al dialysis CRBSIs

Causative organisms CRBIs Gram-positive organisms are responsible for most dialysis

catheter-related infections. Coagulase-negative staphylococcal and S. aureus together account for 40 to 80 % of cases in most studies .

S. aureus infection is commonly associated with significant morbidity and mortality , and usually complicated by metastatic infections : infective endocarditis, septic arthritis, septic emboli, osteomyelitis, epidural abscess and severe sepsis, have been reported.

Local site infections Generally are due to the same organisms, commonly . S. aureus and P. aeruginosa

CRBSI diagnostic approach and

management clinical evaluation microbiologic confirmation

(cultures)

CRBSI ,, Def

CRBSI should be suspected in any dialysis patient with a hemodialysis catheter and signs and/or symptoms of a bloodstream infection, particularly

when there is NO clinical evidence for an alternate source of infection (eg, productive cough, dysuria, foot infection, diarrhea, or skin rash) and focused physical examination (eg,lung auscultation or inspection of the feet).

(NKF K/DOQI, 2006)National Kidney Foundation/ Kidney Disease Outcomes Quality Initiative. 2006 Updates Clinical Practice Guidelines and Recommendations.

1. Clinical evaluation

fever, chills, hemodynamic instability, changes in mental status, catheter dysfunction( (+ or -) signs of local site infection, don’t reflect CRBSI)

2. Microbiological evaluation(Bl. Culture )

should be obtained before antibiotics are administered. Bl. Sample two : drawn from a peripheral vein & drawn from the

dialysis catheter or two drawn from separate peripheral sites. or two separate samples from dialysis catheter (if blood

cannot be obtained from a peripheral vein) , drawn 10 to 15 minutes

N.B avoid withdraw sample during HD session : it is unlikely that there is a meaningful difference between samples drawn from peripheral veins and those drawn from catheters since systemic blood is circulating through the dialysis system.

3. Empiric systemic AntibioticsFor Gram-positive coverage Vancomycin ( iv in a dose of 20 mg/kg, should be given as a loading dose during the last 60 minutes of the dialysis session, followed by 500 mg in the last 30 to 60 minutes of subsequent dialysis sessions) Daptomycin (for patients with vancomycin allergy) ( iv at a dose of 9 mg/kg (for patients using high-permeability dialyzers) or 7 mg/kg (for patients using low-permeability dialyzers) during the last 30 minutes of each dialysis session For Gram-negative coverage Gentamicin ?? or Ceftazidime (iv 2 gm, should be given

after each hemodialysis session)

4. Bl. Culture and sensitivity results positive blood cultures

+ve culture of the same organism from both the catheter tip and

peripheral vein.colony count from the catheter at least 5-fold greater than that obtained from the peripheralvein if quantitative blood cultures are used. Alternatively, catheter cultures should become

positive at least 2 hours earlier than the simultaneously drawn peripheral blood cultures (ie,differential time to positivity

+ve culture of the two samples drawn from catheter lumen at separate times (10 to 15 minutes) are positive.

Intraluminal catheter colonization

if +ve catheter-drawn blood cultures & -ve peripheral blood cultures

Heparin provides a suitable growth medium for microorganisms and a positive result will likely indicate ‘lock’ colonisation as opposed to ‘catheter’ colonisation

5. Treatment Tailor

• Once the culture and sensitivity have been identified, the antibiotic regimen should be modified accordingly

Staphylococcus Methicillin-resistant Staphylococcus

continue Vancomycin, Patients with vancomycin allergy can be treated with daptomycin

Methicillin-sensitive staphylococcus Vancomycin should be substituted with cefazolin (a first-

generation cephalosporin) ( iv 20 mg/kg after each dialysis session)

for penicillin-allergic patients → Vancomycin is the preferred N.B Cefazolin is preferred due in part to the observation that the widespread use of vancomycin has been associated with an increasing incidence of infections due to vancomycin-resistant enterococci. In addition, cefazolin is as or more effective than vancomycin for ttt of methicillin-sensitive staph. infections

Repeat culture (after 48 to 72 of therapy) → if remain +ve → (prolonged S. aureus bacteremia)

(TEE; echocardiograms) should be done to all patients and to check for signs and symptoms of a metastatic infection (e.g infective endocarditis)

Vancomycin-resistant enterococcus

treated with daptomycin(6 mg/kg when it is infused following a dialysis session in inpatients.,, at a dose of 7 mg/kg (for patients using low-flux dialyzers) or 9 mg/kg (for patients using high-flux dialyzers) during the last 30 minutes of each dialysis session.

This higher dose is required to compensate for intra-dialytic Daptomycin removal (dialysable)

Gram-negative organisms

Aminoglycosides?? (risk of aminoglycoside ototoxicity) and ceftazidime (third-generation cephalosporins ) preferred for longer-term treatment.

in resistance to ceftazidime, however , aminoglycosides or carbapenems may be alternate choices.

Candidemia

The isolation of candida requires catheter removal and treatment with Amphotericin B & Azoles ( Fluconazole )

Fluconazole has an excellent safety profile, oral 800 mg (12 mg/kg) loading dose, then 400 mg (6 mg/kg) orally daily

6. Monitoring

Repeat blood cultures 48 to 96 hours after the institution of treatment. If these repeat blood cultures remain positive→1) catheter removal 2) additional evaluation for a metastatic infection or

endocarditis

7. Duration of therapyThe optimal duration of antimicrobial therapy remains uncertain. A. uncomplicated catheter-related bacteremia: (all signs of infection rapidly resolve and follow-up blood cultures after three or more days of appropriate therapy are negative)• if the infected catheter has been removed and replaced with a new catheter or salvaged and treated with an antibiotic lock solution → ttt continues for two to three weeks.• due to S. aureus → ttt for four weeks B. complicated catheter related bacteremia: (evidence of a metastatic infection or when follow up blood cultures remain positive, we advise at least six weeks of therapy. Patients with osteomyelitis, we advise treatment for 6 to 8 weeks.

Algorithm for Suspected catheter related bacteremia (CRBSI)

8. Catheter management As a general role ESNT Vascular Access Guidelines

All Dialysis patients with CRBSIs are administered systemic antimicrobial therapy and Immediate catheter removal followed by placement of a temporary non-tunneled catheter for short-term dialysis access.

After –ve culture results new, tunneled dialysis catheter can be inserted.

since the catheter is both the source of the infection and the vascular access necessary for providing ongoing dialysis →

indication for catheter removalCatheter exchange over a guide wire, with

Antibiotic lock Catheter Salvage, with antibiotic lock

Salvage should be used only as a treatment of last resort, associated with a 5-fold higher risk of treatment failure ,

up to 8-fold in cases with S. aureus CRBSI.

Catheter Removal

should be done immediately , in the following circumstances

Temporary non-cuffed dialysis with CRBSI Severe sepsis Hemodynamic instability Evidence of metastatic infection Accompanying exit-site or tunnel infection,(purulence) If fever and/or bacteremia persist 48 to 72 hours after

initiation of antibiotics to which the organism is susceptible Difficult-to-cure pathogens, [s. aureus, pseudomonas,

candida and fungi, or multiply-resistant bacterial pathogens]

9. Catheter tip culture

Routine culturing of catheter tips is not recommended

considered for confirming pathogen & measuring the effectiveness of interventions

Guidewire catheter exchange is a reasonable option for patients whom immediate removal of the

cuffed catheter is not feasible

Exclude indications for catheter removal the patient can be started on broad-spectrum iv antibiotics without

immediate catheter removal. If the fever resolves within 2 to 3 days (ie, by the next dialysis session),

the infected catheter can be exchanged over a guidewire for a new catheter.

It is not necessary to routinely confirm –ve culture results before catheter exchange as long as the patient is asymptomatic (ie, no fever or chills).

Retrospective studies suggest that catheter exchange over a guidewire is

associated with a cure rate similar to that observed with catheter removal while reducing the number of access procedures required.Tanriover B, Carlton D, Saddekni S, et al. Bacteremia associated with tunneled dialysis catheters: Comparison of two

treatment strategies. Kidney Int. 2000; 57:2151–2155. [PubMed: 10792637]

Catheter colonization

Management :• Repeat to confirm (blood cultures from a peripheral

vein)• Exchange catheter over a guide wire is preferred• Salvage & antibiotic lock therapy (without systemic

therapy) if removal is not feasible• follow up blood cultures

source for subsequent CRBSI

Antibiotic lock (Antibiotic/ heparin solution

If the tunneled dialysis catheter is salvaged The goal is to sterilize the catheter lumens from bacteria

present in biofilms It is a mixture of an anticoagulant ( heparin ) and high

concentrations of an antibiotic in a small volume. prepared immediately before being instilled into each catheter lumen at the end of each dialysis session

for the duration of (3 weeks) if fever or bacteremia persists despite this approach →

Infected catheters should be removed

Vancomycin / ceftazidime / heparin : Vancomycin (1 mL of 5 mg/mL in normal saline solution) plus ceftazidime (0.5 mL of 10 mg/mL in normal saline solution) plus heparin (0.5 mL of 1,000 U/mL solution)

Vancomycin / heparin : Vancomycin (1 mL of 5 mg/mL in normal saline solution) plus heparin (1 mL of 1000 U/mL solution)

Ceftazidime / heparin: Ceftazidime (1 mL of 10 mg/mL in normal saline solution) plus heparin (1 mL of 1000 U/mL solution)

Cefazolin / heparin : Cefazolin (1 mL of 10 mg/mL in normal saline solution) plus heparin (1 mL of 1000 U/mL solution)

Ethanol Lock The biofilm can prevent antibiotics penetration to

the surface of the inner lumen of the catheter. Ethanol locks have been proven to be effective in

this setting (catheter salvage in CRBSIs) Preparation: 1. Draw up 3.5mL of alcohol 100% (ethanol) and 1.5mL sterile

water for injection in a 10mL syringe (makes a total of 5mL of 70%)

2. The dwell time for an ethanol lock is four hours. The ethanol lock should be repeated daily by clinicians for 4-5 days

3. The clinician should flush the CVC pre and post ethanol lock with sodium chloride 0.9%. Post flushing of the line should only occur after the alcohol volume has been withdrawn from the CVC at the conclusion of the four hour dwell time.

Contraindications

If the patient is unstable +ve exit site or tunnel infection If the patient is pregnant or breast feeding If the pathogen is a Stap. aureus, multi-resistant

organism , fungaemia (including candidaemia).

1. Exit site2. Insretion site

3. Tunnel

LOCAL SITE INFECTIONS

Exit site infection Def: Infection confined to the erea of exit site with purulent

discharge, or erythema, tenderness, or indurations (within 2cm of the skin at the exit site) [Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009]

site drainage cultures and blood cultures should be obtained.

Management Uncomplicated exit site infections (without systemic

signs of infection, -ve blood cultures, no purulence) → topical antibiotic agents based on swab culture results (mupirocin 2% & and polysporin ointment for S. aureus infection and ketoconazole or lotrimin ointment for Candida infection), With antibiotic lock.

Complicated exit site infections (that do not resolve with these interventions and/or accompanied by purulent drainage ) → systemic antibiotics for ≤7 days. If failure of systemic antibiotics occurs → immediate catheter removal

Insertion site infection

Insertion site infection of tunneled catheters should prompt catheter removal

(guidewire catheter exchange is not appropriate as it can lead to bacteremia and septic emboli)

Cultures (exudate, blood cultures ) if bloodstream infection is excluded (-ve blood

cultures) → systemic antimicrobial therapy for ≤7 days is sufficient

Tunnel infection (pocket)

Def: erythema, tenderness, and induration overlying the subcutaneous tunnel tract (which extends for ≥2 cm from the exit site). + or − signs of exit site (NKF K/DOQI, 2006)

N.B neutropenic patients may complain of pain in the absence of erythema or swelling . Managemet : catheter removal; (in some circumstances incision

and drainage may also be appropriate). +or – excision, drainage of the tunnel site systemic antibiotics administered for ≤7 days

Educate healthcare workers and provide training for the insertion and maintenance of catheters

Maximal Barrier Precautions ( during Insertion and handling)

Patient education Skin Antisepsis (chlorhexidine is preferred) Catheter Site Dressing Regimens Antimicrobial Lock Solutions Bundles and Checklists

Prevention is always Better

Central Line Insertion Checklist -AdultsOperator:______ ___ __ ___ __ ___ __ ___ _____ __ ___ __ __ __Date:___ ___ __ __ _ __ ___ __ ___ __RN Assisting:_______ __ ___ __ ___ __ _____ __ ___ __ ___ _ _ Room/ Location:____ ___ __ ___ __Safety Pause:

Correct Patient Correct Procedure Correct Site Verbal agreement from all members of the team.

In order to eliminate central line associated blood stream infections, we will be following the Central Line Insertion Procedure Checklist based on CDC Guidelines.

Prior to the Procedure:1. Hand Hygiene done with Chlorhexidine Gluconate (CHG) 2% surgical hand scrub and water or waterless alcohol based gel before patient contact and before donning sterile gloves.YES2. Cleanse Site with 2% CHG with sponge 1.5mL.YES 3. Disinfect Site with a back and forth friction scrub, utilizing 2% CHG wand 10.5mL for 30 seconds and allow to dry completely before catheter insertion. YES 4. Maximum Barriers Did the operator wear:YES Cap/BouffantYES Mask YES Sterile GownYES Sterile GlovesYES Patient draped with full body sterile sheet. During the procedure:5. YES Operator(s) maintained the sterile field.6. YES Personnel assisting wore a cap, mask and donned gloves appropriately.After the procedure:6. Sterile dressing applied immediately by the operator.YES

QUALITY IMPROVEMENTTHIS FORM IS NOT PART OF THE PATIENT'S PERMANENT RECORD.

Please return the form to your Nurse Manager. I f a step has was not followed, please note and the Nurse Manager will follow up with the physician.

Take Home Message

AVF first , Prepare your patient in advance

Pay attention To this

Thank you

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