Central Line–Associated Bloodstream Infections: Prevention and Management

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Definitions

To understand the literature one must understand the terminology used to describe different types of catheters. A catheter can be defined by the type of vessel cannulated (eg, peripheral vein, central vein, artery); its planned duration (eg, short-term vs permanent); its site of insertion (eg, for central venous catheters: subclavian, femoral, internal jugular, or peripherally inserted central catheter [PICC]); the catheter’s pathway from skin to vessel (eg, tunneled vs nontunneled); and

Prevalence, incidence, and impact of CLA-BSIs

In a 1-day point prevalence study during 1992 of 10,038 patients in 1417 European intensive care units (ICUs), Vincent and colleagues7 reported that 12% had a bloodstream infection. A follow-up 1-day point prevalence study during 2007 of 13,796 adult patients in 1265 ICUs from 75 countries revealed that 15.1% had a bloodstream infection.8 The prevalence of CLA-BSIs has not been determined but in the United States, it has been estimated that there are approximately 80,000 CLA-BSIs per year in

Pathogens

The pathogens causing nosocomial bloodstream infections and their associated mortality have been described in an analysis of 49 United States hospitals in the SCOPE surveillance system (Fig. 3).16 The top 3 pathogens were all gram-positive cocci (ie, coagulase-negative Staphylococcus, Staphylococcus aureus, and Enterococcus spp). The SENTRY system monitored both health care- and community-acquired bloodstream infections from a sample of hospitals worldwide. Their data revealed that S aureus was

Pathogenesis

Colonization of a central venous catheter is a prerequisite for infection.21 Colonization most commonly occurs via migration of bacteria along the skin-catheter interface (extraluminal route) or via contamination of a hub (endoluminal route). For short-term use central venous catheters (ie, duration less than 7–10 days), the skin around the catheter insertion site is the most common source of organisms.21, 22 For long-term use central venous catheters, the most common source of organisms are

Risk factors for CLA-BSI

Independent risk factors for CLA-BSI reported in 2 or more published studies have included the following: (1) prolonged hospitalization before catheterization, (2) prolonged duration of catheterization, (3) heavy microbial colonization at the insertion site, (4) heavy microbial colonization of the catheter hub, (5) internal jugular catheterization, (6) neutropenia, (7) premature birth, (8) total parenteral nutrition through the catheter, and (9) substandard care of the catheter (eg, excessive

Basic Recommendations

Several guidelines and reviews have provided recommendations for the prevention of CLA-BSIs.31, 32, 33, 34, 35, 36 These recommendations are based on studies demonstrating a risk with failure to follow the recommendations as well as studies demonstrating effectiveness of the recommended procedures to reduce the risk of CLA-BSI. Recommendations of the most current guidelines from the Society of Healthcare Epidemiologists of America (SHEA) and the Infectious Disease Society of America (IDSA) are

Bloodstream Infections

In evaluating a new fever in an ICU patient, blood cultures should be obtained when clinical evaluation does not strongly suggest a noninfectious source.104 Blood cultures should also be obtained when bacteremia/fungemia is suspected in non-ICU patients with a fever or other signs of sepsis. Cultures should always be obtained before the initiation of antibiotics.105 Before obtaining a blood culture from a peripheral vein, skin disinfection should preferentially be performed with 2%

Surveillance of CLA-BSI

A consensus guideline recommends that all hospitals measure their CLA-BSI rate using the definitions developed by the NHSN.35 The numerator consists of the number of CLA-BSIs in each unit assessed. The denominator consists of total number of catheter days in each unit assessed. This ratio (ie, CLA-BSI/number of catheter days) is multiplied by 1000 so that the measure is expressed as number of CLA-BSIs per 1000 catheter days. The CDC recommends that surveillance should be undertaken in the

General Recommendations

The management of CLA-BSI has been recently reviewed (Box 2).105, 113, 135, 136 If the patient has severe sepsis or septic shock, additional therapy is warranted.137 The following recommendations for management are largely based on the most current IDSA guideline.105 Empiric therapy is often initiated for suspected CLA-BSI. The initial choice of antibiotics depends on the patient’s risk factors for infection, underlying diseases, and likely pathogens associated with the specific intravascular

Summary

Central venous access is an important treatment modality in the current management of critically ill patients or those requiring long-term venous access (eg, hemodialysis, chemotherapy). Recent studies suggest that by strict adherence to current guidelines for insertion and maintenance, the incidence of CLA-BSI can be dramatically reduced. Proper diagnosis and treatment of CLA-BSI can in some cases allow potential catheter retention, as well as reduce the morbidity and mortality associated with

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