Infected temporary central venous catheters ( CVC ) and arterial catheters in adults - Guideline for management of
|Last review: 18/09/2017|
|Next review: 07/12/2019|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2017|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for management of infected “temporary” central venous catheters (CVC) and arterial catheters in adults.
Infected temporary central venous catheters ( CVC ) and arterial catheters in adults
Empirical antimicrobial management
Directed (organism-specific) antimicrobial management
Exit site infection affecting any type of vascular access device is a clinical diagnosis. The pathogen responsible can be determined by sending a pus sample or exit site swab to the microbiology laboratory for culture.
Differential time to positivity (DTP) is a blood culture-based method for diagnosing luminal colonisation or CRBSI (Blot et al., 1999). If a known volume of blood is collected via the lumen of an intravascular catheter and the same volume of blood is then drawn from a peripheral vein, the time taken for each blood culture set to become positive can be used to determine whether the sampled catheter is the likely source of infection. A DTP >2 hours in favour of “through-line” Blood Cultures has a sensitivity of 72-94%, and specificity of 91-95% for CRBSI (Blot et al., 1999; Catton et al., 2005). In other words, using DTP >2 hours will fail to detect some CRBSI, but a positive result has a high probability of being CRBSI. A negative “through-line” blood culture at >100h incubation had a negative predictive value of 100% (Blot et al., 1999; Catton et al., 2005).
Paired Blood Cultures should be sent from all potentially infected lumens and a peripheral vein (Catton et al., 2005).
Acridine orange leukocyte cytospin, quantitative Blood Cultures and endoluminal brush techniques are sensitive and specific methods of in situ diagnosis of intravascular catheter colonisation but are labour intensive, expensive and not routinely available in Leeds.
Semi-quantitative catheter tip culture (often called the “Maki roll”) is a simple and inexpensive method for retrospectively diagnosing colonisation of the external surface of an intravascular catheter. It lacks sensitivity because only the external surface is cultured (missing luminal colonisation) and lacks specificity because the surface of the catheter may become contaminated with organisms colonizing the exit site. Intravascular catheter tips should only be sent for culture to confirm a clinical suspicion of CRI, not as a matter of routine.
There is no evidence that surveillance Blood Cultures of intravascular catheters are of benefit and this service is not therefore recommended by the microbiology department.
The initial choice of antibiotics will depend on the likely pathogen(s) involved.
Empirical therapy should be modified when the causative organism is known i.e to directed or targeted therapy.
Management of CRI is influenced by the type of catheter, severity of symptoms, underlying disease(s), availability of alternative vascular access sites, the pathogen(s) involved and the location of the infection (Bouza et al., 2002; Mermel et al., 2001).
The options for treatment for CRI are:
Removal of the intravascular catheter is the most reliable means of eliminating infection usually in combination with antimicrobial therapy. Attempting salvage of an infected temporary CVC or arterial line is not generally recommended. [Evidence level B]
Management decisions are made either empirically on the basis of clinical suspicion, without any supporting microbiological evidence, or when microbiological information is available.
The decision to remove an intravascular catheter as a matter of urgency is a clinical one, dependent upon the severity of sepsis and the likelihood of CRI. Removal of a CVC should be discussed with the registrar or consultant prior to removal. Indications for urgent catheter removal are summarised below: (Krishnasami et al., 2002; Mermel et al., 2001)
Catheter removal alone may be sufficient for intravascular catheters colonised by low-grade pathogens, such as coagulase-negative staphylococci, in low-risk patients.
Exit site infection, once established, is difficult to eradicate with antimicrobial therapy. Temporary CVCs and peripheral arterial catheters should be removed as soon as possible after a diagnosis of exit site infection has been made and antimicrobial therapy started (see below).
Where intravascular catheters are still required they should ideally be re-sited away from the area of infection.
CRBSI is a microbiological diagnosis. Given the poor predictive value of clinical diagnosis of CRBSI and the risks of changing intravascular catheters, individual management of suspected bloodstream infection should be based on a risk assessment. This decision needs to take into consideration that tests to assist in the in situ diagnosis of CRBSI (i.e without removing the catheter) are currently culture-based and take at least 24 hours to give a result (see above). The necessary action therefore depends on the severity of the patient’s condition and the likelihood of the problem being CRI.
Initially the need for vascular access should be reviewed and catheters that are no longer needed should be removed. This is based on the fact that removing the portal of entry removes the risk of infection and the fact that catheter removal is the most reliable way of managing infection associated with intravascular catheters (Mermel et al., 2001; Sandoe et al., 2002).
Where multiple vascular access devices are in situ and CRBSI is diagnosed full line change should ideally be undertaken because of the significant risk that all catheters in situ at the time of infection have been affected.
Re-wiring catheters should be avoided if at all possible because infection is simply transferred from one catheter to the next via the guide wire (Olson et al., 1992).
Guidelines for insertion and care of new catheters should be followed
The possibility of a contemporaneous primary source of infection distant from the intravascular catheter should be considered, particularly in Staphylococcus aureus CRI and when fever or bacteraemia persist >72 hours after catheter removal (Raad & Sabbagh, 1992; Raad et al., 1992).
|Empirical Antimicrobial Treatment|
Gram-positive organisms, mainly staphylococci, are the most common cause of CVC/AC infections. Considering the high prevalence of meticillin-resistance in staphylococci, empirical antimicrobial therapy should include the administration of Teicoplanin . The prevalence of Gram-negative bacteria causing CRI is variable but no clinical features can reliably rule-out this possibility so empirical regimens for CRBSI when severe sepsis/septic shock is present should include Gram negative cover. All treatment recommendations are Evidence level D.
The choice of Gram-negative cover will be influenced by the age of the patient, local epidemiology on a given unit, recent antimicrobial therapy and comorbidities. If the options below are considered inappropriate the case should be discussed with the on-call or unit-specific microbiologist, other regimens may be entirely appropriate.
Recommended empirical regimens:
# Use of Teicoplanin for this use is off-label and the patient should be informed of this
|Directed Antimicrobial Treatment (when microbiology results are known)|
# Use of teicoplanin for this use is off-label and the patient should be informed of this
*from removal date
|Duration of Treatment|
|Switch to oral agent(s)|
Once an infected catheter has been removed, if a patient has made a good clinically recovery at 48 hours antimicrobials can be switch to oral alternatives. (exception Staphylococcus aureus)
|Please contact microbiology if the patient is not responding to the recommended antimicrobial regimens.|
Infected "temporary" central venous catheters (CVC) and arterial catheters in adults
|Target patient group:||Adults|
|Target professional group(s):||Secondary Care Doctors
Secondary Care Nurses
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A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds Consensus.
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