Catheter related infections

1. Catheter related
infections
Dr. Nadia Mohsen Abdu Ibrahim
Specialist of Nephrology
New Mansoura General Hospital

3. HD Catheter related
Complications
 Mchanical
(Dysfunction)
 Infectious

4. Dialysis catheter
related infections Local site
infection
Exit , insertion
site infection
Tunnel infection
CRBSI

5. non Cuffed, non Tunneled
Catheters (Temporary)
Short.
More ridgid.
< 3wks for IJ.
<5 days for femoral
Exit site= insertion
site
No tunnel
Cuffed Tunneled
Catheters
(Permanent)• Softer
• Sheath for insertion,
Dacron cuff.
• 1 year –Indefinite
• Exit site, insertion site,
tunnel
N.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.

7. 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 .

8. 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

9. 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

10. From: Mermel L, Rhode Island Hospital
POTENTIAL ROUTES OF INFECTION
All sources of infection
are potential targets
for prevention

11. 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.

12. 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)

13. Causative organisms
Organism
(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-
staphylococcal
dialysis CRBSIs

14. 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

16. CRBSI
diagnostic approach and
management
 clinical evaluation
 microbiologic confirmation
(cultures)

17. 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.

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

19. 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.

20. 3. Empiric systemic Antibiotics
For 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)

21. 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 peripheral
vein 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

22. 5. Treatment Tailor
• Once the culture and sensitivity have been
identified, the antibiotic regimen should be
modified accordingly

23. 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

24. 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)

25. 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)

26. 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.

27. 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

28. 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

29. 7. Duration of therapy
The 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.

30. Algorithm for Suspected catheter related bacteremia (CRBSI)

33. 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.

34. since the catheter is both the source of the infection
and the vascular access necessary for providing
ongoing dialysis →
 indication for catheter removal
 Catheter 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.

35. 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]

36. 9. Catheter tip culture
 Routine culturing of catheter tips is not
recommended
 considered for confirming pathogen & measuring the
effectiveness of interventions

37. 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]

38. 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

39. 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

40.  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)

41. 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.

42. 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).

44. 1. Exit site
2. Insretion site
3. Tunnel

45. 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]

46.  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

47. 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

48. 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

50.  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

51. Central Line Insertion Checklist -Adults
Operator:________________________________________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.
YES
2. 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/Bouffant
YES Mask
YES Sterile Gown
YES Sterile Gloves
YES 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 IMPROVEMENT
THIS FORM IS NOT PART OF THE PATIENT'S PERMANENT RECORD.
Please return the form to your Nurse Manager. If a step has was not followed, please note and
the Nurse Manager will follow up with the physician.

52.  AVF first , Prepare your patient in
advance
 Pay attention To this

53. Thank you
Thank you