Robert J. Sherertz

Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America

These updated guidelines replace the previous management guidelines published in 2001. The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them.

Guidelines for the Management of Intravascular Catheter-Related Infections

These guidelines from the Infectious Diseases Society of America (IDSA), the American College of Critical Care Medicine (for the Society of Critical Care Medicine), and the Society for Healthcare Epidemiology of America contain recommendations for the management of adults and children with, and diagnosis of infections related to, peripheral and nontunneled central venous catheters (CVCs), pulmonary artery catheters, tunneled central catheters, and implantable devices. The guidelines, written for clinicians, contain IDSA evidence-based recommendations for assessment of the quality and strength of the data. Recommendations are presented according to the type of catheter, the infecting organism, and the associated complications. Intravascular catheter-related infections are a major cause of morbidity and mortality in the United States. Coagulase-negative staphylococci, Staphylococcus aureus, aerobic gram-negative bacilli, and Candida albicans most commonly cause catheter-related bloodstream infection. Management of catheter-related infection varies according to the type of catheter involved. After appropriate cultures of blood and catheter samples are done, empirical i.v. antimicrobial therapy should be initiated on the basis of clinical clues, the severity of the patients acute illness, underlying disease, and the potential pathogen(s) involved. In most cases of nontunneled CVC-related bacteremia and fungemia, the CVC should be removed. For management of bacteremia and fungemia from a tunneled catheter or implantable device, such as a port, the decision to remove the catheter or device should be based on the severity of the patients illness, documentation that the vascular-access device is infected, assessment of the specific pathogen involved, and presence of complications, such as endocarditis, septic thrombosis, tunnel infection, or metastatic seeding. When a catheter-related infection is documented and a specific pathogen is identified, systemic antimicrobial therapy should be narrowed and consideration given for antibiotic lock therapy, if the CVC or implantable device is not removed. These guidelines address the issues related to the management of catheter-related bacteremia and associated complications. Separate guidelines will address specific issues related to the prevention of catheter-related infections. Performance indicators for the management of catheter-related infection are included at the end of the document. Because the pathogenesis of catheter-related infections is complicated, the virulence of the pathogens is variable, and the host factors have not been well defined, there is a notable absence of compelling clinical data to make firm recommendations for an individual patient. Therefore, the recommendations in these guidelines are intended to support, and not replace, good clinical judgment. Also, a section on selected, unresolved clinical issues that require further study and research has been included. There is an urgent need for large, well-designed clinical studies to delineate management strategies more effectively, which will improve clinical outcomes and save precious health care resources.

Education of Physicians-in-Training Can Decrease the Risk for Vascular Catheter Infection

Vascular catheter infection is a substantial cause of morbidity and death in hospitalized patients. It has been estimated that 50 000 to 100 000 bloodstream infections related to vascular devices occur yearly in the United States; 90% of these infections originate from central venous catheters (CVCs) (1). The attributable mortality rate for CVC-related bloodstream infections ranges from 14% to 28% (2-6). The attributable cost of such infections has been estimated to be as high as

Impact of air filtration on nosocomial aspergillus infections: Unique risk of bone marrow transplant recipients☆

29 000 per episode (4). Various interventions, including skin preparation with chlorhexidine (7), use of vascular catheters with anti-infective coatings (8, 9), and use of maximum barrier precautions during catheter insertion, have been shown to reduce risk for catheter-related infections (10, 11). Currently, the optimal strategy for minimizing risk for vascular catheter infection is unclear. In 1993, the infection control committee at Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, adopted the recommendations of Raad and colleagues (11) and established a policy that called for use of maximum sterile barriers (including a full-size sterile drape, sterile gown, sterile gloves, and a mask) when inserting CVCs. Despite conventional bedside and didactic instruction by critical care medicine faculty over a 2-year period, compliance of physicians-in-training was poor (<20%, according to informal surveys). Unpublished observations during a previous investigation suggested that procedures for CVC insertion varied widely and that a new educational approach was necessary. A multidisciplinary group developed and implemented a 1-day hands-on course to teach basic procedures and infection control practices to physicians completing their first postgraduate year (PGY-1) and third-year medical students. The details of this approach, which nurses call a skills fair, form the substance of our report. Methods Description of the Course The course was organized as follows. Infection control practitioners and a hospital epidemiologist taught 1 hour of basic infection control principles. Content included handwashing, isolation and appropriate use of barrier garments, and handling of patients with resistant organisms and varicella. Occupational Safety and Health Administration (OSHA) considerations for blood and body fluids and tuberculosis were taught in a separate hour-long session on a different day. Thereafter, medical students and PGY-1 physicians rotated through a series of 1-hour stations, at which they received 5 to 15 minutes of didactic instruction followed by hands-on instruction that was overseen by one to three faculty members. Faculty were selected because of their roles in supervising and teaching procedures in patient care settings. The course director observed each instructor for an entire session to ensure that the appropriate content was being delivered. At the hands-on stations, participants received training in 1) blood draws through vascular lines [taught by oncology catheter care nurses], 2) arterial puncture for obtaining an arterial blood gas [taught by respiratory therapists], 3) insertion of arterial catheters and CVCs [taught by critical care medicine faculty and fellows and trauma faculty], 4) urinary catheter insertion [taught by nurse instructors], 5) lumbar puncture [taught by an oncologist], 6) peripheral venous catheter insertion [taught by nurse instructors], and 7) phlebotomy (taught by faculty from the School of Medical Technology at Wake Forest University Baptist Medical Center). At all stations, mannequins were used to simulate patients; urinary catheterization was taught with male and female mannequins. All participants practiced phlebotomy on each other. Participants started peripheral intravenous lines first on mannequins and then on another participant. All of the hands-on sessions employed the same devices and supplies used in the hospital. Fifteen-minute breaks were given in the morning and in the afternoon, and a 1-hour lunch was provided. The PGY-1 physicians were divided into two large groups of approximately 50 persons, each of which was taught on a different day as part of the orientation for new interns. The medical students were taught on a separate day. Each hands-on station had 7 to 16 participants per small group session. In the second year of the course, most of the didactic instruction that preceded the hands-on sessions was done by videotape. A member of our infection control department reviewed the content of each didactic session to ensure its consistency with existing infection control policies. Content of courses on vascular catheters included use of povidone-iodine for skin preparation, avoidance of antibiotic ointment at the insertion site, and use of clear plastic dressings. Participants were also instructed to change dressings and intravenous tubing every 3 days and not to adhere to fixed schedules for changing CVCs. Of note, the hospitals infection control policy on vascular catheters did not change substantially during the study period, with the exception of the educational intervention; in particular, antibiotic-coated catheters were not used. Data Collection Previous Experience with Procedures During each hands-on session, PGY-1 physicians were asked to estimate the number of previous procedures that they had performed during medical school. Course Evaluation At the end of each 1-day course, an evaluation was given to each participant. Participants were asked to rate various factors, including each instructor, on a scale of 1 to 5 (1=poor; 5=excellent). Use of Full-Size Sterile Drapes The purchasing department provided data on the use of full-size sterile drapes. During the baseline year, a locally prepared sterile sheet was used. After the first course, a commercially available, full-size sterile drape (Kimberly-Clark, Roswell, Georgia) was used in all areas of the hospital in which CVCs were inserted. The purchasing department also monitored the number of CVCs inserted before and after each course was taught. Full-size sterile drapes were separate from the CVC kits during the preintervention and postintervention periods. Eight months before the first course (4 months into the baseline period), 140 physicians at all levels of training completed an anonymous survey of the perceived need for use of full-size sterile drapes. Before the first course, immediately after the first course, and 6 months after the first course, the participating group of PGY-1 physicians completed subsequent anonymous surveys. The same PGY-1 physicians were also surveyed about whether CVC insertion required povidone-iodine skin preparation, sterile gowns, sterile towels, and sterile gloves. Catheter-Related Infection To determine whether improved compliance with use of full-size sterile drapes or improvements in other areas of vascular catheter insertion were associated with reduced risk for catheter-related infection, precourse and postcourse surveillance for such infection was performed in six general medicine-surgery intensive care units and the associated step-down unit. We focused on insertion of CVCs and arterial catheters because at our institution, physicians-in-training perform essentially all of these procedures. In addition, we examined primary bloodstream infections because more than 90% of such infections in intensive care units probably originate from CVCs (12-14). Nosocomial primary bloodstream infections were identified on the basis of Centers for Disease Control and Prevention (CDC) surveillance definitions (15). In a primary bloodstream infection, a pathogen is isolated from a blood culture or cultures and is not related to infection at another site, unless that site is a vascular catheter (15). Catheter-related infections were defined as meeting definition three of the CDC Cardiovascular System Infection criteria for arterial or venous infection (15). Fulfillment of this definition required the presence of fever (temperature>38 C), pain, erythema, or heat at the catheter site plus the presence of a negative blood culture or absence of any blood cultures and the presence of a positive roll-plate culture of the catheter. For the positive roll-plate culture, we substituted a positive sonication culture ( 100 colony-forming units/mL) (16). Blood cultures were done by using the Wampole Isolator (Wampole Laboratories, Cranbury, New Jersey) and were predominately drawn only through a peripheral vein or as paired cultures through a peripheral vein and through a catheter. Catheter and bloodstream isolates were not molecularly typed. In the seven study units, use of CVCs was high ([central line days/patient days] 100%=73%). Because of this, we concluded that patient-days could serve as a surrogate of device-days, even though the latter would probably be more accurate under other circumstances (12). Other Procedure Considerations The frequency of blood and body fluid exposures among PGY-1 physicians was evaluated during the year before and the year after the first course. These data were obtained from our employee health service, which has had a formalized reporting program for 6 years. We did not measure changes in practice or outcomes related to lumbar punctures because the number of procedures performed was small and the complication rate is low; this made our sample size inadequate for demonstrating differences. In addition, we did not monitor procedures that are not performed primarily by physicians (that is, arterial punctures, urinary catheter insertions, blood draws through lines, peripheral line insertions, and phlebotomy). Statistical Analysis Proportions were compared by using the two-tailed chi-square test or the Fisher exact test. The rates of catheter-related infection were compared by using the incidence density ratio of the preintervention and postintervention periods, which were obtained by using the z test statistic (17). A P value less than 0.05 was consid

Comparative Activities of Daptomycin, Linezolid, and Tigecycline against Catheter-Related Methicillin-Resistant Staphylococcus Bacteremic Isolates Embedded in Biofilm

Bone marrow transplant recipients were found to have a 10-fold greater incidence of nosocomial Aspergillus infection than other immunocompromised patient populations (p less than 0.001) when housed outside of a high-efficiency particulate air (HEPA) filtered environment. Multivariate analysis demonstrated that number of infections, age, and graft-versus-host disease severe enough to require treatment were independent risk factors for development of nosocomial Aspergillus infection in this group. The use of whole-wall HEPA filtration units with horizontal laminar flow in patient rooms reduced the number of Aspergillus organisms in the air to 0.009 colony-forming units/m3, which was significantly lower than in all other areas of the hospital (p less than or equal to 0.03). No cases of nosocomial Aspergillus infection developed in 39 bone marrow transplant recipients who resided in this environment throughout their transplantation period compared with 14 cases of nosocomial Aspergillus infection in 74 bone marrow transplant recipients who were housed elsewhere (p less than 0.001). Thus, although bone marrow transplant recipients had an order-of-magnitude greater risk of nosocomial Aspergillus infection than other immunocompromised hosts, this risk could be eliminated by using HEPA filters with horizontal laminar airflow.

Effect of a Second-Generation Venous Catheter Impregnated with Chlorhexidine and Silver Sulfadiazine on Central Catheter–Related Infections: A Randomized, Controlled Trial

ABSTRACT In the setting of catheter-related bloodstream infections, intraluminal antibiotic lock therapy could be useful for the salvage of vascular catheters. In this in vitro study, we investigated the efficacies of the newer antibiotics daptomycin, linezolid, and tigecycline, in comparison with those of vancomycin, minocycline, and rifampin, against methicillin-resistant Staphylococcus aureus (MRSA) embedded in biofilm. We also assessed the emergence of MRSA strains resistant to these antibiotics, alone or in combination with rifampin, after 4-hour daily use for catheter lock therapy. Minocycline, daptomycin, and tigecycline were more efficacious in inhibiting MRSA in biofilm than linezolid, vancomycin, and the negative control (P < 0.001) after the first day of exposure to these antibiotics, with minocycline being the most active, followed by daptomycin and then tigecycline, and with vancomycin and linezolid lacking activity, similar to the negative control. After 3 days of 4-hour daily exposures, daptomycin was the fastest in eradicating MRSA from biofilm, followed by minocycline and tigecycline, which were faster than linezolid, rifampin, and vancomycin (P < 0.001). When rifampin was used alone, it was the least effective in eradicating MRSA from biofilm after 5 days of 4-hour daily exposures, as it was associated with the emergence of rifampin-resistant MRSA. However, when rifampin was used in combination with other antibiotics, the combination was significantly effective in eliminating MRSA colonization in biofilm more rapidly than each of the antibiotics alone. In summary, daptomycin, minocycline, and tigecycline should be considered further for antibiotic lock therapy, and rifampin should be considered for enhanced antistaphylococcal activity but not as a single agent.

Quantitative tip culture methods and the diagnosis of central venous catheter-related infections☆

Context Bacterial colonization of central venous catheters is relatively common, and subsequent bacteremia is a serious iatrogenic complication of critical illness. Initial studies of antimicrobial-coated catheters have suggested that this approach might decrease catheter-associated infection. Contribution This randomized, double-blind, controlled study of a new antiseptic-coated catheter versus an uncoated catheter shows a substantial decrease in bacterial colonization in patients receiving the coated device. Caution The study was unable to show a substantial decrease in bloodstream infections, possibly because of the low infection rate as a result of meticulous aseptic techniques used during catheter insertion. The Editors Infections associated with central venous catheters are a substantial problem. Each year in the United States, at least 80 000 patients in intensive care units experience central venous catheterassociated bacteremia (1, 2). These infections are associated with an overall attributable mortality of approximately 3% (3), but estimates vary from 0% to greater than 30% depending on patient population, definitions, and pathogens (4). The attributable cost per infection ranges from

Vascular-access infections in hospitalized patients.

3240 to more than

Comparative In Vitro Efficacies of Various Catheter Lock Solutions

50 000 (5-8). Many strategies have been used to prevent catheter-associated infection. These measures can be divided into 2 groups: those that prevent microbes from gaining access to the catheters and those that discourage microbes from adhering and proliferating on the catheter, such as coating the catheters with various antimicrobial agents. The latter approach has shown promise and has included the use of chlorhexidine and silver sulfadiazine. In a randomized clinical trial, Maki and colleagues (9) observed a statistically significant decrease in colonization and bacteremia in patients who received a catheter coated with chlorhexidine and silver sulfadiazine compared with controls who received an uncoated catheter. In a randomized, comparative trial, Darouiche and colleagues (10) found that catheters impregnated with minocycline and rifampin were associated with fewer infectious complications than catheters coated with chlorhexidine and silver sulfadiazine. However, one of the main differences between the catheters was that the chlorhexidinesilver sulfadiazine coating involved only the external surface of the catheter, whereas the minocycline and rifampin catheter was coated on the internal and external surfaces. More recently, a second-generation antiseptic catheter was formulated that increased the chlorhexidine concentration on the external surface of the catheter 3-fold and incorporated chlorhexidine on the luminal surface of the catheter, extension lines, and hubs. This trial was conducted to assess the efficacy and safety of the second-generation antiseptic catheter compared with an uncoated control catheter. Methods Patients and Study Design This study was a randomized, double-blind, controlled trial conducted between July 1998 and June 2001 at 9 university-affiliated hospitals. The objective was to determine whether the second-generation antiseptic central venous catheter was effective in preventing microbial colonization and bloodstream infection in comparison with an uncoated control catheter. The null hypothesis was that the incidence of bloodstream infection would be the same or worse for the patients who received the antiseptic catheter compared with the patients who received the control catheter. Secondary goals consisted of product safety evaluation, assessment of the microbiology of catheter-associated infection, and microbial susceptibility to chlorhexidine and silver sulfadiazine. The institutional review boards at each hospital approved the protocol. Adult patients who were cared for in critical care units and who required a triple-lumen central venous catheter were eligible for participation. Patients who were pregnant, were allergic to chlorhexidine or sulfa drugs, were hospitalized for burn injuries, had a chronic inflammatory skin disorder at the catheter insertion site, were suspected of having a catheter-associated infection, or were enrolled in another investigational trial were not eligible for participation. All patients or their authorized surrogates granted informed consent. The study sample size was calculated on the basis of an expected catheter-related bloodstream infection rate of approximately 4.5% in the control group and 1.5% in the antiseptic catheter group. Allowing for a 12% dropout rate, 793 patients were required to yield a study with an 80% power at the 0.05 level of statistical significance. Catheters All catheters were 7-French, 20-cm long polyurethane triple-lumen central venous catheters manufactured by Arrow International, Inc. (Reading, Pennsylvania). Control catheters were standard, uncoated triple-lumen catheters. Antiseptic catheters (ARROWgard II Blue Plus, Arrow International, Inc.) were coated with chlorhexidine acetate and silver sulfadiazine on the external surface and chlorhexidine and chlorhexidine acetate on the luminal surfaces. All catheters were indistinguishable in appearance and packaging. Randomization, Catheter Insertion, and Care Procedures Patients were randomly assigned to receive an individually numbered catheter and had an equal probability of assignment to either group. The randomization code was developed by using a computerized random-number generator to select permuted blocks. The block length was 4. Randomization stratification ensured that antiseptic and control catheters were evenly distributed in the de novo and guidewire exchange groups. Patients were randomly assigned in a 1:1 ratio within each of the study centers. Catheter allocation was concealed, and patients, study personnel, and all health care workers were unaware of whether the catheters were coated or uncoated. A subset of patients at each institution (approximately one third of patients) was allowed to receive an initial study catheter through guidewire exchange. Four institutions were also allotted a small number of exchange insertions in which a study catheter could be exchanged for a matched study catheter (randomization and blinding were protected). Figure 1 shows the distribution of patients. Catheters were inserted by using full sterile barrier precautions, which included the operators wearing a sterile long-sleeve gown, sterile gloves, hat, and mask, and using a large sterile drape. Before insertion, the skin was cleansed with 10% povidone-iodine (chlorhexidine-based antiseptics were not approved by the U.S. Food and Drug Administration for insertion-site preparation). Before a study catheter was inserted over a guidewire into a preexisting site, the hub of the first catheter was cleansed with povidone-iodine. The tip of the preexisting catheter was submitted for microbiological testing. Insertion sites were dressed with a transparent polyurethane dressing (OpSite 3000, Smith & Nephew, Inc., Largo, Florida). No antimicrobial ointment was applied at the insertion site. Depending on institutional routine, dressings were changed every 72 to 96 hours using a standardized kit. At the time of dressing change, the insertion site was cleansed with povidone-iodine. The patients attending physician made the decision to remove the catheter. Figure 1. Distribution of initial study catheters by type and method of insertion. Measurements and Definitions At the time of catheter insertion, the following data were recorded: patient demographic characteristics, indication for catheter insertion, underlying medical conditions, indication for admission to the intensive care unit, length of hospital stay and length of intensive care unit stay, and severity of illness score (Acute Physiology and Chronic Health Evaluation [APACHE] II score). Study catheters were inspected daily. Local and systemic signs and symptoms of infection were recorded. The presence of other intravascular and indwelling devices was noted, and the antibiotics that were administered were recorded. At the time of catheter removal, a 20-cm2 circular template was placed at the catheter insertion site and a moistened swab (Culturette, Becton Dickinson and Co., Sparks, Massachusetts) was used to sample the pericatheter insertion site. The swab was sent to the institutional microbiology laboratory, where it was used to inoculate a blood agar plate. Catheters were removed by using an aseptic technique. The subcutaneous portion of the catheter was cut from the rest of the catheter, and the 2 portions were placed in separate sterile plastic bags for transport to the laboratory. The subcutaneous portion of the catheter was divided into four 2.5-cm segments. A neutralizing media (D/E Neutralizing Broth or Agar, Remel, Lenexa, Kansas) was used to minimize any potential antimicrobial carryover effect. Proximal and distal segments were cultured by using the roll-plate method (11), and similarly, proximal and distal segments were cultured by using a sonication technique (12). At 2 centers, the catheter hubs were cultured by using moistened swabs. Blood cultures were obtained from the catheter and from a peripheral vein on any patient with suspected catheter-associated infection. Signs and symptoms of a catheter-associated infection included fever (temperature > 38 oC) without another obvious source and local signs of infection, such as erythema, cellulitis, purulent drainage, or excessive tenderness. All microbes recovered from cultures of the patients blood, catheter, skin, or other sites were shipped to a central laboratory (University of Iowa, Iowa City, Iowa) for confirmatory identification and susceptibility testing. Catheters were defined as colonized if cultures revealed at least 15 colony-forming units per segment by the roll-plate method or at least 100 colony-forming units per segment by the sonication method. Catheter-related bloodstream infection was defined as catheter colonization with positive blo

Guidelines for the management of intravascular catheter-related infections

The diagnostic usefulness of two quantitative catheter culture methods was compared in a prospective study of central venous arterial catheters. The roll-plate method followed by sonication was used to culture 177 catheters from 85 patients, and the sonication method was used to culture 136 catheters from 68 patients. All patients were evaluated for catheter-related infections. Catheter-related infections were associated with greater than or equal to 100 colony-forming units (CFU) isolated from catheter tips by either roll plate (p = 0.01) or sonication (p less than 0.001). The sensitivity, specificity, and positive and negative predictive values of greater than or equal to 10(3) CFU by roll plate for catheter-related septicemia were 56%, 97%, 63%, and 96% compared with 93%, 95%, 76%, and 99%, respectively, for the same level by sonication. For central venous and arterial catheters, the sonication method can distinguish infection from contamination and is superior to the roll-plate method in that it may offer a more sensitive and predictive alternative in the diagnosis of catheter-related septicemia.