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Intravascular catheter-related infection – current concepts Department of Medicine, Division of Pulmonology and Critical Care, Johannesburg
Hospital and University of the Witwatersrand, Johannesburg
Mervyn Mer, MB BCh, Dip PEC (SA), FCP (SA), MMed (Int Med), FRCP (Lond)
Intravascular devices are an integral component been completed, show that this topic is of particular of modern-day medical practice. They are used to relevance to practice in our geographical area. This administer intravenous fluids, medications, blood study evaluated device-associated infections in 55 products and parenteral nutrition. In addition they intensive care units (ICUs) in the USA and eight September
serve as a valuable monitor of the haemodynamic developing countries. There was a substantially status of critically ill patients.
significant difference in the number of central venous catheter-associated bloodstream infections in so-called Over the past 2 decades the focus of research and developing countries compared with units in the USA development in this field has been the physicochemical (approximately four times higher). This study has been properties of catheters, looking at such aspects as submitted for publication by the workers involved.9 improved catheter materials, tensile strength, rupture resistance, biocompatibility and the creation of catheter Guidelines for the management of nosocomial micro-environments hostile to invading organisms.
infections in South Africa, which include intravascular infections, have recently been published.10-12 Intravascular devices have represented a major advance in terms of patient comfort and care, but with them has Definitions of CRIs come the burden of complications, including a variety of local and systemic infectious complications. In Definitions relating to intravascular CRI have been general, intravascular devices can be divided into those put forward by various workers, but many have used for short-term (temporary) vascular access and complicated matters and been confusing. In part this those used for long-term (indwelling) vascular access. has been because definitions used for surveillance and Long-term intravascular devices usually require research purposes have differed from those used for surgical insertion while short-term devices can be clinical diagnosis. The Centers for Disease Control and inserted percutaneously. The main focus of this review Prevention have suggested sensible definitions13 that and guideline is on short-term catheters.
incorporate both clinical and laboratory evidence of catheter infection. These should be universally used in Magnitude of the problem the definition of intravascular catheter infection and are documented in modified form in Table I.
Catheter-related infections (CRIs) remain among the top three causes of hospital-acquired infections, Pathogenesis of CRIs (Fig. 1) with a mortality of up to 25%, and result in prolonged hospitalisation and increased medical costs.1-6 Central The skin around the insertion site is the most common venous catheters (CVCs) account for an estimated 90% portal of entry.14-16 Following placement, a fibrin sheath of all catheter-related bloodstream infections (CRBSIs).7 develops around the catheter which promotes the Reported rates of bloodstream infection range from 4 to adherence of pathogens (biofilm layer). Skin organisms ≥ 30 per 1 000 central catheter days.8 then migrate from the insertion site along the external surface of the catheter to colonise the distal Given the magnitude and seriousness of the problem intravascular tip and ultimately cause bloodstream of CRI, it is essential for health care workers involved with catheter use to have a clear understanding of the diagnosis, pathogenesis, prevention and treatment Contamination of the catheter during its manipulation of this problem and of new developments in the by medical and nursing personnel is the second most field. Most of these infections can be reversed with common portal of entry of micro-organisms.15,17-19 Less appropriate diagnosis and treatment, and many can be common causes include haematogenous dissemination from a distal infectious focus, administration of contaminated infusates, and contaminated transducer The findings of the International Nosocomial kits, disinfectants and infusion lines.20,21 Infection Consortium (INICC) study, which has just 8/28/06 2:50:55 PM 8/28/06 2:50:55 PM Table I. Definitions of CRIs
Catheter colonisation: growth of ≥ 15 colony-forming units (semiquantitative culture) or ≥ 103 colony-forming units
(quantitative culture) from a proximal or distal catheter segment in the absence of local or systemic infection
Local infection: erythema, tenderness, induration or purulence within 2 cm of the skin insertion site of the catheter
Catheter-related bloodstream infection: isolation of the same organism (i.e. the identical species as per
antibiogram) from culture (semiquantitative or quantitative) of a catheter segment and from the blood of a patient with
accompanying clinical symptoms and signs of bloodstream infection and no other apparent source of infection
or is of abrupt onset or associated with shock, the possibility of CRI needs to be considered.
Fundoscopy should always form part of the clinical examination, as focal retinal lesions are common in patients with CVC-derived candida infection, even when blood cultures are negative (Fig. 2).
September
Contamination or purulence at the catheter insertion site is seen in less than half of cases. It is also not predictive of CRBSI with short-term non-cuffed CVCs.27 The laboratory components include culture of blood and the catheter.
Fig. 1. Pathogenesis of catheter-related infections. Blood cultures are central to the diagnosis of CRBSI. Microbiological profile of CRIs Two to three 10 ml samples, ideally from separate peripheral venepuncture sites, should be sent to the The microbiology of CRI reflects a predominance of skin Paired quantitative cultures, which involve taking organisms such as coagulase-negative staphylococci blood from both the catheter and a peripheral site, may and Staphylococcus aureus. Contamination from the be particularly useful where luminal colonisation is hands of medical and nursing personnel is frequently predominant. The diagnosis is suggested when 5-fold responsible for infection with such organisms as or more colonies are isolated from the blood drawn from Pseudomonas aeruginosa, Acinetobacter species, the vascular catheter compared with the concurrent Stenotrophomonas maltophilia and Candida species.22-24 Emerging pathogens include species of Enterococcus, Micrococcus, Achromobacter, non-tuberculous The most widely used laboratory technique for mycobacteria and other fungal organisms.15,22,25,26 culturing the catheter is the semiquantitative roll-plate method.24 Growth at ≥ 15 colony-forming units from Diagnosis of CRI a proximal or distal catheter segment is regarded as significant. Quantitative techniques for culturing the Establishing a diagnosis of CRI involves both clinical catheter include the sonication and vortexing methods, and laboratory components.
which involve extracting micro-organisms from the catheter surface into a medium for culturing.23,28-30 The clinical features are generally nonspecific and include fever, rigors, hypotension and confusion. If Newer diagnostic culture techniques include that of the there is no apparent source of sepsis in a patient with endoluminal brush31,32 and the Gram stain and acridine- an intravascular line (especially a CVC) and if the orange leucocyte cytospin (AOLC) test.33,34 sepsis appears to be refractory to antimicrobial therapy Table II. Common organisms associated with CRIs
Coagulase-negative staphylococci Staphylococcus aureus Candida species Acinetobacter species Pseudomonas aeruginosa Bacillus species Stenotrophomonas maltophilia (especially JK strains) 8/28/06 2:50:56 PM wards and operating theatre are also beneficial in decreasing the rates of CRI.37,38 Maximum sterile barriers
Careful hand washing together with the use of sterile gloves, a mask, gown and cap and a large drape have September
been associated with a more than 6-fold decrease in CVC-related sepsis.39 The usefulness of this practice cannot be overemphasised.
Cutaneous antimicrobials and
Given the important role of cutaneous microflora in the pathogenesis of CRIs, measures to reduce cutaneous Fig. 2. Candida involving retina. colonisation of the insertion site are of vital importance. A three-group trial40 comparing efficacy of skin Use of the endoluminal brush allows samples to be decontamination prior to catheter insertion showed taken via the lumen of the catheter while the catheter that 2% chlorhexidine gluconate was associated with remains in situ. High sensitivities and specificities a four-fold decrease in CRBSI compared with 10% have been reported in the diagnosis of CRI with this povidone-iodine and 70% alcohol.
technique. The technique does not require sacrifice of the catheter, but there is still a delay before culture It is the practice in our unit to use a chlorhexidine results are known. There is also a concern that the gluconate-containing solution for skin preparation.
process of brushing may lead to embolisation of infected biofilm. The place of the endoluminal brush in Tunnelling of CVCs
clinical practice is still to be fully determined.
This involves placing the proximal segment of the catheter under the skin at a distance from the point of The Gram stain and AOLC test is a recently described entry to the vein. Tunnelling was reported to decrease method for rapidly diagnosing CRBSI without catheter the rate of CRBSI in one study in critically ill patients.41 removal. The test is performed on blood samples drawn More data are required to support this observation.
from the CVC and has been reported to have high sensitivities and specificities. The method compares Silver-chelated subcutaneous collagen
favourably with other diagnostic methods, particularly those that require the removal of the catheter, and may permit early targeted antimicrobial therapy.
These cuffs may be attached to percutaneously inserted CVCs and are designed to act as both a Strategies for prevention of CRI mechanical barrier to the migration of micro-organisms and an antimicrobial deterrent (through the effect of Strict adherence to hand washing and aseptic
silver ions). They have been shown to lower the risk technique remains the cornerstone of prevention
of catheter colonisation and CRBSI in critically ill patients.42,43 The anti-infective effect is short-lived, Several other measures have been reported to confer however, as the collagen to which the silver ions are additional protection, some of which need to be chelated is biodegradable. Other drawbacks include considered in the preventive strategy. These include cost and the need for specialised training.
infusion therapy teams, maximal use of barrier precautions during catheter insertion, cutaneous antimicrobials and antiseptics, site of catheter These have been designed to protect against hub insertion, types of catheter, catheter-site dressings, and colonisation. Initial work demonstrated a 4-fold luminal antimicrobial flushes and lock solutions.
decrease in catheter-related sepsis with their use.44 A major limitation, however, is that protection is only Infusion therapy team
conferred against organism migration along the internal The presence of an infusion therapy team whose task surface of the catheter. They do not protect against the is to insert and maintain catheters has been shown to migration of skin organisms along the external surface.
decrease the rate of CRBSI by up to 8-fold and limit A subsequent randomised trial in 130 catheters failed overall costs.35,36 Similarly, strict adherence to protocols to show a protective effect.45 for catheter insertion in the intensive care unit (ICU), 8/28/06 2:50:57 PM Systemic antifungal therapy (together with removal of the catheter) should be given in all cases of catheter- There has been an ongoing debate concerning the related candidaemia in view of the potentially best method of catheter dressing. This has essentially significant sequelae.51 Amphotericin B and fluconazole revolved around the relative merit of gauze versus (except for fluconazole-resistant organisms such as transparent films. In a meta-analysis of catheter Candida glabrata and C. krusei) for at least 14 days dressing regimens, CVCs on which a transparent have been shown to be equally effective.52 Newer dressing was used were associated with a significantly antifungal agents may also be considered.
higher incidence of catheter tip colonisation but a non-significant increase in CRBSI.46 Specific catheter types and A chlorhexidine-impregnated hydrophilic polyurethane foam dressing has been reported to be associated Specific catheter types that will be reviewed include with a reduction in CVC-related infection.47,48 These antiseptic dressings are affixed about newly inserted short peripheral intravenous catheters, peripheral catheters, pressed firmly onto the skin and covered arterial catheters, CVCs, pulmonary artery catheters with a transparent dressing.
(PACs) and peripherally inserted CVCs.
September
The preference in our unit is to use an adhesive gauze Short peripheral intravenous
dressing with a central non-adherent pad following prior appropriate administration of a chlorhexidine gluconate-containing solution to the insertion area.
These remain the most commonly used intravenous device. There is a significant risk of contamination 72 - Antimicrobial coating of catheters
96 hours after insertion.13,53,54 The insertion site should be upper extremity or external jugular vein. A greater In recent years antimicrobial substances have been risk of infection with lower extremity sites and with effectively bonded to catheters in an attempt to limit cutdowns exists.
CRI. Much of this work has pertained to short-term CVCs and will be discussed in further detail later.
Peripheral arterial catheters
Luminal antimicrobial flushes and
These catheters are associated with less infection than PACs, CVCs and short peripheral catheters.55 This may be explained by high arterial flow around the catheter, This practice has been utilised in some units in which probably decreases the adherence of micro- selected cases with variable success, but it is currently organisms. It has generally been suggested that these not routinely recommended. Agents that have been catheters be replaced and relocated no more frequently used include vancomycin-heparin, minocycline-EDTA than every 7 days.54 and alcohol (25% ethanol). It is our current unit policy to keep peripheral arterial Treatment principles in CRI
catheters in place for up to 30 days prior to replacement and relocation, unless otherwise indicated.
Treatment depends on the stage of infection and the pathogen. As a general rule, if CRBSI is suspected the catheter must be removed and replaced only if necessary. CVCs account for an estimated 90% of all CRBSIs. Non-tunnelled (percutaneously) inserted CVCs are the most Most of the infectious complications are self-limiting commonly used catheters. and resolve after removal of the catheter. Indications for antibiotic therapy include persistent sepsis despite A host of risk factors for CVC-related infections have catheter removal, evidence of septic thrombosis of the been reported56-62 including duration of catheterisation, great veins, clinical or echocardiographic evidence of location of the catheter (internal jugular reportedly endocarditis, metastatic foci of infection, underlying having a higher rate of CRI than the subclavian vein), valvular heart disease (especially prosthetic valves) and the presence of sepsis, type of dressing, multi-lumen an underlying imunosuppressed state. catheters (increased frequency of manipulation), less stringent barrier precautious during placement, In terms of specific pathogens and CRBSI, S. aureus experience of personnel inserting the device, and and Candida species require special mention. In the administration of parenteral nutrition.
setting of uncomplicated S. aureus CRBSI, the catheter should be removed and at least 2 weeks (and preferably The duration of CVC use has remained controversial. 4 weeks) of parenteral antibiotics given. There is a As a consequence, scheduled replacement remains high relapse rate if antibiotics are given for a shorter widely practised in many ICUs.63 The duration of catheterisation has been shown to be a risk factor 8/28/06 2:50:57 PM 8/28/06 2:50:57 PM for infection in several studies.56-60,62 Despite the areas, and offers suitable direction. On the basis of controversy, no catheter should be left in place longer these results it is our practice to keep standard CVCs than absolutely necessary. Over the past few years, in place for 14 days, unless there is an indication antimicrobial-impregnated catheters have been for earlier removal. This practice is combined with introduced in an attempt to limit CRI and increase a stringent protocol relating to aseptic insertion the time that CVCs can safely be left in place. These technique and maintenance of the catheter. This include chlorhexidine/silver sulphadiazine- and protocol is shown in Table III.37,38 minocycline/rifampicin-impregnated catheters. Several studies have shown potential benefits of such catheters in terms of reduction of catheter colonisation as well Varying rates of infection have been reported with as CRBSI. A recent meta-analysis concluded that PACs (Swan-Ganz catheters), but most are similar chlorhexidine-silver sulfadiazine CVCs appear to be to CVCs. Higher rates have been attributed to the effective in reducing CRI.64 number of manipulations performed. The ‘Hands-Off Catheter', which is enclosed in a contamination-proof Recently published guidelines have, however, been vague and nonspecific with regard to the role of shield enabling the doctor to prepare, test and insert it antimicrobial-impregnated catheters and when they without exposure to external contamination, has been should be considered for use. A further concern about associated with a decrease in systemic infection.66 September
the use of these catheters relates to the possible Most PACs are heparin-bonded, which reduces development of antimicrobial resistance, and if they are catheter thrombosis and microbial adherence.67 used a continued surveillance for resistance is required.
These catheters may be left in place for up to 7 days if necessary,38,54 by which time the patient frequently no A recently completed randomised prospective double- longer requires this form of catheter. blind study in our multidisciplinary ICU spanning approximately 35 000 catheter hours has addressed With the increasing popularity of non-invasive many of these issues.65 This study compared a haemodynamic monitoring devices, PACs are being 14-day placement of standard triple-lumen versus used less frequently. antimicrobial-impregnated CVCs on the rates of CRI. The study demonstrated no difference in CRI rates Peripherally inserted central venous
between the two types of catheter, and indicated that standard CVCs could safely be left in place for 14 days (together with appropriate infection control measures). PICCs provide an alternative to subclavian or jugular In this study, the use of parenteral nutrition was not vein catheterisation and are inserted into the superior noted to be a risk factor for CRI and there was no vena cava or right atrium via the cephalic and basilar difference in infection related to catheter insertion site veins of the antecubital fossa.
(internal jugular versus subclavian vein).
Compared with other CVCs they have traditionally We believe that this study has shed some light on been associated with few mechanical complications, an previously unanswered questions and controversial apparent lower rate of infection, and decreased cost.68,69 However, recent work has demonstrated that PICCs Table III. Protocol for insertion and maintenance of central venous catheters
• Clean the skin around the insertion site over a wide area by rubbing for 2 minutes with sterile gauze or cotton wool soaked in a chlorhexidine gluconate-containing solution. Sterile gloves must be worn.
• The doctor, wearing a mask and cap, scrubs up (using a chlorhexidine gluconate-containing scrub solution) and then dons a sterile gown and gloves.
• The doctor then cleans the area again and drapes widely to include the patient's head, neck, chest, limbs and torso down to the pelvis. Only the portion necessary for catheter insertion should be left exposed.
• The ‘flush' (heparin 1 000 IU in 19 ml sterile saline) is drawn up, avoiding any contamination by the doctor after cleansing of the stopper on the heparin container. The doctor draws up the ‘flush' with a sterile syringe and needle, while the assistant holds the vials.
• Once the line has been inserted, a sterile piece of gauze soaked in a chlorhexidine gluconate-containing solution is applied over the insertion site and adjacent area for approximately 30 seconds.
• The area is then dried with sterile gauze and an adhesive gauze dressing with a central non-adherent pad applied.
• The dressings are changed daily and the insertion site inspected and cleaned in a sterile fashion. Cleaning includes removal of old blood, clots, exudates and crusts and the application of a chlorhexidine gluconate-soaked piece of sterile gauze to the insertion site for approximately 30 seconds, before drying and dressing the area.
• Any signs of local infection (red, hot, swollen, painful, purulence) must be reported.
8/28/06 2:50:58 PM are associated with a rate of CRBSIs similar to that of • Bridges and their attached lines, transducers and conventional CVCs placed in the internal jugular or continuous flush devices can be replaced at 7-day subclavian veins.70 intervals, provided there is strict adherence to aseptic technique.
• Aseptic technique also extends to care of ports and A recent meta-analysis of CVC replacement caps attached to intravascular devices and includes September
strategies revealed that guidewire exchanges the spraying of a chlorhexidine gluconate-containing were associated with greater risk of CRI but fewer solution following manipulations.
mechanical complications than new-site replacement.71 If guidewire exchange is used, meticulous aseptic technique is necessary. The procedure should not be performed in the setting of confirmed or clinically Intravascular CRI remains a major problem. Despite suspected sepsis. several new technologies and advances, stringent adherence to aseptic technique and infection control In our unit we do not practise guidewire exchanges. measures remain the cornerstone of prevention.
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