Central Line Infection: Pull or Leave it in David Nguyen PGY 2 5/1/12

Objective  Determine catheter related blood stream infection (CRBSI)  Key Factors to consider when removing cathether: Patient-related factors Organism Catheter

Case 1  65 y/o pmhsx DMII, HTN, CAD presents with severe sepsis likely source PNA into ICU, had right IJ central line placed and all the right abx and pressors started. Several days later, noticed that the patient had developed fever and leukocytosis, which had been trending down to normal. Site of IJ is slightly erythematous, not too tender, no pus drainage. Patient’s MAP > 65, not tachycardic, has been off of pressors for 1 day. How do you proceed?

Clinical Evaluation  Local inflammation  Hemodynamic stability  Sepsis  Blood culture  Catheter dysfunction  Rapid improvement following catheter removal

Diagnosis  Blood cultures from catheter AND peripheral vein at ~ same time. (A-II)  If cannot get peripheral vein, get 2 or more blood samples through different catheter lumens (C-III)  Differential time to positivity (DTP)  Quantitative blood culture (not used by our micro lab)*

Dx: Differential time to positivity  Catheter microbial growth detected 2 hours before peripheral vein  Sens: 85% and spec 91% (1)  More cost-effective than quantitative method and can be done here at UCI

Case 1 revisited… Next steps  Obtain blood culture from peripheral vein and from the central line.  If the blood culture from the central line becomes positive at least two hours before that of the peripheral line, then diagnosis of CRBSI.  How do you proceed if positive CRBSI?

Treatment  What to do with the catheter? Remove vs Salvage vs Exchange  Type of device: short vs long term (excluding HD)  Infecting pathogens  Presence of alternative venous access sites  Duration of anticipated need for access  Systemic antibiotics

Catheter removal indications  Severe sepsis  Hemodynamic instability  Endocarditis or evidence of metastatic infection  Erythema due to suppurative thrombophlebitis  Persistent bacteremia after 72 hrs abx to which organism is susceptible

Case 2  65 y/o with DMII, HTN p/w LLL PNA. Had L IJ line placed (difficult stick) as this was the weekend and could not get PICC. Pt’s vitals on admission only significant for fever Treating for CAP.  3 days later, pt’s bp drops to 80s/40s hr: 120s, febrile again 39.3, pt more lethargic. Blood cultures drawn from periphery and central line, UA and CXR unremarkable, WBC increased to 16, lactate 4. How do you proceed?

Case 2 A.Keep the line, transfer the patient to the ICU and broaden abx. B.Change the line via guidewire as patient is difficult stick and broaden abx. C.Transfer pt to ICU (IVF and pressors) and broaden abx. Obtain another access site, pull the line. D.Keep the line, keep pt on floor, fluid boluses and follow up on cultures in the morning.

Case 2 A.Keep the line, transfer the patient to the ICU and broaden abx. B.Change the line via guidewire as patient is difficult stick and broaden abx. C.Transfer pt to ICU (IVF and pressors) and broaden abx. Obtain another access site, pull the line. D.Keep the line, keep pt on floor, fluid boluses and follow up on cultures in the morning.

Case 3  65 y/o woman with DMII, HTN p/w sepsis 2/2 UTI. PICC line was placed on previous admission so pt can get home IV abx. You obtain blood cultures from that line and periphery and blood culture from line grew out s. aureus 1 day prior to periphery which also grew out same organism. Pt currently hemodynamically stable, afebrile on ceftriaxone for UTI. Leukocytosis has improved to normal range now. How should you proceed?

Case 3 A.Treat with vancomycin and await sensitivities. B.Obtain another set of blood cultures from PICC and peripheral. Start vancomycin thereafter. C.Obtain another set of blood cultures from PICC and periphery, pull the line and start vancomycin. D.Pull the line, that things been in there for way too long.

Catheter removal indications  Short term catheters (< 14 days) S. aureus, enterococci, gram neg bacilli, fungi, and mycobacteria Erythema or purulence at insertion site  Low virulence but difficult to eradicate (eg, Bacillus spp, Micrococcus spp, or Propionibacteria) No evidence for catheter exchange i.e. salvage

Case 3 A.Treat with vancomycin and await sensitivities. B.Obtain another set of blood cultures from PICC and peripheral. Start vancomycin thereafter. C.Obtain another set of blood cultures from PICC and periphery, pull the line and start vancomycin. D.Pull the line, that things been in there for way too long.

Case 3 A.Treat with vancomycin and await sensitivities. B.Obtain another set of blood cultures from PICC and peripheral. Start vancomycin thereafter. C.Obtain another set of blood cultures from PICC and periphery, pull the line and start vancomycin. D.Pull the line, that thing has been in there for way too long.

Approach to the management of patients with short-term central venous catheter–related or arterial catheter–related bloodstream infection. CFU, colony-forming units; S. aureus, Staphylococcus aureus.

Case 4  62 y/o w/hsx of liver mets has a Port-a- cath presents with altered mental status. Not receiving chemotherapy currently. Family says that after discharge, pt has become more confused, no fever, cough, dysuria or hematuria, diarrhea. PE: no erythema or tenderness at site or port-a- cath. UA Blood cultures grew out E.coli from portacath site. Repeat cultures demonstrated same organism from catheter and peripheral site. What should be done next?

Catheter removal indications  Long term catheters (> 14 days) S. aureus, Gram negative bacilli, P. aeruginosa, fungi, or mycobacteria Tunnel infection, port abscess Hickman catheter, tunneled Port-A-Cath

Approach to the treatment of a patient with a long-term central venous catheter (CVC) or a port (P)-related bloodstream infection.

Case 4  Essentially you need to remove this catheter as you cannot treat through this in light of cultures growing out E.coli.  Remember the other organisms that require removal: S. aureus, Gram negative bacilli, P. aeruginosa, fungi, or mycobacteria  Other scenarios that necessitate removal: Tunnel infection, port abscess

Factors Affecting Abx Choice  Factors: severity of illness risk factors for infection likely pathogens a/w specific catheter  Start with Vancomycin Coag negative staph are most common and usually resistant to methicillin. Be careful with Vanc resistance  daptomycin  Neutropenia, sepsis  empiric coverage for gram negative

Empiric Antibiotic  Cover for candidemia when (B-II): TPN Prolonged use of broad-spectrum abx Hematologic malignancy Bone marrow or solid organ transplant Femoral catherization Colonization due to Candida species at multiple sites  Ex: caspo, micafungin, fluconazole (if organism is susceptible) (A-II)

Antibiotic Duration  Typically 10 to 14 days (day one is the first day on which negative blood cultures are obtained)  4 to 6 weeks in patients with recent prosthetic valve placement placed prosthetic valves, even if investigation fails to demonstrate evidence of IE.  Patients with persistent bacteremia >72 hours following catheter removal should generally receive tx for at least 4 to 6 weeks  Complications related to bacteremia (such as suppurative thrombophlebitis, endocarditis, osteomyelitis, metastatic infection) the duration of therapy should be tailored accordingly depending on the nature of infection.

Take home points  Time to positivity dx: catheter site culture should have growth at least 2 hrs before peripheral site  Catheter removal: “complicated” infection, short term CVC: S. aureus, enterococci, gram neg bacilli, fungi, and mycobacteria Long term CVC: S. aureus, P. aeruginosa, fungi, or mycobacteria  Abx choice: depends on severity of illness, risk factors (neutropenia, candida coverage)

Reference 1)Meta-analysis: methods for diagnosing intravascular device-related bloodstream infection. Safdar N, Fine JP, Maki DG. Ann Intern Med Mar 15; 142(6) : Safdar NFine JPMaki DGAnn Intern Med. 2)Clinical Practice Guidelines for Dx and Management of Intravascular Catheter- Related Infection: IDSA 2009 guidelines 3)UpToDate: Intravascular catheter device dx and management