1. Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA (Prof I Raad MD, H Hanna MD); and Section of Infectious Diseases, University of Wisconsin Center for Medical Sciences, Madison, WI, USA Lancet Infect Dis 2007; 7: 645–57 R4. JaeJoon Han/ Prof. MiSuk Lee 1

2. Contents Introduction Introduction Types of intravascular devices Types of intravascular devices Clinical manifestations and definitions Clinical manifestations and definitions Diagnosis: quantitative methods Diagnosis: quantitative methods Novel preventive strategies Novel preventive strategies Management: a multifaceted approach Management: a multifaceted approach Conclusion Conclusion 2

3. Introduction Vascular catheter-related blood stream infections (CRBSIs) Vascular catheter-related blood stream infections (CRBSIs) More than 250,000 CRBSIs occur annually in the USA More than 250,000 CRBSIs occur annually in the USA Mortality ranging from 12% to 25% in critically ill patients Mortality ranging from 12% to 25% in critically ill patients An added cost ranging from US $3,000 to $ 56,167 An added cost ranging from US $3,000 to $ 56,167 3

4. Types of intravascular devices Non-tunneled CVCs Non-tunneled CVCs Polyurethane or silicone material s Polyurethane or silicone material s Inserted into subclavian vein or jugular vein Inserted into subclavian vein or jugular vein Tunneled CVCs Tunneled CVCs Tunnelled surgically under the skin for several inches to the cannulated vein Tunnelled surgically under the skin for several inches to the cannulated vein The cuff is used to anchor the catheter in place subcutaneously The cuff is used to anchor the catheter in place subcutaneously The cuff also creates a tissue interface that acts as a barrier against migration of microorganisms The cuff also creates a tissue interface that acts as a barrier against migration of microorganisms Groshong catheter: two-slit valve Groshong catheter: two-slit valve 4

5. Types of intravascular devices Implantable ports Implantable ports Ports are implantable vascular access devices made of plastic or titanium material and inserted completely beneath the skin Ports are implantable vascular access devices made of plastic or titanium material and inserted completely beneath the skin 5

6. Types of intravascular devices Peripherally inserted CVCs Peripherally inserted CVCs A method for long-term venous access ( 6 weeks to 6 months) A method for long-term venous access ( 6 weeks to 6 months) The catheter is inserted peripherally at or above the antecubital space into the cephalic, basilic, medial cephalic, or medial basilic vein The catheter is inserted peripherally at or above the antecubital space into the cephalic, basilic, medial cephalic, or medial basilic vein It is advanced into the superior vena cava It is advanced into the superior vena cava 6

7. Contents Introduction Introduction Types of intravascular devices Types of intravascular devices Clinical manifestations and definitions Clinical manifestations and definitions Diagnosis: quantitative methods Diagnosis: quantitative methods Novel preventive strategies Novel preventive strategies Mangement: a multifaceted approach Mangement: a multifaceted approach Conclusion Conclusion 7

8. Clinical manifestations and definitions Local catheter infections Local catheter infections an exit site infection an exit site infection an tunnel infection an tunnel infection an pocket infection an pocket infection Induration, erythema, warmth, Induration, erythema, warmth, and pain or tenderness 8

9. Clinical manifestations and definitions Systemic catheter infections Systemic catheter infections Fever, chill, and hypotension in the absence of hypovolemia or a cardiac event Fever, chill, and hypotension in the absence of hypovolemia or a cardiac event The infectious diseases society of america (IDSA): One of the following microbial methods to confirm diagnosis of CRBSI The infectious diseases society of america (IDSA): One of the following microbial methods to confirm diagnosis of CRBSI Positive semiquantitative or quantitative culture of the catheter Positive semiquantitative or quantitative culture of the catheter Simultaneous quantitative blood cultures drawn through the CVC and peipheral vein with a ratio of 5:1 or more (CVC versus peripheral) Simultaneous quantitative blood cultures drawn through the CVC and peipheral vein with a ratio of 5:1 or more (CVC versus peripheral) Differential time to positivity Differential time to positivity 9

10. Diagnosis: quantitative methods Catheter-sparing diagnostic methods Catheter-sparing diagnostic methods 10

11. Diagnosis: quantitative methods Diagnostic methods requiring catheter removal Diagnostic methods requiring catheter removal 11

12. Diagnosis 12

13. Contents Introduction Introduction Types of intravascular devices Types of intravascular devices Clinical manifestations and definitions Clinical manifestations and definitions Diagnosis: quantitative methods Diagnosis: quantitative methods Novel preventive strategies Novel preventive strategies Management: a multifaceted approach Management: a multifaceted approach Conclusion Conclusion 13

14. Traditional measures for the prevention of catheter-related infection Education of health-care workers on proper catheter insertion and maintenance Education of health-care workers on proper catheter insertion and maintenance Routine monitoring of institutional rates of CRBSI Routine monitoring of institutional rates of CRBSI Hand hygiene Hand hygiene Use of a dedicated infusion therapy team Use of a dedicated infusion therapy team Use of sterile semipermeable dressings Use of sterile semipermeable dressings Evidence of femoral insertion Evidence of femoral insertion Removing the catheter as soon as possible Removing the catheter as soon as possible 14

15. Novel preventive strategies Cutaneous antisepsis Cutaneous antisepsis Maximum sterile barrier Maximum sterile barrier Chlorhexidine-impregnated sponge Chlorhexidine-impregnated sponge Antimicrobial catheters Antimicrobial catheters Antimicrobial catheter lock Antimicrobial catheter lock Antiseptic practice versus novel technology Antiseptic practice versus novel technology 15

16. Novel preventive strategies Cutaneous antisepsis Cutaneous antisepsis Povidone-iodine : the most frequently used for local catheter insertion sites Povidone-iodine : the most frequently used for local catheter insertion sites 2% chlorhexidine- containing cutaneous antiseptic regimen 2% chlorhexidine- containing cutaneous antiseptic regimen Maki and colleagues showed 2% aqueous chlorhexidine gluconate tended to decrease CRBSI compared with 10% povidone-iodine or 70% alcohol Maki and colleagues showed 2% aqueous chlorhexidine gluconate tended to decrease CRBSI compared with 10% povidone-iodine or 70% alcohol 16

17. Novel preventive strategies Maximum sterile barrier precautions Maximum sterile barrier precautions Wearing a sterile gown, gloves, and cap Wearing a sterile gown, gloves, and cap Using sterile drape during the insertion of the CVC, similar to the drapes used in the operating room Using sterile drape during the insertion of the CVC, similar to the drapes used in the operating room 17

18. Novel preventive strategies Chlorhexidine-impregnated sponge Chlorhexidine-impregnated sponge A commercially available chlorhexidine-impregnated sponge A commercially available chlorhexidine-impregnated sponge about 2.5cm in diameter, can be placed over the CVC insertion site and covered with transparent polyurethane about 2.5cm in diameter, can be placed over the CVC insertion site and covered with transparent polyurethane The latest guidelines for the prevention of intravascular cather-related infections made no recommendation The latest guidelines for the prevention of intravascular cather-related infections made no recommendation Usefulness is considered to be an unresolved issue Usefulness is considered to be an unresolved issue 18

19. Novel preventive strategies Antimicrobial catheters Antimicrobial catheters Antiseptic catheter: chlorhexidine/sulfadiazine impregnated on external and internal surfaces Antiseptic catheter: chlorhexidine/sulfadiazine impregnated on external and internal surfaces Antibiotic-coated catheter: minocycline and rifampicin coated Antibiotic-coated catheter: minocycline and rifampicin coated Silver-impregnated catheter: oligodynamic iontophoresis ( silver, platinum, and carbon are incorporated into the catheter, allowing topical silver ion release) Silver-impregnated catheter: oligodynamic iontophoresis ( silver, platinum, and carbon are incorporated into the catheter, allowing topical silver ion release) HICPAC guidelines recommend HICPAC guidelines recommend Use antiseptic or antibiotic-coated CVCs in patients whose catheter is expected to remain in place for more than 5 days Use antiseptic or antibiotic-coated CVCs in patients whose catheter is expected to remain in place for more than 5 days 19

20. Novel preventive strategies Antimicrobial catheter lock Antimicrobial catheter lock Several prospective randomised studies have shown that an antimicrobial catheter lock is superior to heparin alone as lock solution in preventing catheter infection Several prospective randomised studies have shown that an antimicrobial catheter lock is superior to heparin alone as lock solution in preventing catheter infection A meta-analysis of seven randomized controlled trials showed that the use of vancomycin lock solution in mostly cancer patients with long-term CVCs reduced the risk of CRBSI (risk ratio 0.49), but the test of heterogeneity was significant A meta-analysis of seven randomized controlled trials showed that the use of vancomycin lock solution in mostly cancer patients with long-term CVCs reduced the risk of CRBSI (risk ratio 0.49), but the test of heterogeneity was significant Limited activity of vancomycin against staphylococci embbeded in biofilm Limited activity of vancomycin against staphylococci embbeded in biofilm Other catheter lock solutions: minocycline and EDTA, taurolidine, or ethanol Other catheter lock solutions: minocycline and EDTA, taurolidine, or ethanol 20

21. Novel preventive strategies A large multicentre trial in 108 ICUs in Michigan, USA A large multicentre trial in 108 ICUs in Michigan, USA 5 antiseptic techniques recommended by CDC guidelines 5 antiseptic techniques recommended by CDC guidelines Hand hygiene, Use of chlorhexidine for skin preparation, Maximum sterile barrier precautions, Use of the subclavian vein as the preferred insertion site, Removal of unnecessary CVCs Hand hygiene, Use of chlorhexidine for skin preparation, Maximum sterile barrier precautions, Use of the subclavian vein as the preferred insertion site, Removal of unnecessary CVCs Decrease in the mean rate of CRBSI from 7.7 bloodstream infections per 1000 catheter-days at baseline to 1.4 infections at 16-18 months follow up Decrease in the mean rate of CRBSI from 7.7 bloodstream infections per 1000 catheter-days at baseline to 1.4 infections at 16-18 months follow up → Hawthorn effect of being involved in the study → Hawthorn effect of being involved in the study Policy of strict adherence to antiseptic techniques and Introduction of novel technology in high-risk patients Policy of strict adherence to antiseptic techniques and Introduction of novel technology in high-risk patients 21

22. Mangement: a multifaceted approach Making decisions related to Making decisions related to Whether the CVC should be removed or retained with antibiotic catheter lock therapy Whether the CVC should be removed or retained with antibiotic catheter lock therapy The type of antimicrobial therapy based on the type of organism and its resistance pattern The type of antimicrobial therapy based on the type of organism and its resistance pattern The duration of antimicrobial therapy The duration of antimicrobial therapy 22

23. Mangement: a multifaceted approach Coagulase-negative Staphylococcus spp Coagulase-negative Staphylococcus spp Staphylococcus epidemidis Staphylococcus epidemidis Nasal mucosa rather than the CVC skin insertion site is the major source Nasal mucosa rather than the CVC skin insertion site is the major source Vancomycin is the most frequently used antistaphylococcal antibiotic Vancomycin is the most frequently used antistaphylococcal antibiotic Dalbavancin,daptomycin Dalbavancin,daptomycin 23

24. Mangement: a multifaceted approach Staphylococcus aureus Staphylococcus aureus Septic thrombosis or endocarditis Septic thrombosis or endocarditis Removal of CVC in S aureus CRBSI is associate with more rapid response and lower relapse rate. Removal of CVC in S aureus CRBSI is associate with more rapid response and lower relapse rate. MSSA MSSA 1 st generation cephalosporin 1 st generation cephalosporin Semisynthetic antistaphylococcal penicillin Semisynthetic antistaphylococcal penicillin MRSA MRSA Vancomycin Vancomycin Daptomycin Daptomycin Dalbavancin Dalbavancin 24

25. Mangement: a multifaceted approach Gram-negative bacilli Gram-negative bacilli Klebsiella pneumoniae, Enterobacter spp, Pseudomonas spp, Acinetobacter spp, Stenotrophomonas maltophilia Klebsiella pneumoniae, Enterobacter spp, Pseudomonas spp, Acinetobacter spp, Stenotrophomonas maltophilia High frequency of relapse if CVC is retained High frequency of relapse if CVC is retained 25

26. Mangement: a multifaceted approach Candida species Candida species CVC should be removed within 72 h in patients with suspected or documented catheter-related candidemia CVC should be removed within 72 h in patients with suspected or documented catheter-related candidemia Fluconazole or an echinocandin should be considered as an efficacious and safer alternative to amphotericin B Fluconazole or an echinocandin should be considered as an efficacious and safer alternative to amphotericin B Higher rates of fluconazole-resistant Candida glabrata and Candida krusei : echinocandin should be used Higher rates of fluconazole-resistant Candida glabrata and Candida krusei : echinocandin should be used 26

27. Mangement: a multifaceted approach 27

28. Conclusion A successful approach to managing CRBSI A successful approach to managing CRBSI Remove or spare the CVC Remove or spare the CVC Use of efficacious antimicrobial therapy for the optimum duration of treatment Use of efficacious antimicrobial therapy for the optimum duration of treatment 28