1. Catheter-Associated Bloodstream Infections Based on Infectious Disease Society of America guidelines Clinical Infectious Diseases 2001;32:1249-72. Rey Vivo, MD Department of Internal Medicine Texas Tech University Health Sciences Center CA-BSI

2. Case 1 57F was discharged from the hospital after a diagnosis of native valve endocarditis. A home nurse visited to give daily Vancomycin injections through the central venous catheter (CVC) placed into her left subclavian vein. 5 days after discharge, the nurse noticed that the surrounding skin appeared erythematous with scant yellow exudate; temp=99.8F. 2 sets of blood C/S drawn from different peripheral sites were negative. What is the best diagnosis? A. Exit-site infection B. Catheter colonization C. CA-BSI D. Normal skin reaction

3. Catheter-related infections Phlebitis/Exit-site infection Tunnel/Pocket Infection Catheter colonization CA-BSI

4. Pathogenesis Extraluminal colonization - from skin - hematogenous seeding of tip - biofilm Intraluminal colonization of hub and lumen

5. Case 2 65M was admitted to the ICU for DKA and got a left femoral CVC for fluids and IV insulin (peripheral access was difficult). He continued to have problems with glycemic control and on the 4 th HD developed a temp=102.7F; the rest of his vital signs were stable. What is the next best test to make a diagnosis of CA-BSI? A. No need for tests; clinical findings are sensitive and specific B. Draw 2 sets of blood C/S from 2 different peripheral sites C. Draw 2 sets of blood C/S, 1 through the CVC and 1 percutaneously D. Remove the CVC and send the tip for culture

6. Definition and Diagnosis CA-BSI - bacteremia or fungemia in a patient with an IV device with: (1) clinical signs of infection of no other apparent source; and (2) >1 (+) blood C/S drawn peripherally - one of the ff should be present: (1) (+) semi-quantitative [>15 cfu/segment] or quantitative [>10 2 cfu/segment] where same organism is isolated from device and peripheral site; (2) (+) simultaneous quantitative blood C/S with a ratio of >5:1 [CVC vs. peripheral] (3) (+) differential time to positivity (at least 2 hours)

7. Answer IDSA Guidelines, 2001

8. Case 3 49M with no medical history was admitted for extensive burns in his trunk and both arms. A CVC was inserted into his right internal jugular vein for fluids and blood products. On his 8 th HD, he developed a fever (temp=103.1F). The rest of his vital signs were stable. CXR and urinalysis were normal. 2 sets of blood C/S drawn from the CVC and percutaneously revealed coagulase-negative Staphylococcus. Obtaining vascular access elsewhere is difficult. What is the next best step? A. Remove CVC and treat with antibiotics for 2 weeks B. Remove CVC and treat with antibiotics for 4 weeks C. Retain CVC and treat with antibiotics for 2 weeks D. Retain CVC and treat with antibiotics for 4 weeks

9. Answer IDSA Guidelines, 2001

10. Case 3B IV Vancomycin was started. Sensitivities later revealed Methicillin- susceptible coagulase-negative Staphylococcus and the antibiotic was switched to IV Nafcillin. The fever resolved on his third day on Nafcillin and his overall condition improved. The burn team advised discharge to home and the CVC was taken out. What is the best oral antibiotic to prescribe to this patient? A. Trimethoprim-sulfamethoxazole B. Clindamycin C. Levofloxacin D. Linezolid

11. Answer S. aureusPreferredAlternative MSSANafcilllin or OxacillinCefazolin or Cefuroxime MRSAVancomycinLinezolid or Quin/Dalf VRSALinezolid or Quin/Dalf Coag-neg Staph Meth-susceptibleNafcillin or Oxacillin1 st gen ceph or TMP/SMX Meth-resistantVancomycinLinezolid or Quin/Dalf

12. Case 4 37F diabetic, hospitalized for MRSA osteomyelitis of the right ankle, was discharged without fever after 1 week. After receiving IV Vancomycin for 5 more weeks, the PICC line in her right arm was removed. 5 days after, she experienced chills, SOB and gradual swelling of her right arm. In the ED, vital signs were: BP 105/70, HR 120, RR 24, temp=103.4F. Her right upper extremity had erythema, warmth and edema extending to the ipsilateral neck. Chest was clear; no murmurs were auscultated. Blood C/S from 2 sites grew gram (+) cocci in clusters; sensitivities were pending. What is the next best step? A. Admit and treat with Vancomycin for 2 weeks B. Admit and treat with Vancomycin for 6 weeks C. Admit and treat with Vancomycin for 6 weeks; send for spiral CT of the chest D. Admit and treat with Vancomycin for 2 weeks; start thrombolysis

13. Answer IDSA Guidelines, 2001

14. Take Home Points IDSA Guidelines, 2001

15. Thank you