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Catheter-Related Infections. (The Effective Physician).

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Background

More than 200,000 nosocomial bloodstream infections occur each year, most related to use of intravenous devices. A recent metaanalysis of over 2,500 catheter-related bacteremic infections demonstrated a case-fatality rate of 14%. The Infectious Diseases Society of America published evidence-based guidelines for management of catheter-related infections in 2001.

Conclusions

Clinical signs and symptoms are unreliable for diagnosing catheter-related infection.

Catheters placed less than 1 week prior to suspected infection are most commonly colonized by a skin microorganism; intraluminal contamination and spread from the hub are more likely for longer-dwelling devices.

Peripheral and central venous catheter-related infections are most commonly caused by coagulase-negative staphylococci, Staphylococcus aureus, aerobic gram-negative bacilli, and Candida albicans. Blood cultures positive for these organisms, in the absence of other identifiable sources of infection, should increase suspicion of a catheter-related bacteremia.

Therapy for catheter-related infection should be initiated intravenously but may be changed to the oral route once the patient's condition has stabilized an antibiotic sensitivities are known. Suitable agents include quinolones, trimethoprim-sulfamethoxazole, and linezolid; all of which have excellent oral bioavailability.

Implementation

Blood cultures should be obtained both percutaneously and through the suspect catheter. Quantitative or semiquantitative culture of the catheter tip or barrel should be performed.

Short-term peripheral venous catheters should be removed and cultured for suspected infections. Any exudate at the catheter site should be submitted for Gram stain and culture prior to initial antibiotic therapy

Percutaneous central venous catheters should not routinely be removed in patients with fever and mild disease. They should be removed, however, in the presence of inflammation at the catheter site, with signs of the sepsis syndrome, in catheter-related gram-negative bacillary or S. aureus bacteremia, and with suspected metastatic infection.

Infective endocarditis commonly occurs with catheter-associated S. aureus bacteremia. Transesophageal echocardiography if not contraindicated, should be performed. Transthoracic echocardiography has poor sensitivity for catheter-related endocarditis.

Tunneled catheters or ports may be salvaged in patients with uncomplicated intraluminal infections with S. aureus, coagulase-negative staphylococci, or gram-negative bacilli with a combination of standard systemic antimicrobial agents and 2 weeks of antibiotic lock therapy Salvage therapy for catheter-related fungemia is not recommended.

Tunneled catheter pocket or port site abscesses necessitate removal of the device and at least 7-10 days of antimicrobial therapy

All types of central venous catheters should be removed, if possible, in the setting of complicated catheter-related infections. Nontunneled catheters may be replaced after the initiation of antimicrobial therapy Replacement of tunneled devices should be deferred until repeat blood cultures are negative, ideally after the completion of appropriate systemic antimicrobial therapy and a delay of 5-10 days.

There are no data supporting specific empiric antimicrobial regimens for catheter-related bacteremia. Vancomycin is usually recommended in regions and institutions with a significant incidence of methicillin-resistant staphylococci. The addition of empiric coverage with a third- or fourth-generation cephalosporin for enteric gram-negative bacilli and Pseudomonas aeruginosa may be warranted for severely ill or immunocompromised patients. If fungemia is suspected, empiric antifungal treatment with amphotericin B also should be considered, intravenous fluconazole may be appropriate in selected patients.

Recommendations regarding duration of therapy are based on limited data. Uncomplicated infections with coagulase-negative staphylococci in which the catheter is removed may be adequately treated with regimens as brief as 5-7 days. Nonimmunocompromised patients with uncomplicated infections may be treated for 10-14 days for organisms other than coagulase- negative staphylococci. Patients with endocarditis, septic thrombophlebitis, or persistent signs of infection after catheter removal should be treated for 4-6 weeks. Patients with osteomyelitis may require 6-8 weeks therapy.

Reference

Leonard A. Mermel et al. Guidelines for the Management of Intravascular Catheter-Related Infections. Clin. Infect. Dis. 32(9):1249-72, 2001.
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Article Details
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Author:Golden, William E.; Hopkins, Robert H.
Publication:Internal Medicine News
Geographic Code:1USA
Date:Feb 1, 2002
Words:602
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