16. Catheter-Related Bloodstream Infection (CRBSI)

Overview

Catheter-related bloodstream infections (CRBSIs) are documented bloodstream infections associated with central catheters. CRBSIs are associated with significant morbidity, mortality, and cost to the healthcare system. We often use the term CLABSI (central line associated blood stream infections) for surveillance purposes.

Etiology

  • Risk factors
    • Chronic illness, BMT, immunocompromised state (esp. neutropenia), malnutrition, TPN, previous bacteremia, extremes of age, loss of skin integrity (i.e. burns, etc.).
  • Microbiology
    • Most common infective organism is coagulase-negative Staph, then S. aureus, GNRs, and C. albicans.
    • Mortality rate is highest for S. aureus catheter-related bacteremia and is lowest for coag-negative Staph.
  • Prevention of central line infection
    • See Procedures for details on central line placement. Always use sterile technique with maximal sterile barriers (gown, gloves, cap, mask, sterile drapes) with hand hygiene.
    • Subclavian lines have lower risk of infection rates compared to femoral or internal jugular lines.
    • Use antibiotic impregnated catheters (if available).
    • Use chlorhexidine-alcohol for skin disinfection and let dry before catheter insertion.
    • Use antimicrobial disks (placed at insertion site right after line insertion).
    • No good evidence for routine replacement of central lines (e.g., replacing without any evidence or concern for infection).
    • Inspect sites daily; do not use topical creams/antibiotics with dressings.
    • Replace lines not placed under sterile conditions (e.g., during codes) ASAP.
    • Remove lines once they are no longer indicated.

Diagnosis

See Critical Care: Fever + central line.

Management

  • For guidelines, see Critical Care: Fever + central line.
  • Consult ID to help with decisions regarding duration of therapy and line management.
  • If clinically indicated, empiric therapy should include:
    • Vancomycin +/- anti-pseudomonal coverage until culture data returns.
    • Can also consider adding an echinocandin empirically depending on risk factors for candidemia and clinical stability.
  • Await culture results prior to narrowing antibiotics.
  • Balance the need for line vs. risk of infection; remove any unnecessary lines.
  • Remove lines for (a) virulent organisms (S. aureus, Pseudomonas, Candida) or (b) complicated infections (shock, metastatic infection, tunnel infection, thrombophlebitis, or not improving clinically on appropriate antibiotics).
    • For other organisms, line removal depends on the line type and clinical situation (see the IDSA guidelines referenced below for details).
  • In hemodialysis patients with poor access, line salvage (with systemic antibiotics and antibiotic lock therapy) or guide wire exchange can be considered.
  • The presence or absence of complicated infection, e.g. thrombophlebitis, endocarditis, osteomyelitis, hardware, etc. determines length of therapy.
  • All treatment duration is taken from the first day that cultures have cleared after source control is achieved (i.e. the line is removed).
  • See also the IDSA guidelines on management of CRBSI (http://cid.oxfordjournals.org/content/49/1/1.full)

Key Points

  • Placement of lines under sterile conditions greatly reduces risk of CRBSI.
  • The most common organisms are coag-negative Staph and Staph aureus.
  • Lines that are no longer indicated should be removed.
  • The risks of line removal must always be weighed against the benefits in patients with complicated access or in whom permanent lines are a necessity.

Mermel LA, Allon M, Bouza E, et al. Clinical Practice Guidelines for the diagnosis and Management of Intravascular-Catheter-Related Infection:  2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49(1)1-45.

O’Grady NP, Alexander M, Dellinger MP, et al. Guidelines for the prevention of intravascular catheter-related infections. Infect Control Hosp Epidemiol 2002;23:759-769.