Causes of catheter-associated bloodstream infections. Catheter-associated bloodstream infections. Causes of infection associated with a central venous catheter
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1 130 UDC Catheter associated bloodstream infections B.V. Berezhansky, A.A. Zhevnerev Departmental Hospital at Smolensk Station, Smolensk, Russia Catheter-associated bloodstream infections occupy third place among all nosocomial infections and first place among causes of bacteremia, accounting for up to 10% of all infections in hospitalized patients, 20% of all nosocomial infections and up to 87% from primary bacteremia. In Europe and the USA, more than 500 thousand cases of catheter-associated infections are registered annually, of which 80 thousand cases are registered in the ICU. The article discusses the epidemiology, etiology and classification of catheter-associated bloodstream infections, their clinical manifestations, basic methods and diagnostic criteria, as well as approaches to therapy. The possibilities of preventing this pathology are discussed in detail. Key words: bloodstream infections, catheter-associated infections, central venous catheter, epidemiology, etiology, treatment, prevention. Catheter-associated Bloodstream Infections B.V. Berezhanski, A.A. Zhevnerev Smolensk Railway Station Hospital, Smolensk, Russia Catheter-associated bloodstream infections take a third place among nosocomial infections, and are the most common cause of bacteremia. These infections account for 10% of all infections in hospitalized patients, 20% of nosocomial infections and up to 87% of primary bacteremia. In Europe and USA, > cases of catheter-associated infections occur annually with cases are reported in ICU patients. This paper reviews epidemiology, etiology and classification of catheter-associated bloodstream infections, their clinical forms, main diagnostic principles and criteria, and approaches to therapy. Potential for the prophylaxis of these infections is considered in detail. Key words: bloodstream infections, catheter-associated infections, central venous catheter, epidemiology, etiology, treatment, prevention. Contact address: Boris Vitalievich Berezhansky Email: mail:
2 131 Introduction It is difficult to imagine modern medicine without providing vascular access. In many cases, this is achieved by placing a central venous catheter (CVC), which is necessary both for monitoring (determining central venous pressure, pulmonary capillary wedge pressure, degree of hydration) and for administering medications, electrolytes, blood components and parenteral nutrition. In the United States, more than 150 million vascular catheters are purchased annually by medical institutions, of which about 5 million are used for central venous catheterization; in the UK, up to 200 thousand central venous catheterizations are performed annually. If we consider such an indicator as the number of days of central venous catheterization, then in US intensive care units it reaches 15 million per year. With the increasing number of vascular catheterizations, the frequency of complications such as catheter-associated bloodstream infections (CABI) is increasing. This pathology leads not only to increased length of hospital stay and, consequently, increased treatment costs, but also to increased mortality, especially among patients in critical condition. Catheter-associated bloodstream infections rank third among all nosocomial infections and first among causes of bacteremia, accounting for about 10% of all infections in hospitalized patients, 20% of all nosocomial infections, and up to 87% of primary bacteremias. In Europe and the USA, more than 500 thousand cases of catheter-associated infections are registered annually, of which 80 thousand cases are registered in the ICU. More than 15% of patients with a catheterized central venous line develop complications. Mechanical complications occur in 5-19% of patients, infectious in 5-26% and thrombotic in up to 26%. The two most common complications of CVC use that require removal are CAIC and catheter thrombosis. To quantify CAIC, the US Centers for Disease Control and Prevention (CDC) has proposed an indicator of the number of infections per 1000 days of catheterization. In departments and hospitals of different structures and profiles, the number of CAICs varies from 2.9 (in cardiothoracic ICUs) to 11.3 per 1000 days of catheterization (in intensive care units for children weighing less than 1000 g). In the general ICU, in patients with short-term CVCs, an average of 4.3–7.7 cases of CAIC are recorded per 1000 days of catheterization. In Russia, according to preliminary data from the CASCAT study, CAIC is 5.7 cases per 1000 days of catheterization. CVC colonization was detected in 16.4% of cases, which corresponds to 21.5 cases per 1000 days of catheterization. In the USA and European countries, the mortality rate for CAIC averages up to 19–25% and directly depends on the pathogen. Thus, the mortality rate for CAIC caused by coagulase-negative staphylococci is 2-10%, and for CAIC caused by Candida spp. and Pseudomonas aeruginosa, 38 and 50%, respectively. In a more detailed analysis of fatal CAIC cases, the attributable mortality rate is 2.7% (8.2% for infection caused by S. aureus and 0.7% for coagulase-negative staphylococci), the remaining percentage is due to the underlying disease. Up to $2.3 billion is spent annually on the treatment of patients with CAIC in the United States; each case of CAIC costs an average of up to $29 thousand. Unfortunately, due to little knowledge of the problem in Russia, there are no statistical data on KAIC in our country. Etiology The spectrum of microorganisms that cause CAIC depends on a number of factors, such as the severity of the patient's condition, the type of catheter, the profile of the department, the route of infection, etc. The most often isolated in CAIC are coagulase-negative staphylococci (34-49.1%) and Staphylococcus aureus ( 11.9 17%). Less commonly isolated are other pathogens, such as Enterococcus spp. (5.9 6%), Candida spp. (7.2 9%), Pseudomonas spp. (4.9 6%), as well as representatives of the Enterobacteriaceae family. Interestingly, in general, the frequency of isolation of the main pathogens in CAIC remains approximately the same over time (Table 1). At the same time, perhaps due to improved treatment of the underlying disease and an increase in the number of patients with immunodeficiency conditions, the diversity of microorganisms causing CAIC is growing accordingly. The dependence of the etiology of CAIC on certain conditions and the profile of the department is shown in Table. 2.
3 132 Table 1. Frequency of occurrence of pathogens of CAIC Pathogen years, % years, % 2001, % Coagulase-negative staphylococci Staphylococcus aureus Enterococcus spp Escherichia coli 6 2 Enterobacter spp Pseudomonas aeruginosa Klebsiella pneumoniae Candida spp Table 2. Dependence of the etiology of CAIC on the profile of the department and clinical characteristics Conditions for using CVC Specific microflora Other microorganisms General departments Gram(+) cocci (>60%) MRSA** (5 30%) ICU Gram() bacteria (30 40%) CNS*, S. aureus (30% ) Immunosuppressive state CNS* (>50%) S.aureus (10%) Total parenteral nutrition S. aureus (>30%) CNS* (20%), Candida spp. (~10%) Note: *KNS coagulase-negative staphylococci; **MRSA methicillin-resistant S. aureus. Unfortunately, in Russia at the moment, data on the etiology of CAIC are extremely limited. There is only one study (CASCAT), conducted since 2004, in which 75% of cases of CAIC and 63% of cases of CVC colonization isolated gram-positive microorganisms, mainly represented by coagulase-negative staphylococci (unpublished data). Pathogenesis There are several routes of CVC colonization and infection (Fig. 1). The most common migration of bacteria occurs from the skin, somewhat less often through the external opening of the catheter. Infection due to the transfusion of contaminated infusion solutions and the hematogenous route of infection of the catheter are less likely. An important role in the development of CAIC is played by the catheter material and the virulence of the microflora. Penetration of microorganisms representing the normal microflora of the patient’s skin along the outer surface of the catheter (extraluminally) is most likely for short-standing catheters during the first 10 days after installation. According to a prospective study of 1263 patients with short-term catheters, extraluminal infection occurs in up to 60% of cases. In this case, catheters are most often colonized by S. epidermidis and other coagulase-negative staphylococci, S. aureus, Bacillus spp., Corynebacterium spp. Also, from the skin of the hands of medical personnel, the surface of the catheter can be colonized by P. aeruginosa, Acinetobacter spp., Stenotrophomonas maltophilia, Candida albicans, Candida parapsilosis. In a later period, the likelihood of intraluminal colonization of the inner surface of the catheter increases if asepsis is violated when caring for the catheter. Colonization of catheters is also possible when using contaminated infusion devices Contamination during the process of replacing a container with a solution or an intravenous infusion system Defects in the container Contamination during the manufacture of the infusion medium Infection through the inlet of the air filter Colonization during intravenous injections, the use of heparin locks, penetration of microorganisms from the skin through the hole for placing a catheter Fig. 1. Routes of colonization/infection of venous catheters.
4,133 solutions. In this case, Enterobacter spp., Citrobacter spp. are most often isolated. and Serratia spp. This route of contamination is more common in neonatal intensive care units. Extremely rare cases include the hematogenous route of colonization of catheters. This pathway is most typical for candidemia in cancer patients treated with chemotherapy. After penetration into the lumen of the vessel, microorganisms, interacting with the surface of the catheter, form a biofilm consisting of two phases: sessile (or immobile, consisting of slowly dividing bacterial cells and intercellular matrix) and planktonic (or freely suspended, which is actually responsible for the development of clinical symptoms of infection ) . Both one and several types of microorganisms can participate in the formation of biofilm. Biofilm consists of several layers of microorganisms covered with a common glycoprotein (mucous) capsule-like layer. The basis of biofilm is polysaccharides produced by microorganisms. Glycoproteins facilitate adhesion and provide the structural matrix of the biofilm. The ability to form a glycoprotein layer is most pronounced in coagulase-negative staphylococci. The described layer effectively protects microorganisms from humoral and cellular factors of the macroorganism. Most of the microorganisms included in the biofilm are in a dormant state, which dramatically increases their resistance to antibacterial drugs. The chemical nature of the material from which the catheter is made plays an important role. Thus, catheters made of polyethylene and polyvinyl chloride are much more susceptible to the adhesion of microorganisms than catheters made of silicone, Teflon and polyurethane. Therefore, in the manufacture of modern vascular catheters, Teflon, polyurethane and silicone are used. Catheter Biofilm IV System Vein Fig. 2. Localization of biofilm on an installed vascular catheter. Unfortunately, in Russia most catheters are still made from polyethylene. Most bacteria are, to one degree or another, capable of attaching to the surface of catheters through nonspecific adhesion mechanisms. However, a number of microorganisms have significantly higher adhesive properties. Thus, in many respects the ability to adhere to the surface of the catheter depends on the presence of specific receptors for proteins of the macroorganism. For example, S. aureus and fungi of the genus Candida spp. have receptors for fibronectin, fibrinogen and laminin, and coagulase-negative staphylococci (CNS) bind highly efficiently to fibronectin. A number of studies have shown that substances administered through the CVC may promote biofilm formation. Thus, the introduction of catecholamines into the catheter stimulates the growth of coagulase-negative staphylococci, and this phenomenon is dose-dependent. Methods and criteria for diagnosis Colonization of the CVC can be accompanied by various clinical manifestations or be asymptomatic. Clinical symptoms are quite unreliable due to their low specificity and sensitivity. For example, clinical manifestations in the form of fever with or without chills have high sensitivity, i.e. they often accompany CAIC, but have extremely low specificity (they are not pathognomonic signs of CAIC); inflammation of the skin and suppuration around the vascular catheter have high specificity (with high there is a degree of probability that one can claim the development of CAIC), but low sensitivity, up to 65% of cases of catheter-related bloodstream infections are not accompanied by signs of local inflammation (Fig. 3). In a recent multicenter clinical and epidemiological study, less than 50% of CAIC occurred with local symptoms. In Russia, the diagnosis of catheter infections is difficult due to the lack of vigilance among medical personnel, and therefore even obvious signs of CAIC are either not noted or are interpreted incorrectly. In the US, the Centers for Disease Control and Prevention (CDC) offers the following classification and diagnostic criteria for catheter-associated infections. 1. Colonized catheter: absence of clinical symptoms; growth >15 CFU using semi-quantitative assessment method
5 134 Exudation Erythema Edema Pain Phlebothrombosis Fig. 3. Frequency of local symptoms of CAIC colonization according to D.Maki; growth >10 3 CFU/ml using a quantitative method to assess catheter colonization. 2. Infection of the catheter insertion site: hyperemia, soreness, thickening or suppuration of the skin within 2 cm of the catheter insertion site with negative blood culture results. 3. “Pocket” infection: suppuration of a subcutaneous pocket at the site of an implanted vascular catheter and/or necrosis of the skin over it with negative blood culture results. 4. Tunnel infection: hyperemia, pain, induration and suppuration within more than 2 cm from the catheter insertion site and along the tunneled catheter with negative blood culture results. 5. Infusate-associated infection: isolation of the same microorganism from the transfused solution and blood from a peripheral vein in the presence of systemic signs of infection. 6. Catheter-associated bloodstream infection: primary bacteremia or fungemia in patients with a vascular catheter and systemic clinical manifestations of infection (hyperthermia, chills and/or hypotension), the absence of other obvious sources of infection and quantitative release from the catheter surface (> 10 3 CFU/ml with segment of the catheter) or semi-quantitative method (>15 CFU from the tip of the catheter or subcutaneous segment) of the same microorganism as from the blood, or by obtaining a fivefold difference in the number of microbial cells in blood cultures taken simultaneously from the CVC and a peripheral vein or by a differential time to positive the results of these blood cultures (more than 2 hours). Microbiological methods for diagnosing CAIC % Laboratory diagnosis of CAIC is carried out using various methods: direct microscopy, cultural examination of smears of discharge at the site of an installed catheter, semi-quantitative and quantitative cultural methods for studying a removed catheter, the method of simultaneous culture of blood from the catheter and from a peripheral vein. Attempts have also been made to study the biofilm on the inner surface of the catheter without removing it using special brushes. All techniques can be divided into two groups: those requiring and those not requiring removal of the CVC. Methods for diagnosing CAIC without removing the CVC include the quantitative method of paired blood cultures from the CVC and peripheral vein, the non-quantitative method of paired blood cultures from the CVC and peripheral vein, and the AOLC (acridine orange leucocyte cytospine) test. The most commonly used microbiological diagnostic method is the semi-quantitative method of examining a removed catheter. Thus, in microbiological laboratories in European countries, only a semi-quantitative method is used in 63.8%, only a quantitative method in 14.8%, a semi-quantitative or quantitative method in 10%, and only a qualitative method in 11.4% of cases. It is important to understand that when using qualitative determination methods, single contaminating microorganisms often lead to a false-positive result. D. Maki proposed to determine the causative agent of CAIC by rolling the distal fragment (5–7 cm long) of the removed catheter four times on the surface of a dense nutrient medium (5% blood agar), followed by incubation at C for hours (preferably in a CO 2 incubator). Although the use of this method allows the assessment of colonization only on the outer surface of the catheter, it has high sensitivity (92%) and specificity (83%). The assessment of the study results is presented in table. 3. Later, a quantitative method for microbiological diagnosis of CAIC was proposed. The method consists of treating the distal part of a removed catheter 5-6 cm long with ultrasound at a frequency of 55 kHz for 1 minute in 10 ml of trypticase soy broth for 15 seconds. The resulting suspension in a volume of 0.1 ml is applied to 5% blood agar with further incubation at 37 C for 5 days, followed by multiplying the number of grown colonies by the corresponding dilution factor. Contamination >10 3 CFU/ml is considered an indicator of the presence of CAIC. Using this method, it is possible to assess the colonization of external
6 135 Table 3. Assessment of the growth of microorganisms using the D. Maki method Hemoculture Positive Negative Number of colonies when examining the catheter Conclusion > 15 CFU The catheter is a source of bloodstream infection< 15 КОЕ Микробное обсеменение катетера гематогенным путем >15 CFU The catheter is infected, transient bacteremia cannot be excluded< 15 КОЕ Катетер колонизирован и внутренней поверхности катетера вне зависимости от характера биопленки . Количественный метод бактериологического исследования позволяет оценить относительное число микроорганизмов при смешанных инфекциях, его чувствительность составляет 97,5%, а специфичность 88% . До появления полуколичественного метода, предложенного D. Maki, для выявления инфицированных катетеров наиболее часто использовали посев в жидкую питательную среду. Однако эта техника очень часто дает ложноположительные результаты . Для ускорения получения результатов некоторые авторы рекомендуют проводить окраску фрагмента удаленного катетера по Граму. Чувствительность и специфичность методов, основанных на окраске катетеров, являются предметом дискуссий, и они применимы не ко всем типам катетеров . Диагноз катетер ассоциированной инфекции может быть установлен и без удаления катетера. С этой целью возможно применение количественного метода парных гемокультур из ЦВК и периферической вены. Если из обоих образцов выделяется один и тот же микроорганизм, а количественное соотношение обсемененности образцов из катетера и вены 5, то катетер следует признать источником инфекции . Чувствительность описанного метода диагностики составляет 94% , а специфичность достигает 100% . Однако данный метод достаточно редко используется в клинической практике в связи с относительной сложностью . Высокой чувствительностью и специфичностью (91 и 94% соответственно для непродолжительно стоящих, 94 и 89% для длительно стоящих катетеров) обладает метод с определением дифференциального времени до положительного результата или неколичественный метод парных гемокультур из ЦВК и периферической вены . Оно определяется как разница во времени до положительного результата гемокультур, полученных через центральный венозный катетер и из периферической вены, и может быть измерено только при использовании автоматических гемоанализаторов. Диагностически значимой считается разница в 2 и более часа . Однако при применении у пациентов антибактериальных препаратов до взятия гемокультур отмечается снижение специфичности метода до 29% при неизменно высокой чувствительности 91% . Данный метод может считаться оптимальным для постановки диагноза КАИК при длительно стоящих катетерах и предпочтительным по сравнению с количественным методом парных гемокультур из ЦВК и периферической вены . Американское общество по инфекционным болезням рекомендует количественный метод непарных гемокультур из ЦВК как альтернативу количественной методике парных гемокультур из периферической вены и из ЦВК. Данный метод используется при невозможности забора крови из периферической вены по тем или иным причинам. Метод является диагностически значимым при выделении 100 КОЕ/мл в гемокультуре из ЦВК. Специфичность данного метода составляет 85%, чувствительность 75% . В целях получения материала для микробиологического исследования катетеров без их удаления разработаны специальные нейлоновые щетки, прикрепленные к проводнику. Эти щетки позволяют соскоблить биопленку с внутренней поверхности катетера, с последующим центрифугированием и окраской лейкоцитарного осадка акридиновым оранжевым (AOLC тест) . У пациентов, получающих полное парентеральное питание, этот метод имеет чувствительность 95% и специфичность 84% . Данная методика позволяет получить предварительный результат в течение мин без удаления ЦВК, а также решить вопрос о необходимости назначения специфической антибиотикотерапии и удаления ЦВК . Недавно был предложен ИФА тест для серологической диагностики КАИК, вызванных коагулазонегативными стафилококками. Методика предполагает определение титра IgG к липиду S, продуцируемому большинством грамположительных микроорганизмов. Тест имеет чувствительность 75% и специфичность 90% . Данный тест может использоваться как дополнение к уже
7,136 existing methods for diagnosing CAIC, helps make a diagnosis without removing the CVC, and prevents unnecessary antimicrobial chemotherapy. Diagnostic methods with a retained catheter can be considered only in the absence of emergency indications for catheter removal, such as septic shock, severe local manifestations of CAIC, thrombophlebitis if catheter removal is undesirable or impossible. Treatment The simplest and most important step in treating catheter-associated bloodstream infections is removal of the colonized or suspicious catheter. This recommendation is feasible for most nontunneled catheters. One of the issues that needs to be resolved after removal is the choice of method for installing a new catheter - replacement along a guidewire or using a new access. In all cases, it is preferable to use a new access, since during the replacement process along the guidewire, the new catheter will most likely also become colonized and will require replacement after some time. However, there are likely to be isolated situations in which catheter replacement over a guidewire is acceptable. For example, the expected short period of operation of the catheter. The following option is also quite acceptable: the suspicious catheter is changed along the guide and examined. If significant colonization is detected, a catheter is installed through a new access. Significant problems arise when inserting a new catheter is associated with significant difficulties, and the potential risk to the patient associated with the procedure for inserting a new catheter and the development of infection must be carefully assessed. Typically, such difficulties arise when it is necessary to install Hickman-type catheters or implant subcutaneous ports. The most serious arguments in favor of the need to remove the catheter, despite the potential risks associated with installing a new one, include a high likelihood of developing an infection, pronounced signs of a local infectious process, sepsis, persistent bacteremia, infective endocarditis, thromboembolism. In the absence of suspicion of local or metastatic infectious complications, signs of persistent bloodstream infection, a low-virulent pathogen (coagulase-negative staphylococcus), and the absence of artificial heart valves and vascular prostheses, you can try to save the vascular catheter for a short time. In the absence of local signs of infection, the need for microbiological diagnostics sharply increases to resolve the issue of the fate of the catheter. First of all, it is necessary to confirm the fact of catheter-associated infection, since fever and changes in laboratory parameters can be associated with an infectious process of another localization, as well as with non-infectious causes. Another major problem is deciding the need, type and duration of antibacterial therapy after removal of the central venous catheter. Systemic antibiotic therapy for CAIC is often given empirically. The initial choice of antibacterial drug will depend on the severity of clinical symptoms, the presence of risk factors and the suspected pathogen and its resistance. For example, in hospitals with a high incidence of MRSA, it makes sense to prescribe vancomycin or linezolid as a starting drug. This choice is based on the high activity of these drugs against leading gram(+) pathogens of catheter-associated infections, including multidrug-resistant strains. Approaches to the selection of antimicrobial drugs depending on the clinical characteristics and the isolated pathogen are presented in Table. 4 and 5 and in Fig. 4. The success of systemic antibiotic therapy and the possibility of preserving the catheter largely depend on the location of the infection and the type of pathogen. For example, an infection at the catheter insertion site is more quickly treatable than a tunnel infection, just as infections caused by coagulase-negative staphylococci are easier to treat than infections caused by Staphylococcus aureus, Candida spp. and Pseudomonas aeruginosa. If there is a quick adequate response to the use of antibacterial therapy in a non-immunocompromised patient without cardiovascular system implants, then its duration may be limited to days and 7 days when CNS is isolated. The duration of parenteral antibiotic therapy remains a matter of debate. However, its use for S. aureus CAI for less than 10 days is associated with significantly more
8 137 Table 4. Antibacterial therapy for catheter-associated infections depending on clinical features Patient characteristics and pathology Infection associated with venous catheters, infusions, without burns, without neutropenia Parenteral nutrition-treated CAIC, burn-associated, with neutropenia Main pathogens S. epidermidis S. aureus Treatment of choice Oxacillin IV 2 g 4 times a day Cefazolin IV 1 2 g 3 times a day The same + Candida spp. The same ± fluconazole or amphotericin B S.epidermidis S.aureus Pseudomonas spp. Enterobacteriaceae Aspergillus spp. Cefepime IV 1 2 g 2 times a day Ciprofloxacin IV 0.6 g 2 times a day or levofloxacin IV 0.5 g 1 2 times a day or ceftazidime IV 1 2 g 3 times a day + Oxacillin IV 2 g 4 times a day Table 5. Antibacterial therapy for a known pathogen Alternative therapy Vancomycin IV 1 g 2 times a day Linezolid IV 0.6 g 2 times a day Imipenem IV 0.5 g 4 r/s or meropenem IV 1 g 3 r/s or cefoperazone/sulbactam IV 2 g 2 times/day ± linezolid IV 0.6 g 2 times/day or vancomycin IV 15 mg/kg 2 times/day Microorganisms Treatment of choice Alternative therapy Staphylococcus aureus MSSA MRSA Coagulase-negative staphylococci methicillin-sensitive methicillin-resistant Enterococcus faecalis ampicillin-sensitive ampicillin-resistant, vancomycin-sensitive vancomycin-resistant Escherichia coli Klebsiella spp. Enterobacter spp. Serratia spp. Acinetobacter spp. Oxacillin Vancomycin Linezolid Oxacillin Vancomycin Linezolid Ampicillin + gentamicin Vancomycin + gentamicin Linezolid Cefepime Ceftazidime Imipenem Meropenem Ertapenem Imipenem Meropenem Cefoperazone/sulbactam Cefazolin Vancomycin + rifampicin or co-trimoxazole Cefazolin Vancomycin Co three moxazole Co trimoxazole Vancomycin Linezolid Linezolid Ciprofloxacin Levofloxacin Cefepime Ciprofloxacin Levofloxacin Cefepime Pseudomonas aeruginosa Ceftazidime or cefepime ± amikacin Imipenem or meropenem ± amikacin Candida spp. Fluconazole Amphotericin B Caspofungin Corynebacterium spp. Vancomycin Penicillin ± gentamicin Burkholderia cepacia Co trimoxazole Imipenem Flavobacterium spp. Vancomycin Co-trimoxazole Ochrobacterium anthropi Co-trimoxazole Imipenem + gentamicin Ciprofloxacin Trichophyton beigelii Ketoconazole high rate of relapse and metastasis of infection. Therefore, patients with even uncomplicated CAI caused by S. aureus require systemic antibiotic therapy for at least 14 days. According to a meta-analysis of 11 studies, 30% of infections caused by S. aureus, were complicated by endocarditis and metastasis, so patients with signs of septic thrombophlebitis and endocarditis, persistent bacterial
9 138 Aemia or fungemia after catheter removal requires antimicrobial therapy for at least 28 days. If osteomyelitis is detected in a patient, antibacterial therapy continues for up to 6-8 weeks. In patients with surgically implanted vascular devices (silicone Hickman, Broviac, Groshond or Portacath-type catheters), their removal followed by antimicrobial therapy for 4-6 weeks is indicated in the absence of the above-mentioned complications. For infections caused by Candida spp., systemic antifungal therapy is indicated in all cases, along with mandatory removal of the catheter. When C. albicans is isolated, parenteral fluconazole is prescribed, provided there is no previous prevention of candidiasis with this drug. If prophylaxis has taken place, or if C. krusei or C. glabrata is detected, as well as in immunocompromised patients, the prescription of caspofungin is justified. Persistence of a vascular catheter is an independent risk factor for persistent candidemia and death. In addition to the systemic prescription of antibiotics, in some cases, when it is impossible/difficult to remove the catheter (for example, during hemodialysis), “locks” with antibiotics are used. As a result of 14 studies on the use of “locks” with antimicrobial drugs, their effectiveness reached 82.6%. In this case, the catheter lumen was filled with an antibiotic solution in the intervals between infusions. The largest number of studies assessing the effectiveness of “locks” with antibiotics has been carried out for ciprofloxacin, vancomycin, teicoplanin, gentamicin and amikacin. To prepare the lock, ciprofloxacin is diluted at the rate of 1-2 mg/ml, vancomycin 5-10 mg/ml, teicoplanin 10 mg/ml, gentamicin and amikacin 10 mg/ml, administration is carried out in a volume of 1-2 ml for 10 days. To prevent thrombus formation in the catheter lumen, it is advisable to mix the antibacterial drug with heparin in a dose of IU to obtain a total volume of up to 5 ml. The effect of using an antibacterial lock is largely determined by the type of pathogen. Thus, the clinical effect was observed in 87% of patients with CAIC caused by gram-negative flora, in 75% of S. epidermidis and only in 40% of patients with S. aureus. Prevention The difficulties of diagnosing and treating catheter-associated infections confirm the advisability of organizing their effective prevention. There are many recommendations aimed at preventing the development of this pathology, but the effectiveness of not all of them is unequivocally confirmed. Area of catheterization The choice of puncture site should be based on the criteria of convenience, safety and the ability to maintain aseptic conditions. The degree of skin contamination at the catheter insertion site is a major risk factor for CAIC. In order to reduce the risk of infection, catheterization of the subclavian vein is considered preferable compared to the jugular or femoral vein. A higher frequency of colonization of the catheter in the femoral vein has been proven in Infections associated with the central venous catheter (CVC) Complicated Uncomplicated Thrombosis, endocarditis, osteomyelitis, etc. CNS S. aureus Gram () bacteria Candida spp. Remove CVC, systemic antibiotic therapy 4 6 weeks (6 8 weeks for osteomyelitis) Remove CVC, systemic antibiotic therapy 5 7 days; when saving the CVC, add “antibacterial locks” Remove the CVC, systemic antibiotic therapy 14 days, for endocarditis 4 6 weeks Remove the CVC, systemic antibiotic therapy days Remove the CVC, therapy with antifungal drugs 14 days Fig. 4. Algorithm for the management of patients with CAIC
10,139 adults and higher risk of deep vein thrombosis compared to internal jugular and subclavian veins. A number of studies have demonstrated a higher risk of infectious complications with pulmonary artery catheterization via the jugular vein compared with the subclavian or femoral approach. However, a recent study including 657 patients with 831 central venous catheterizations showed no statistically significant difference in the incidence of catheter colonization and the occurrence of CAIC when using subclavian, jugular, and femoral vein catheterization approaches, provided adequate catheter site care was provided. . Catheter Material As previously mentioned, the risk of CAIC is determined in part by the type of biomaterial used and the surface of the catheter. The use of non-alkalizing, ultra-smooth catheters with an anti-adhesive hydrophilic coating reduces the likelihood of infection. The use of Teflon, silicone or polyurethane catheters reduces the likelihood of infectious complications compared to catheters made of polyvinyl chloride or polyethylene. To increase the hydrophilicity of the surface of polyurethane catheters, they began to introduce hydroxyethyl methacrylate, which significantly reduces the adhesion of S. epidermidis. A new approach is to create catheters with a negatively charged surface. Microbial colonization is reduced due to the “repulsion” of microorganisms from the catheter surface, the cell wall of which also has a negative charge. Hand sanitizing and aseptic technique Hand sanitizing is the cornerstone of preventing infectious complications. Hand washing by health care personnel or using alcohol-based hand rubs is the most important intervention to significantly reduce the spread of infection. Thus, ordinary hand washing with soap for 10 seconds leads to the removal of almost all transient gram() bacteria from the surface of the skin. To remove gram(+) and some gram() microflora, a 2% solution of chlorhexidine gluconate is more effective than povidone-iodine and 70% alcohol. The use of gloves is intended to protect personnel and meets the requirements for the prevention of infections with parenteral transmission. Compared with peripheral venous catheters, CVCs carry a significantly higher risk of infection. Therefore, the level of protection against infection during central venous catheterization should be more stringent. One randomized trial showed that the maximum amount of asepsis (cap, mask, sterile gown, sterile gloves and wide debridement and sterile dressing of the surgical field) during central venous catheterization significantly reduced the incidence of CAIC compared with standard measures (sterile gloves and narrow treatment of the surgical field). When catheterizing central veins through peripheral veins, the maximum amount of asepsis should also be used, although the effectiveness of this approach has not yet been studied. Thorough hand washing is extremely important not only before and after inserting or re-inserting a catheter, but also when changing dressings. Treating the skin at the catheter insertion site Treating the skin at the catheter insertion site is of great importance in preventing catheter infections. The most common antiseptic for arterial and central venous catheterization sites in the United States is 10% povidone iodine. However, there is evidence from 8 randomized studies of a reduction in the number of KAICs when treating the catheterization site with 2% aqueous chlorhexidine compared with 10% povidone iodine or 70% alcohol. When chlorhexidine 0.5% was compared with povidone-iodine 10% in a prospective randomized trial in adults, there was no benefit in preventing CAIC. Caring for the Catheter and its Insertion Site Dressings for the Catheterization Site Clear, semi-permeable dressings are widely used to cover the catheterization site. They are safe for catheters, allow visual control of the catheterization area, take a shower without removing the dressing, do not need frequent replacement compared to gauze dressings, and reduce staff labor costs.
11,140 Colonization with clear impervious films was comparable (5.7%) to gauze dressings (4.6%); There were no clinically significant differences in the incidence of colonization of the catheterization site or the development of phlebitis during peripheral catheterization. Compared with daily changes of gauze dressings and skin treatment with 10% povidone iodine, chlorhexidine sponges placed on the catheterization area and requiring replacement once a week were shown to be more effective in multicenter studies. Catheter fixation Sutureless catheter fixation has advantages over catheter suturing in terms of preventing CAIC. As an alternative to quick, seamless fixation of the catheter to prevent its accidental removal, which is critical during cardiopulmonary resuscitation, fixation using special staplers and staples is used (Arrow, USA). The entire procedure takes only about 10 seconds. However, fixation with staples is less reliable compared to sutures, although it reduces the risk of infectious complications. Bacterial filters Bacterial filters have been effective in reducing the incidence of infusion-related phlebitis, but there is no evidence of increased effectiveness in preventing CAIC. Reducing the risk of infusion-related infections can be achieved using less expensive methods. In addition, filters may become blocked when dextrans or mannitol are used. Therefore, the use of bacterial filters to reduce the risk of CCA is not recommended. Catheters and cuffs impregnated with antibiotics and antiseptics Currently, catheters impregnated with chlorhexidine in combination with silver sulfadiazine and minocycline with rifampicin are produced industrially. Some catheters and cuffs coated or impregnated with antibiotics and antiseptics (chlorhexidine/silver sulfadiazine) can reduce CVC colonization by up to 3-fold, and CAIC colonization by up to 4-fold in randomized trials, and potentially reduce the costs associated with the treatment of CAIC, despite the costs of additional processing of catheters. However, these data are typical for short-standing catheters due to the impregnation of silver only on its outer surface, while colonization of long-term CVCs is carried out more often through the intraluminal route. Studies have shown no development of in vitro resistance when using chlorhexidine/silver sulfadiazine-impregnated catheters. Data from a prospective randomized clinical trial indicate a reduction in CCA in cancer patients with long-term use of minocycline/rifampicin-impregnated catheters. Another randomized clinical trial showed a reduction in the risk of infection with minocycline/rifampicin from 26% to 8% compared with uncoated catheters. A recent multicenter, prospective, randomized, double-blind, controlled trial confirmed a 2-fold reduction in colonization and a 1.5-fold reduction in CCA when using catheters impregnated with minocycline and rifampicin. When the outer and inner surfaces of catheters were impregnated with minocycline/rifampicin, a decrease in the amount of KAIC was found compared to catheters coated on the outside with chlorhexidine/silver sulfadiazine. Benefits were observed after the 6th day of catheterization, but after 30 days they were absent. There are recommendations for the clinical use of catheters impregnated with chlorhexidine/silver sulfadiazine and minocycline/rifampicin in patients with a risk of CAIC rate greater than 3.3 per 1000 days of catheterization during parenteral nutrition and neutropenia. A randomized controlled trial conducted in Germany showed the effectiveness of combining miconazole with rifampicin. CVCs impregnated with this composition reduced catheter colonization by 7 times and the incidence of CAIC by 4 times. A reduction in the risk of developing CAIC has been described when using catheters with cuffs coated with platinum/silver ions. The effectiveness of such catheters decreases significantly after the second week of use. However, the cuffs, located on the outer surface of the catheter, do not prevent the intraluminal spread of microorganisms from a contaminated cannula or infusion solution. Today, cuffed catheters are used quite rarely. Other studies have shown
12 141 no difference in colonization and occurrence of CAIC between silver-impregnated catheters and conventional polyurethane catheters. A number of studies have shown that catheters treated with antibacterial and antiseptic drugs have an antimicrobial effect only during a short-term (less than 10 days) period of use. Prophylactic use of antibiotics To date, there are no studies proving a reduction in the incidence of CAIC with systemic prophylactic use of antibiotics in adults. In low birth weight infants, a reduction in the number of KAICs without a reduction in mortality has been shown with prophylactic use of vancomycin. However, vancomycin use is an independent risk factor for the emergence of vancomycin-resistant enterococci (VRE), which outweighs the benefit of prophylactic vancomycin use. Topical use of antibiotics and antiseptics Povidone iodine ointment applied to the insertion site of hemodialysis catheters has been shown to reduce the incidence of distal catheter infection, catheter tip colonization, and CAIC. There are results of studies on the effectiveness of using mupirocin ointment for the prevention of CAIC. Along with a decrease in the risk of CAIC, an increase in microflora resistance to mupirocin and the possibility of damage to the material of the polyurethane catheter were noted. Intranasal mupirocin reduces both the carriage rate of S. aureus and the risk of CAIC. However, with regular use, the risk of developing resistance to mupirocin in S. aureus and CNS increases. Other ointments containing antibiotics have also been used, but the results have been inconsistent. To avoid damage to the catheter, any ointment applied to the catheterization area must be compatible with the catheter material, which should be reflected in the manufacturer's recommendations. Prophylactic use of antibacterial “locks” This approach has been shown to have potential benefits in neutropenic patients with long-term catheter use. When comparing the “lock” effect with heparin (10 U/ml), heparin/vancomycin (25 μg/ml) and vancomycin/ciprofloxacin/heparin, the number of CAICs caused by vancomycin-sensitive microorganisms was significantly lower. Episodes of bacteremia caused by vancomycin-sensitive microorganisms occurred at a later time in patients receiving the combinations of vancomycin + ciprofloxacin + heparin and vancomycin + heparin, compared with heparin. However, due to the high risk of selection of vancomycin-resistant enterococci and ineffective action against microorganisms located in the biofilm, the use of vancomycin is usually not recommended. One study found that methicillin and ethylenediaminetetraacetate (M EDTA) locks were a relatively effective preventive measure for CAIC and were effective against staphylococci, gram bacteria, and Candida. This combination of drugs also reduces colonization of hemodialysis catheters by 9 times and has anticoagulant properties comparable to heparin. There has also been a slight reduction in the incidence of CCA for hemodialysis catheters when heparin locks are used in combination with gentamicin (5 mg/mL) compared with heparin alone (5000 U/mL). Anticoagulants Anticoagulant solutions are widely used to prevent catheter thrombosis. The area of deposition of blood clots, fibrin and thrombin can serve as a site of colonization of vascular catheters, so the use of anticoagulants may indirectly affect the incidence of CAIC. When using heparin (3 U/ml in solution, 5000 U every 6 or 12 hours intravenously or 2500 U low molecular weight heparins subcutaneously) in patients with short-term central venous catheterization, the risk of catheter thrombosis was reduced, but there were no significant differences in the incidence of CAIC in adults. Since most heparin solutions contain preservatives with antimicrobial activity, the decrease in the number of KAICs may be the result of a decrease in thrombus formation, the presence of preservatives, or a combined effect of both. Most pulmonary artery, umbilical and central venous catheters are coated with heparin and a preservative that also has antimicrobial activity.
13,142 One prospective, double-blind, randomized trial showed a reduction in thrombus formation and infection associated with vascular catheterization in critically ill patients when using heparin-impregnated catheters. Catheter replacement In 1998, a group of scientists found that routine, routine catheter replacement is not cost-effective, does not reduce the incidence of CAIC, and leads to increased mortality in critically ill patients. The use of metal guides to replace CVCs led to an increase in the incidence of catheter colonization. The results of a meta-analysis of 12 randomized trials indicated that there is no need for CVC replacement on a specific schedule if it is functioning normally and there are no signs of local or generalized complications. Catheter exchange over a guidewire is an acceptable method only for damaged catheters or for exchange of a pulmonary artery catheter with a CVC when further hemodynamic monitoring is not necessary. Insertion of a catheter over a guidewire is less painful for the patient and is accompanied by a significantly lower number of mechanical complications compared to replacing the catheter in another area; In addition, this method is recommended in patients with limited vascular access. Replacement of temporary catheters over a guidewire in the presence of local inflammatory changes or bacteremia is unacceptable, since the source of infection is usually a colonized skin tunnel. However, in some patients with bacteremia and tunneled hemodialysis catheters and in patients with limited venous access, the catheter can be exchanged over a guidewire, provided adequate antibiotic therapy is provided. Replacing transfusion systems The optimal interval for replacing intravenous infusion systems is hours. In the case of infusions of liquids with an increased likelihood of contamination with microorganisms (fat emulsions and blood components), more frequent replacement of systems is indicated, since these drugs are independent risk factors for CAIC. Additional ports with taps (for administering medications, solutions, blood sampling) pose a potential danger of microorganisms entering the catheter, vessels, and infusion fluids (contamination of taps is noted in 45–50% of cases). However, whether such contamination is the source of KAIC has not yet been proven. Other Prevention Methods There is evidence of the impact of staff training programs on catheter colonization and the development of CAIC. Thus, in the United States, a short course of lectures with practical exercises led to an increase in the frequency of use of wide sterile “drapes”, as well as a decrease in CCI by 28%. The overall rate decreased from 3.29 to 2.36 cases per 1000 days of catheterization. In Germany, similar data were obtained on the basis of 84 ICUs using guidelines and recommendations for the installation and care of CVCs for the purpose of preventing CAIC. The introduction of programs to control the AIC, according to some data, also leads to a decrease in the AIC by several times. Conclusion In general, CAIC is a widespread problem in critical care medicine, widely studied in Western countries and undeservedly forgotten in Russia. It should be remembered in the context of the transition of domestic medicine to an insurance basis about the financial and economic losses of medical and preventive institutions associated with the occurrence of this type of complications. Awareness of the very fact of the relevance of this problem, the development of organizational methodological guidelines and standards for catheterization of the bloodstream and the care of vascular catheters, training of medical personnel on these issues will reduce the number of KAICs that arise, thereby reducing the length of the patient’s stay in the hospital, and consequently reducing the cost of treatment. References 1. Seifert H., Jansen B., Widmer A.F., Farr B.M. Central venous catheters. In: Seifert H., Jansen B., Farr B.M., editors. Catheter related infections. 2nd ed. New York: Marcel Dekker; p Mermel L.A., Farr B.M., Sherertz R.J., et al. Guidelines for the management of intravascular catheter related infections. Clin Infect Dis 2001; 32: McGee D., Gould M. Preventing complications of central venous catheterization. N Engl J Med 2003; 348:
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... the importance of this problem is determined by the widespread introduction into healthcare practice of intensive and invasive therapy methods, which are inextricably linked with the need to provide vascular access, most often achieved through vascular catheterization.Infections associated with vascular catheterization are infections that arise as a result of colonization and infection of catheters installed in the vascular bed.
Epidemiology. Infections associated with central venous catheterization are observed in 4 - 14% of all cases of venous catheterization, when using catheters with inflatable balloons (Swangans type) - in 8 - 43%. Infections most often occur in pediatric intensive care units (7.7/1000 days of catheterization), most rarely in cardiac departments (4.3/1000 days of catheterization).
Etiology and pathogenesis. The high probability of infection of the outer and inner surfaces of the catheter, the tunnel around it and the entry of microorganisms into the blood is due to the fact that:
catheter - a foreign body in the vascular bed;
there is a skin wound around the catheter;
there is free access from the external environment through the lumen of the catheter to the vascular system.
The catheter-associated infection is caused by nosocomial microflora, which is usually highly resistant.
Main pathogens. In the early 90s, the main causative agents of ISCC were coagulase-negative staphylococci (about 60%), Staphylococcus aureus (about 30%) and fungi of the genus Candida (6-7%), among which the most common were C. albicans and C. parapsilosis. Rare pathogens included corynebacteria, Bacillus spp. and gram-negative bacteria (Acinetobacter spp., Pseudomonas spp., S. maltophilia), extremely rarely - microorganisms of the intestinal group (E. coli, K. pneumonia) and enterococci. At the end of the 90s, 40% of ISCC were caused by staphylococci, 30% by gram-negative pathogens, 12% by fungi of the genus Candida, 12% by enterococci.
Main sources of catheter infection. The skin in the area where the catheter is inserted is the most common source of infection during short-term catheterization. The main pathogens that come from the skin are coagulase-independent and Staphylococcus aureus, and from environmental objects are gram-negative bacteria.
The catheter pavilion (lock) is the most common source of infection during prolonged catheterization (more than three weeks). microorganisms enter the pavilion from the hands of personnel when working with the catheter, and then migrate along the internal surface.
Foci of infection in various organs (lungs, gastrointestinal tract, urinary tract and others). very rarely the source of infection is hematogenous. When the source of infection is the gastrointestinal tract, about half of infections are caused by fungi of the genus Candida. Other pathogens spread from the lungs and urinary tract are P. aeruginosa and K. pneumonia.
Contaminated solutions are a very rare source of infection. the main pathogens are gram-negative microorganisms (Enterobacter spp., Pseudomonas spp., Citrobacter spp., Serratia spp.), rarely others (for example, C. parapsilosis, Malassezia furfur).
Risk factors for infection:
colonization of the catheterization area and catheter pavilion;
improper care of the catheter;
the use of non-perforated polymer films for catheter fixation;
violation of the terms and conditions of storage of disinfectants for catheter treatment;
long-term catheterization;
contamination with hospital flora before catheterization;
catheterization of the internal jugular vein with multichannel catheters for hemodialysis;
neutropenia;
catheter thrombosis;
catheter material – polyvinyl chloride, polyethylene;
the presence of previous ISCS, as a result of which the catheter was replaced.
When using venous peripheral catheters, the risk of infection increases daily by 1.3%, arterial peripheral catheters - by 1.9%, central venous catheters - by 3.3%. ISCCs develop less frequently in women than in men.
Main ways of spreading infection:
from the surface of the skin, through a skin wound;
through objects of the external environment, the hands of medical staff;
hematogenous dissemination.
In the lumen of the vessel, a biofilm consisting of fibrin and fibronectin quickly (within several hours) forms on the surface of the catheter, which promotes the attachment of microbes and, on the contrary, impedes phagocytosis and the penetration of antibodies and antibiotics. After attachment to fibrin and fibronectin, microbes participate in the formation of biofilm (glycocalyx is formed). The degree of microbial adhesion depends not only on the characteristics of the microorganisms, but also on the properties of the catheter (electrostatic charge, surface tension, hydrophobicity, and others).
Clinical signs and symptoms. The clinical picture consists of local (in the area of catheterization) and systemic signs and symptoms.
Local signs and symptoms:
hyperemia and swelling of soft tissues;
painful sensations (spontaneous or arising during manipulation of the catheter);
serous-purulent discharge from the wound.
Signs and symptoms of localized or generalized infection:
increased body temperature (above 37.8 °C);
the appearance or worsening of shortness of breath;
tachycardia;
increased leukocytosis with a band shift.
Microbiological examination of the catheter. Cultures are used to assess catheter contamination:
catheter (after removing the catheter from the vessel, its distal part is rolled over a dense nutrient medium); it allows you to determine contamination !
outer surface of the catheter (semi-quantitative method);
conductor (sterile conductors are passed through the distal lumen of the catheter to a depth of about 5 cm); this culture makes it possible to determine contamination !
the inner surface of the catheter.
To assess the severity of contamination of the internal and external surfaces of the catheter (quantitative method), special equipment is required that allows the distal end of the removed catheter to be treated with ultrasound, centrifugation or vibration in a vortex.
The disadvantage of all of the above methods is the need to remove the catheter. In cases where catheter removal is undesirable or impossible, quantitative blood cultures are used. For this purpose, the same volume of blood is taken from the catheter and a peripheral vein (by venipuncture) for culture.
Microbiological signs of ISKS:
isolation from the blood of a pathogen characteristic of ISCS;
isolation from blood taken from a catheter of the same pathogen (species, genus) as from venous blood;
the same antibiotic sensitivity phenotype of pathogens isolated from blood taken from a catheter and from a peripheral vein;
the number of colonies grown from a blood sample taken from a catheter exceeds the number of colonies grown from a blood sample taken from a vein by more than 10 times.
Determination of the type of ISKS:
type of infection – catheter contamination: no clinical or laboratory signs,< 15 КОЕ при посеве катера, при посеве крови нет роста;
type of infection - catheter colonization: clinical and laboratory signs in the form of local inflammation, > 15 CFU on catheter culture, no growth on blood culture;
type of infection - ISKS: clinical and laboratory signs in the form of generalized inflammation, > 15 CFU on boat culture, positive growth on blood culture;
type of infection - sepsis associated with vascular catheterization: clinical and laboratory signs disappear without antibacterial therapy 48 hours after removal of the catheter or remain with 72-hour antibiotic therapy without removing the catheter; > 15 CFU on boat culture, positive growth on blood culture.
General principles of treatment. If you suspect ISKS, you must:
carry out blood culture from a peripheral vein and catheter (quantitative determination);
remove the catheter;
if there are indications (infiltration in the area of the catheter tunnel, purulent discharge from the wound), perform surgical treatment and drainage of the purulent focus;
conduct an ultrasound examination of the patency of the vein in which the catheter was located to identify infected parietal thrombi;
choose an adequate regimen of empirical antimicrobial therapy based on the expected etiology and level of pathogen resistance according to the principles of treatment of endocarditis.
In hospitals with low levels of oxacillin-resistant staphylococci:
drugs of choice (treatment regimens) – IV: oxacillin 2 g 4 – 6 times a day + gentamicin 3 – 5 mg/kg/day;
alternative medicines (treatment regimens) – IV: vancomycin 1 g 2 times a day; cefazolin 2 g 3 times a day + gentamicin 3 – 5 mg/kg/day.
In hospitals with high levels of oxacillin-resistant staphylococci:
drugs of choice (treatment regimens) – IV: vancomycin 1 g 2 times a day;
alternative medicines (treatment regimens) – IV: linezolid 0.6 g; rifampicin 0.3 g + moxifloxacin 0.4 g.
After the pathogen is isolated from the blood, if necessary, antimicrobial therapy is adjusted based on the results of studying the sensitivity of the isolated strains. If the results of a microbiological study are negative and there is no positive effect of therapy for 2 - 3 days (and the catheter is removed), an antimicrobial drug active against gram-negative microorganisms (3rd - 4th generation cephalosporin, carbapenem or aminoglycoside) should be added to vincomycin.
Duration of antimicrobial therapy may vary:
for uncomplicated catheter infections – 3–5 days after removal of the catheter;
with the development of angiogenic catheter sepsis - up to several weeks.
When treating ISCS, it is necessary to remember that vascular catheterization is carried out to solve serious medical problems, therefore the development of catheter infection or catheter sepsis is necessarily accompanied by a worsening of the underlying pathology (decompensation of diabetes mellitus, cardiovascular and respiratory, renal failure or failure of other organs).
Prevention:
(1) Use of aseptic catheterization technique.
(2) Training medical personnel in proper catheter care:
treatment of the skin and the outer surface of the catheter with effective disinfectant drugs;
local use of antibiotics (2% mupirocin skin ointment for regular cleaning of the catheter site);
impregnation of catheters with antimicrobial drugs;
daily administration of fluids through the catheter and rinsing with heparin solution; flushing the catheter with heparin in combination with vancomycin led to a decrease in colonization of its internal surface with gram-positive bacteria sensitive to vancomycin compared with flushing with heparin, but did not reduce the number of bacteremias;
a solution of minocycline + EDTA showed high activity against methicillin-resistant staphylococci, gram-negative flora and C. albicans, however, there is still insufficient data on its clinical effectiveness;
use of sterile gloves when working with catheters;
extensive treatment of the surgical field;
use of sterile masks, gowns and caps when performing vessel catheterization.
A significant reduction in the number of infections was obtained when treating the skin:
povidone-iodine solution;
2% chlorhexidine solution (4 times more effective than 70% alcohol solution, 10% povidone-iodine solution and 0.5% chlorhexidine solution);
ointment with a combination of polymyxin, neomycin and bacitracin (disadvantages: high cost, increased risk of fungal colonization and infection).
Changing the catheter over the guidewire did not reduce the risk of ISK. Two controlled studies found no benefit from regular catheter replacement compared with clinically indicated catheter replacement. Moreover, one study showed that regular catheter replacement over the guidewire increases the risk of developing angiogenic infection. In the experiment, changing the catheter along the guide not only increased the risk of infection of the new catheter, but also contributed to the appearance of small septic emboli in the lungs.
Catheter-associated infections are caused by peripheral intravenous catheters, central venous catheters, pulmonary artery catheters, and arterial catheters. They may become colonized by bacteria as a result of breakdown of the skin at the insertion site, contamination during catheter insertion or maintenance, and bacteremia in patients with distant sites of infection.
Symptoms of catheter-associated infections
Catheter-associated infection caused by a peripheral intravenous catheter is easy to diagnose and treat. Hyperemia and purulent discharge from the tube insertion area indicate the presence of a catheter-associated infection. Removal of the catheter promotes healing. Empiric antibiotic therapy to cover Gram-positive organisms may be required in patients with fever, cellulitis, or lymphangitis.
Patients receiving total parenteral nutrition (TPN) are particularly vulnerable to central venous catheter infections because the high concentration of glucose administered creates an ideal environment for bacterial and fungal growth. Catheter colonization and infection can be prevented by using sterile insertion, maintenance, and dressing techniques. A culture of a central venous catheter can be obtained by removing it under sterile conditions and using the tip to inoculate the culture medium. Evidence regarding the benefits of periodic changes of central venous tubing remains controversial. Staphylococcus aureus is often isolated from central venous tubing contaminated during insertion, while S. epidermidis and fungi are isolated from immunocompromised patients with prolonged central venous access. Gram-negative flora is carried by blood. Catheter colonization is defined as growth of less than 105 CFU/ml. Catheter infection is defined as a growth of more than 105 CFU/ml without signs of systemic infection and negative blood cultures. Catheter-based sepsis is defined as 105 CFU/mL or more in a patient with positive blood cultures, evidence of sepsis, or both.
Diagnosing central line infections can be difficult. Hyperemia or purulent discharge in the area where the tube is inserted indicates the presence of infection. Sepsis or bacteremia of unknown origin should be considered as a possible consequence of catheter-associated infection. In this case, the tube must either be removed or, in case of further need for venous access by the patient, replaced with a new one. The tip of a suspicious catheter should be directed for culture; If the culture is positive, the central catheter should be placed in a new location. However, in seriously ill patients with many possible septic foci, only the growth of identical bacteria in the blood culture and culture from the tube indicates the catheter nature of sepsis. It is difficult to interpret blood culture results from blood obtained through a central catheter, so such studies are of little value. Treatment for colonization or infection of a central venous catheter should involve its removal. If a catheter-associated infection is suspected, in the absence of signs of local inflammation, a new catheter can be installed over the guide in the same place; in this case, the removed tube is sent for culture. Detection of bacterial growth requires removal of the tube from the area. Antibiotic therapy is prescribed if the patient has symptoms of catheter sepsis or if a blood culture is detected.
Treatment of catheter-associated infection
In order to overcome the resistance of Staphylococcus epidermidis until culture data are obtained, the use of vancomycin is necessary. For proven catheter infection, treatment should be continued for 7 to 15 days, or for a longer period in immunocompromised patients or patients with sepsis. If the patient does not respond to treatment within 48-72 hours, the catheter should be removed and sent for culture, and the antibiotic regimen should be reconsidered. In addition, the diagnosis of purulent thrombophlebitis should include double inspection of the affected vein. Vein removal in a patient with catheter infection should be considered if thrombosis is present.
Although the incidence is low, the possibility of arterial catheter infection should be considered if there is erythema or purulent discharge at the catheter insertion site, as well as signs of infection from an unknown source. In a patient with bacteremia, treatment consists of tube removal and antibiotic therapy.
Pulmonary artery catheters rarely become infected. Usually the infection is localized in the area where the tube or guidewire is inserted. Diagnosis and treatment are the same as for central venous catheter infections.
Purulent thrombophlebitis
This complication occurs in patients with a venous catheter. The risk of developing this catheter-associated infection increases 72 hours after catheter insertion. Purulent thrombophlebitis is manifested by chills, fever, local symptoms and signs of infection, as well as deterioration of the patency of the affected vein. If the central vein is affected, diagnosis can be difficult. In this case, identifying gram-positive bacteremia and signs of thrombosis of the affected vein with double ultrasound helps to go in the right direction. Treatment of catheter-associated infection includes removal of the catheter, antibiotic therapy to block gram-positive bacteria, especially Staphylococcus aureus and epidermidis, and removal of the affected vein.
The article was prepared and edited by: surgeonA hospitalized patient has catheter sepsis. The entry gate for infection is a catheter or other intravascular device, and the resulting bacteremia is primary (that is, the pathogen is isolated from the blood in the absence of another source of infection). Other hospital-acquired infections, such as hospital-acquired pneumonia and hospital-acquired urinary tract infections, are accompanied by secondary bacteremia.
In one controlled study, catheter-related sepsis occurred in 2.7% of intensive care unit admissions and was associated with a 50% mortality rate and an increase in length of stay by 24 days.
In hospitals, central venous catheters are installed in 25% of patients, and in 20-30% of cases catheters are used for parenteral nutrition.
The frequency of catheter infection depends on the severity of the disease and ranges from 2 to 30 per 1000 days that the catheter is in the vein. In severely ill patients with catheter-based sepsis, the mortality rate reaches 35%, and the cost per survivor is $40,000.
Most complications associated with catheters are caused by improper placement or care of the catheters, rather than by defects in the catheters themselves. In large hospitals, where catheters are installed and cared for by specially trained staff, the incidence of complications is reduced by 80%, which in turn improves patient outcomes and reduces treatment costs.
It is difficult to distinguish between true bacteremia and contamination of a blood sample with skin microflora. However, this is necessary for catheter sepsis, which is often caused by representatives of skin microflora, for example. Typically, bacteria enter the body from the skin at the site of the catheter and spread deep into its outer surface. Catheter infection can also be caused by infected solutions and systems for IV infusions, leaky connections, etc. Sometimes the catheter itself becomes a source of infection if, during transient bacteremia, microorganisms settle at its distal end and begin to multiply there.
The most dangerous pathogens of catheter sepsis remain gram-negative aerobic bacteria, however, according to the US State Register of Hospital Infections for 1980-1989. and more recent studies, the frequency of their isolation from the blood has not increased over the previous decade. At the same time, coagulase-negative staphylococci and Candida spp. began to be detected much more often. In addition, catheter sepsis is often caused by Staphylococcus aureus and enterococci.
The diagnosis of catheter sepsis is made by exclusion. If, in addition to fever, there are signs of infection at the venipuncture site (suppuration, redness, tenderness, swelling), after taking blood samples, the catheter is removed, the distal end is cut off and sent to the laboratory for quantitative bacteriological testing. A colony count of more than 15 means that the catheter is a source of bacteremia. However, most often there are no signs of infection at the venipuncture site. Whether it is necessary to remove the catheter in this case is a controversial issue. If no other sites of infection are identified, it is usually recommended to remove the catheter.
Changing a central venous catheter over a guidewire is simple and safe, but the feasibility of this procedure in cases of suspected catheter infection is questionable. As a rule, if the catheter is removed, a new one is installed in a different place. However, if it is necessary to preserve this particular vascular access, you can wait to change the catheter. Modern tunneled catheters, designed to create long-term vascular access, cannot be changed along the guide at all. Therefore, at present, if an infection is suspected, they try to preserve the catheter: they leave it in place and begin antibiotic therapy. This approach is often successful if the infection is caused by coagulase-negative staphylococci, but is less effective in other cases, particularly when