Hospital-Acquired Catheter-Related Bloodstream Infections

Amanda A. Cavanagh, DVM, DACVECC, Colorado State University

Carlee Fiddes, PSM, BS, AAS, LVT, Colorado State University

August 2016|Peer Reviewed

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A hospital-acquired infection (HAI) is an infection developing after 48 hours of hospitalization that was not present or incubating at the time of admission.^1-3 Common HAI sites include the respiratory and urinary tracts, surgical incisions, and the bloodstream. Bloodstream infections, while representing only a small percentage of hospital-acquired infections in people, have a high fatality rate.¹

Hospital-acquired bloodstream infections most commonly originate from IV catheters and should be suspected in any patient with an IV catheter that develops systemic inflammatory response syndrome without an extravascular infection source.^2-4 Catheter insertion- site inflammation may not be present.⁵ Antimicrobial resistance is common in HAIs; therefore, tissue, blood, and catheter culture and sensitivity testing must be performed to select appropriate antimicrobial therapy.

Case Summary Treatment & Outcome Team Management

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Case Summary

Amanda A. Cavanagh, DVM, DACVECC, Colorado State University

An 8-year-old neutered male borzoi presented with lung lobe torsion. Following a right middle-lung lobectomy, he was hospitalized in the ICU with a multilumen central venous catheter in his right jugular vein to facilitate fluid and drug therapy. On hospital day 5, he developed a fever of 103.4° F, hypotension, neutropenia, and acute kidney injury. HAI was suspected based on the patient’s acute clinical signs and biochemical changes consistent with severe sepsis.⁶

Common hospital-acquired infection sites include the respiratory and urinary tracts, surgical incisions, and the bloodstream.

Pneumonia, surgical site, urinary tract, and catheter-related bloodstream infections (CR-BSIs) are the most common HAIs.^3,7,8 In this patient, on hospital day 5, the central venous catheter insertion site was erythematous with purulent discharge. Jugular vein palpation suggested thrombosis, which was ultrasonographically confirmed. Additional diagnostic results, including surgical incision inspection, thoracic radiographs, thoracic fluid cytology and culture, and urinalysis with culture, were negative. The patient was diagnosed with CR-BSI.

According to the Infectious Diseases Society of America (IDSA) guidelines, blood should be collected for culture in critically ill humans (ie, with hypotension and/or organ failure) who have acute onset of fever and suspected CR-BSI.⁴ Additionally, all IV catheters should be removed and replaced only as necessary.⁴ A CR-BSI diagnosis requires paired positive quantitative catheter tip and peripheral blood cultures.^9-11

Quantitative culture is performed via sonication of the distal 5 cm of catheter. Sonication is the application of sound waves (55 000 Hz) to a catheter segment submerged in culture broth, thus dislodging bacteria from the catheter surface for plating on agar after serial dilution.^12,13 Catheter sonication dislodges bacteria from the extra- and intraluminal surfaces and may dislodge bacteria within a biofilm.⁴ As colonization of the intraluminal surface is likely the most common source of CR-BSI, sonication is the recommended method of catheter tip culture.

Definitive diagnosis of CR-BSI requires a positive quantitative culture of >10³ colony-forming units (CFUs) per catheter segment if the same organism is cultured from peripheral blood.^4,9 The greater the number of CFUs obtained from a positive (>10³ CFU) catheter culture, the greater the likelihood blood cultures will be positive for the same organism.^13,14

The semiquantitative roll plate catheter technique is also an acceptable method of diagnosing CR-BSI, but can result in false-negative results in cases of intraluminal catheter colonization.^15-17 Bacteria are cultured from the extraluminal surface in the roll plate technique via rolling the catheter tip on an agar plate.¹⁸

A cutoff of >15 CFU distinguishes contaminated catheters from colonized catheters, and >1000 CFU is correlated with CR-BSI caused by the same organism.¹⁸ In humans with short-term catheters (ie, indwelling for <7 days), the roll plate technique is superior for detection of catheter colonization.¹⁵

In this patient, the catheter tip and peripheral blood were cultured according to IDSA guidelines.⁴ Cytologic examination and gram staining of purulent discharge from the insertion site showed suppurative inflammation with intracellular gram-positive cocci and gram-negative rod bacteria.

References and Author Information

References

Case Summary, Treatment, and Outcome

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Team Management

Ducel G, Fabry J, Nicolle L. Prevention of Hospital-Acquired Infections: A Practical Guide. 2nd ed. Geneva, Switzerland: WHO Press; 2002.
Yokoe D, Anderson DJ, Berenholtz SM, et al. A compendium of strategies to prevent healthcare associated infections in acute care hospitals: 2014 updates. Am J Infect Control. 2014;42(8): 820-828.
Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732.
Raad I, Hannah H, Maki D. Intravascular catheter-related infections: advances in diagnosis, prevention, and management. Lancet Infect Dis. 2007;7(10):645-657.
Mathews KA, Brooks MJ, Valliant AE. A prospective study of intravenous catheter contamination. JVECC. 1996;6(1):33-43.
Pessoa-Silva C, Hugonnet S, Pfister R, et al. Reduction of health care associated infection risk in neonates by successful hand hygiene promotion. Pediatrics. 2007;120(2):e382-390.
Pittet D, Boyce JM. Revolutionising hand hygiene in health-care settings: guidelines revisited. Lancet Infect Dis. 2003;3(5):269-270.
Safdar N, Maki DG. Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters. Crit Care Med. 2002;30(12):2632-2635.
Mangram AJ, Horan TC, Pearson ML, Sliver LC, Jarvis WR. Guideline for prevention of surgical site infection. Am J Inf Control. 1999;27(2):97-134.
Mimoz O, Lucet JC, Kerforne T, et al. Skin antisepsis with chlorhexidine–alcohol versus povidone iodine–alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open- label, multicentre, randomised, controlled, two-by-two factorial trial. Lancet. 2015;386 (10008):2069-2077.
Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infection by using maximal barrier precautions during insertion. Infect Control Hosp Epidemiol. 1994;15(4):231-238.
Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med. 2000;132(5):391-402.
Seguela J, Pages JP. Bacterial and fungal colonization of peripheral intravascular catheters in dogs and cats. J Small Anim Pract. 2011;52(10):531-535.

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Hospital-Acquired Catheter-Related Bloodstream Infections

Amanda A. Cavanagh, DVM, DACVECC, Colorado State University

Carlee Fiddes, PSM, BS, AAS, LVT, Colorado State University

Case Summary

References

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