CATHETER RELATED

BLOOD STREAM
INFECTION

SUBMITTED BY,
ATHIRA K J
BSC MLT FINAL YEAR
NOSOCOMIAL INFECTION

• The term nosocomial infection is applied to the infections developing in

hospitalized patients.
• Such infections may become evident during the stay in hospital or
sometimes only after the discharge.
TYPES OF HAI

• The main HAIs are:

>Catheter associated UTI
>Catheter related blood stream infection
>Ventilator associated pneumonia
>Surgical site infection
CATHETER RELATED BLOOD STREAM
INFECTION
• It is defined as the presence of bacteremia originating from an IV
catheter.
• It is one of the most frequent, lethal and costly complication of central
venous catheterization and also the most common cause of nosocomial
bacteremia.
• Blood stream infection in hospitalized patients may either develop
directly without any secondary source or occurs secondary to another
site specific infections.
TERMINOLOGIES

• Two closely related terminologies are used to describe central venous

catheter associated intravascular infection.
>Catheter Related Blood Stream Infection (CRBSI)
>Central Line Associated Blood Stream Infection (CLABSI)
CATHETER RELATED BLOOD STREAM
INFECTION
• It refers to the blood stream infection attributed to an intravenous
catheter by quantitative culture of the catheter tip or difference in
growth between catheter and peripheral venipuncture blood culture
specimen.
CENTRAL LINE ASSOCIATED BLOOD STREAM
INFECTION
• It refers to the blood stream infection that appears in the presence of a
central line catheter or within 48 hrs of removal of a central venous
catheter and which cannot be attributed to an infection unrelated to
catheter.
CENTRAL VENOUS CATHETER

• Also referred to as central line.

• It is an intra venous device that terminate in great vessels.
EPIDEMIOLOGY

• Approximately, less than 3% of hospitalized patients require central line

at some point of time during their stay, out of which 3-8% develop
central line associated blood stream infection.
RISK FACTORS

• It includes :-
>Patient related factors
>Operator related factors
>Catheter related factors
PATIENT RELATED FACTORS

• Increasing severity of illness

• Granulocytopenia
• Compromised integrity of skin
• Presence of distant infection
OPERATOR FACTORS

• Risk increases after breaks in aseptic technique during placement and

maintenance and with frequency of catheter access.
CATHETER FACTORS

• Catheter type – risk of blood stream infection increases with increase in

lumen number.
• Antibiotic or anti microbial coating of catheter can reduce risk of CRBSI.
• For non tunneled catheters risk of BSI varies by anatomical site.
MICROBIOLOGY

• CRBSI is caused by gram positive pathogens(64%) followed by gram

negative bacteria (36%).
• Organisms commonly associated with CLABSI are :
-Coagulase Negative Staphylococcus (31%)
-Staphylococcus aureus (20%)
-Enterococcus (9%)
-Escherichia coli (6%)
PATHOGENESIS

• There are several routes by which organism can gain access to the
extraluminal or intraluminal surface of the central vein catheter.
• The pathogenesis is attributed by 4 primary causes:
a)Migration of patient’s skin flora along the surface of the catheter
with colonization.
b)Direct contamination of catheter or its hub through hands of medical
personnels.
c)Hematogenous route from other focus of infection.
d)Contamination of device or fluid at production level.
ROUTES OF TRANSMISSION OF ORGANISM
• Following events take place after entry of organism into the central
venous catheter:
1) Foreign body reaction.
2) Colonization of organism by microbial adherence.
3) Biofilm formation on catheter surface.
1) Foreign body reaction :- It is a tissue response to central line,
characterized by infiltration of inflammatory cells.
2) Colonization of the organism by microbial adherence:- Certain
virulence factor of organism help in microbial adherence eg:-
Staphylococcus aureus express clumping factor, which adhere to the
host protein.
3) Biofilm formation on catheter surface:- Biofilm formation is observed
with certain organisms such as CoNS, Staphylococcus aureus, and
candida species.
- Biofilm is an extracellular polymeric substance enriched by divalent
metallic cations
 such as calcium, magnesium and iron, in which the organisms are
embedded.
- It help the organism to withstand host defense mechanisms or
preventing the entry of antimicrobial agents.
DIAGNOSIS

• The diagnosis of CRBSI is established when a patient on central line

meets the clinical criteria and the microbiological criteria; in the
absence of evidence for other source of BSI.
• Clinical criteria:- include presence of chill, rigor, fever or hypotension
after the CL is placed and/or signs of catheter site infection such as
erythema, tenderness, warmth and swelling with in 2cm of the catheter
exit site.
• Microbiological criteria:- one of the following should be present
1)A positive result of semiquantitative or quantitative catheter
segment culture.
2)Paired quantitative blood cultures drawn through central and
peripheral line.
3)Differential time to positivity.
• Microbiological methods can be divided into 2 categories:-
> Methods not requiring catheter removal
> Methods requiring catheter removal
 Methods not requiring catheter removal:-

a) Qualitative blood culture through CL- one or more blood cultures

drawn through central line.
- Criteria for positivity : Any growth
-Sensitivity 87% -Specificity 83%
b) Quantitative blood culture through CL :- one blood culture drawn
through CL and subjected to pour plate or lysed centrifugation.
-Criteria for positivity : colony count of >1000CFU/ ml.
-Sensitivity- 77% -Specificity- 90%
c) Paired quantitative blood cultures:- simultaneous cultures drawn
through CL and PL.
-It is the most accurate available method but it is labor intensive and
technical demanding, hence less commonly used in routine.
-Criteria for positivity :- CL culture is atleast 5 fold higher than PL.
d) Differential time of positivity:- simultaneous culture drawn through CL
and PL, monitored continuously.
- It is the most widely practiced method world wide.
-It is easy to perform and gives a fair result .
- Criteria of positivity:- CL blood culture positive greater than or equal
to 2hrs earlier than PL culture.
e) Acridine orange leukocyte spin test:-
- 1ml of CL drawn blood is centrifuged and stained with acridine
orange and focused under fluorescence microscope.
-Criteria for positivity:- if any bacteria are seen, it is considered to be
positive.
f) Endoluminal brush culture:-
- A sample of the biofilm from the catheter lumen is withdrawn by
using guide wire with a nylon brush.
-Brush is then vortexed with buffered saline and plated onto agar.
-Criteria for positivity :- colony count of >100 CFU/ml.
 Methods requiring catheter removal:-

a) Qualitative catheter segment culture-

- CL segment is removed and immersed in broth media and
incubated for 24-72 hrs.
- Criteria for positivity :- any growth indicate that the catheter is
colonized.
b) Semiquantitative roll plate catheter culture :-
- The distal 5cm segment of CL is cut and rolled 4times across a blood
agar plate and incubated overnight.
-Criteria for positivity:- >15CFU per catheter segment indicates that
the catheter is colonized.
c) Quantitative catheter segment culture:-
-The distal 5cm segment of CL is removed and flushed or sonicated
with the broth, serially diluted and plated on blood agar and incubated.
- Criteria for positivity:- >100 CFU/ catheter segment indicate that the
catheter is colonized.
d) Microscopy of stained catheter:-
- Gram stain or acridine orange staining.
-Criteria for positivity:- if any bacteria are seen, it is considered to
be positive.
TREATMENT

• Treatment of CRBSI consist of :-

1)Systemic Antimicrobial Therapy (SAT)
-Empirical SAT
-Pathogen detected SAT
2)Antimicrobial Lock Therapy(ALT)
• Empirical SAT:- It should be started as soon as the clinical suspension is
made
- The choice of empirical therapy is based on the local antibiogram
pattern.
a)Gram positive coverage:-
- For institution with higher MRSA incidence – Vancomycin is the
drug of choice.
-Daptomycin – used in place of vancomycin in facilities where the
prevalence of MRSA with reduced vancomycin susceptibility is increased.
b) Gram negative coverage:-
-Based on the local antibiogram pattern and severity of the disease.
-4th generation Cephalosporin (Cefepime)
- Carbapenem
c) Empirical coverage for MDR-GNB :- It is indicated if patient is critically
ill with sepsis or neutropenic or has history of colonization with MDR-GNB
until the culture results are available.
d) Empirical therapy for candida :-It is indicated for septic patients with
anyone of the risk factors such as hemolytic malignancy, transplant
recipients or femoral catheterization.
- Echinocandin or amphotericin B
-Fluconazole
• Pathogen detected SAT:- After 2-3 days once the culture report is
available, the empirical therapy is tailored to initiate pathogen directed
therapy.
- Urokinase and other thrombolytic agents are not recommended as
adjunctive therapy for patients with CRBSI.
 Antimicrobial lock therapy :-

- It involves installation of highly concentrated antibiotic solution into a

intravascular catheter lumen and is left to dwell with in the lumen for a
predefined period, ranging from hours to days.
-It should contain a combination of highly concentrated antimicrobial
solution with an anticoagulant heparin.
PREVENTION

• The preventive measures for CRBSI can be grouped into those used
before, during and after insertion of catheter.
 Preventive measures prior to central venous catheter insertion:-

a) Education, training and staffing:- Health care worker should be

educated regarding the indication of CVC use , method of insertion and
maintenance and appropriate infection control measures.
b)Selection of catheter type:- Catheter should be selected based on the
basis of the intented purpose and duration of use, anticipated
complication etc.
-Catheter material:- polyurethane, Teflon and silicone have low risk of
CRBSI .
- For long term use:- tunneled catheter and totally implantable catheter
should be considered as they have low risk for developing CRBSI.
- Lumen :- single lumen catheter should be used unless otherwise, it is
essential to use multiple ports.
c) Site of insertion:-insertion site with the lowest risk of complication
should be selected.
- Subclavian vein is the most preferred site following jugular vein.
-Femoral vein – highest risk.
d)Antimicrobial impregnation catheter:- CVCs impregnated with
antimicrobial agents such as cefazolin, vancomycin, chlorhexidine-silver
sulfadiazine, platinum-silver or non antimicrobial agent such as heparin.
- Not for routine use.
 Preventive measures during CVC insertion :- prior to insertion, the procedure must
be explained to the patients to relieve fear and anxiety.
• Central venous catheter insertion technique:- The insertion of catheter is considered
as minor surgical procedure, therefore maintenance of complete asepsis is
mandatory.
-Hand hygiene:- It should be performed before and after palpating catheter insertion
site as well as before and after inserting, replacing, accessing, repairing or dressing an
intravascular catheter.
-Maximum sterile barrier:-precaution like cap, mask, sterile gown, sterile gloves and
a sterile
Full body drape during the placement of the CVC.
-skin preparation:- the skin insertion site is disinfected with more than
0.5%chlorhexidine with alcohol or 10% povidone-iodine with friction for
atleast 2-3 min.
-Insertion:-following venipuncture of the vessel, with the help of a guide
wire the cvc is inserted.
-Securement:-catheter is secured with suture or clip
-Dressing and labelling
 Preventive measures after CVC insertion:-

a) Catheter site dressing:- use either sterile gauze or sterile transplant,

semipermeable dressing to cover the catheter site.
-gauze dressing- changed atleast every 2 days.
-semipermeable dressing:- changed atleast every 7 days.
-Chlorhexidine is the recommended disinfectant used for dressing,
except for neonates where povidone-iodine is used.
b) Antimicrobial impregnated sponge:-chlorhexidine impregnated sponge
covered by a transparent dressing. Considered only after all other basic
infection prevention measures fail in patients more than 2 months of
age.
c)Anticoagulant flush solution:- anticoagulants have been used to
prevent catheter thrombosis and presumably reduce the risk of infection.
d)Antimicrobial lock prophylaxis:-not used routinely.
- Recommended in patients with limited venous access and having
history of recurrent CRBSI.
CONCLUSION

• Nosocomial infection
• Definition
• Epidemiology
• Risk factors
• Microbiology
• Pathogenesis
• Diagnosis
• Treatment
• Prevention
THANK YOU!