Management of CRBSI Leilani Paitoonpong MD MSc Chusana Suankratay MD PhD Division of Infectious Diseases Chulalongkorn University

Transcription

1 Management of CRBSI Leilani Paitoonpong MD MSc Chusana Suankratay MD PhD Division of Infectious Diseases Chulalongkorn University

2 A 60-year-old man was admitted for CABG surgery due to triple-vessel disease. He had diabetes, HT, and dyslipidemia. One day before surgery, the surgeon plan to insert subclavian CVC. What would you recommend to prevent CRBSI?

3 Background: Epidemiology Modifiable Risk Factors Characteristic Risk Factor Hierarchy Insertion circumstances Skill of inserter Insertion site Emergency > elective General > specialized Femoral > subclavian Skin antisepsis 70% alcohol, 10% povidone-iodine > 2% chlorhexidine Catheter lumens Multilumen > single lumen Duration of catheter use Barrier precautions Longer duration of use greater risk Submaximal > maximal

4 Maximal sterile barrier The person inserting the central line wears A head cap Face mask Sterile body gown Sterile gloves Uses a full size drape to cover the patient from head to toe

5 Optimal Site/Line Selection Hand Hygiene Chlorhexidine Skin Antisepsis Maximal Barrier Precautions at insertion 8 Aseptic Technique at Line 7 Access and Dressing 6 5 Changes 4 Daily Review of Line 3 2 Necessity 1 0 and Prompt Removal Mean BSI/ 1000 Cather-day Baseline 18 months

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11 Lancet 2013; 381:

12 Chlorhexidine impregnated dressings

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14 The patient underwent CABG using bilateral saphenous v. & internal mammary a. grafts. 5 days after operation, he had fever with chills. PE: BP 120/80 mmhg, HR 120/min, RR 18/min, BT 39 O C; good surgical wounds at chest wall & legs; good exit site of right subclavian triple lumen catheter insertion, mild decreased breath sound at right lung with no discharge per previous ICD sites (just removed 2 days ago) CRBSI was suspected, what would you do to confirm the Dx?

15 Clinical evaluation Local At insertion site At tip of catheter site Septic thrombosis Endocarditis Systemic SIRS Distant metastasis

16 Methods for the diagnosis of acute fever for a patient suspected of having short-term central venous catheter infection IDSA Guidelines for Intravascular Catheter-Related Infection CID 2009:49 (1 July)

17 Laboratory Diagnosis for CRBSI CVC is not removed Simultaneous quantitative cultures of blood samples with a ratio of 5:1(CVC:peripheral) Differential time to positivity a positive result of culture from a CVC is obtained at least 2 h earlier than is a positive result of culture from peripheral blood CVC is removed Semiquantitative (roll plate) 15 cfu per catheter segment quantitative (vortex or sonication methods) 10 2 cfu per catheter segment

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19 Roll plate

20 Differential time to positivity

21 The patient underwent CABG using bilateral saphenous v. & internal mammary a. grafts. Vancomycin was given for 48 hrs. 5 days after operation, he had fever with chills. PE: BP 120/80 mmhg, HR 120/min, RR 18/min, BT 39 O C; good surgical wounds at chest wall & legs; good exit site of right subclavian triple lumen catheter insertion, mild decreased breath sound at right lung with no discharge per previous ICD sites (just removed 2 days ago) Blood cultures for differential time were performed What is the most appropriate empiric antibiotic(s)? Should CVC be removed?

22 Choice of empiric antibiotic(s). Gram stain of purulent discharge if available 2. Based on prevalence of causative agent of CRBSI in - Each hospital AND - Each unit in the hospital 3. Local susceptibility data of each unit in the hospital - S. aureus: methicillin-resistant S. aureus (MRSA)? - CoNS: methicillin-resistant CoNS? - Gram-negative bacilli (GNB): MDR or PDR? The most common pathogen: CoNS &/or GNB

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24 Indications for CVC removal 1. Suspected CRBSI & unstable hemodynamics 2. Complicated CRBSI: 2.1 Local complication: exit site, port/tunnel infection, suppurative thrombophlebitis, endocarditis 2.2 Systemic complication: osteomyelitis, distant abscess etc 3. Causative agent-specific Rx: 3.1 Short-term CVC or A catheter: all agents; may retain if CoNS 3.2 Long-term CVC or port catheter: S. aureus, Candida; may retain in CoNS, Enterococcus, GNB 3.3 Perm catheter: S. aureus; guidewire exchange if CoNS, GNB, Candida 4. Failure of conservative Rx (usually h after Rx) Coagulase-negative Staphylococcus: CoNS Gram-negative bacilli: GNB Mermel et al & IDSA. CPGs for Dx & Mx of IV catheter-related infection. Clin Infect Dis 2009

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34 PE: no evidence of thrombophlebitis, TR, & embolic phenomena. CXR: no pulmonary infiltrate The patient had empirically received vancomycin + meropenem. Blood culture via CVC: Gram-positive cocci in clusters at 6 hrs Blood culture via peripheral vein: no growth What is the most appropriate action? Continue only vancomycin

35 PE: no evidence of thrombophlebitis, TR, & embolic phenomena. CXR: no pulmonary infiltrate The patient had empirically received vancomycin + meropenem. Blood culture via CVC: finally grew CoNS Blood culture via peripheral vein: no growth What is the most appropriate action? Should CVC be removed? What s antibiotic lock?

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37 PE: no evidence of thrombophlebitis, TR, & embolic phenomena. CXR: no pulmonary infiltrate The patient had empirically received vancomycin + meropenem. Blood culture via CVC: finally grew CoNS Blood culture via peripheral vein: no growth What is the most appropriate action? Should CVC be removed? What s antibiotic lock?

38 Pathogenesis of CRBSI Migration of skin organisms: exit site or tunnel infection Contamination of device prior to insertion Contamination of catheter hub Contaminated infusate Hematogenous seeding O Grady et al & the Healthcare infection Control Practices Advisory Committee (HICPAC). Clin Infect Dis 2011.

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40 Antibiotic lock Krishnasami et al. Kidney Int Rijnders et al. J Antimicrob Chemother Droste et al. J Antimicrob Chemother Vercaigne et al. Pharmacotherapy Robinson et al. J Antimicrob Chemother 2005.

41 Rijnders et al. J Antimicrob Chemother 2005.

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45 Am J Nephrol 2011.

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48 Incidence of catheter replacement

49 Incidence of relapse

50 Days of infection-free survival

51 CRBSI caused by CoNS 1. CVC management: - CVC retention: stable hemodynamics, uncomplicated CRBSI & CoNS isn t S. lugdunensis 2. Duration of antibiotic Rx: days if CVC removal days if CVC retention & antibiotic lock Mermel et al & IDSA. CPGs for Dx & Mx of IV catheter-related infection. Clin Infect Dis 2009

52 The patient had empirically received vancomycin + meropenem. Blood culture via CVC: yeasts at 6 hrs Blood culture via peripheral vein: yeasts at 10 hrs What is the most appropriate action? Should CVC be removed?

53 Antifungal Rx of candidemia First-line Rx 1. Fluconazole (BIII): - Less critically ill & no recent azole exposure, no neutropenia, no risk for C. krusei or C. glabrata mg loading dose, then 400 mg/d 2. Echinocandins (BIII): - Caspofungin: 70 mg loading dose, then 50 mg/d - Anidulafungin: 200 mg loading dose, then 100 mg/d - Micafungin: 100 mg/d Alternative Rx AmphotericinB deoxycholate or lipid amphotericinb (BIII): - Intolerance to other antifungals mg/kg/d Pappas et al & Infectious Diseases Society of America (IDSA). CPGs for Mx of candidiasis. Clin Infect Dis Mermel et al & IDSA. CPGs for Dx & Mx of IV catheter-related infection. Clin Infect Dis 2009

54 The patient had empirically received vancomycin + meropenem. Blood culture via CVC: yeasts at 6 hrs Blood culture via peripheral vein: yeasts at 10 hrs What is the most appropriate action? Should CVC be removed?

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56 2 subgroup studies of multicenter double-blind RCTs Inclusion criteria: - CVC-associated candidemia - Age >16 YO - Receipt of >1 dose of study drug Nucci et al. Clin Infect Dis 2010.

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59 Univariate analysis of 5 outcomes 24 h 48 h Time to mycological eradication

60 Multivariate analysis of the effect of early CVC removal on Rx success & survival

61 Thank you for your attention