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Catheter Related Blood Stream Infection (CRBSI)
Diagnosis & Management Step-Wise Practical Approach in HD Patients
Mohammed Abdel GawadNephrology Specialist
Kidney & Urology Center (KUC)
Alexandria – EGY
1st Annual Interventional Nephrology Meeting – ESNTMansoura, 26-27/Oct/2017
Talk Outline
• Diagnosis
• Management
• Prevention
Talk Outline
• Diagnosis
• Management
• Prevention
Paired Blood Cultures
Peripheral vein
From the catheter
Culture of the catheter tip (distal 5 cm)
or
Paired Blood Cultures
or
When a peripheral blood sample cannot be obtained
From the catheter
From Dialysis circuit
2 quantitative blood cultures of samples obtained through
2 catheter lumens
Culture Results
Results Diagnosis
Same organism from both samples CRBSI Confirmed
Both negative CRBSI Unlikely
Negative peripheral blood cultureBUT
Positive central blood culture
Probably contamination (don’t treat EXCEPT if
Staph. Aureus)
Talk Outline
• Diagnosis
• Management
• Prevention
Talk Outline
• Diagnosis
• Management
• Prevention
Pathway 1: Catheter Salvage
Start Empirical Antibiotics + Antibiotic Lock Therapy
Reassess after 2-3 days: Clinically (fever) & Lab (WBC, CRP)
Improving?
Yes
Continue antibotics, then:
Pathway 3: Surveillance
No
Pathway 4: Catheter removal
Pathway 1: Catheter Salvage
Empirical Antibiotics Antibiotic To cover Condition
Vancomycin MRSA for institutions in with preponderance of MRSA
Gentamycin(if absolutely
contraindicated use Quinolones)
Gram –ve---------------------
Meropenem, Imipenemor Etrapenem
or Piperacillin/Tazobactamin community with low incidence of antibiotic
resistance
MDR Gram –ve In neutropenic patients, severely ill patients with sepsis, or patients
known to be colonized with such pathogens
Fluconazole or Echinocandin
Candidemia total parenteral nutrition, prolonged use ofbroad-spectrum antibiotics, hematologic
malignancy, receipt of bone marrow or solid-organ transplant, femoral catheterization,or colonization due to Candida species at
multiple sites
Alternatives to vancomycin as a first choice broad spectrum
Condition Alternative
the preponderance of MRSA isolates have vancomycin
minimum inhibitory concentration (MIC) values 12
mg/mL
Daptomycin
Antibiotic Doses: VANCOMYCIN
2017
Antibiotic Doses: GENTAMICIN
2017
Dialyziability & Residual Renal Function Effect
• Vancomycin is not removed by HD; gentamicin is.
• Measure gent levels daily (levels will decrease sooner in patients with significant residual function).
• Monitor predialysis trough levels if possible
2017
Antibiotic Doses: MEROPENEM
2017
Antibiotic Doses: IMIPENEM
2017
Antibiotic Doses: ERTAPENEM
2017
Antibiotic Doses: PIPERACILLIN/TAZOBACTAM
2017
Antifungal Doses: FLUCONAZOL
2017
Pathway 1: Catheter Salvage
Start Empirical Antibiotics + Antibiotic Lock Therapy
Reassess after 2-3 days: Clinically (fever) & Lab (WBC, CRP)
Improving?
Yes
Continue antibiotics, then:
Pathway 3: Surveillance
No
Pathway 4: Catheter removal
Pathway 1: Catheter Salvage
Pathway 1: Catheter Salvage
Start Empirical Antibiotics + Antibiotic Lock Therapy
Reassess after 2-3 days: Clinically (fever) & Lab (WBC, CRP)
Improving?
Yes
Continue antibiotics, then:
Pathway 3: Surveillance
No
Pathway 4: Catheter removal
Pathway 1: Catheter Salvage
Duration of Systemic and
Antibiotic Lock
Duration of Systemic and Antibiotic Lock
Pathway 1: Catheter Salvage
If catheter is retained for a patient with S. aureus CRBSI
Continue systemic and antibiotic
lock therapy for 4 weeks
Duration of Systemic and Antibiotic Lock
Pathway 1: Catheter Salvage
If catheter is retained for a patient with any other organism
No clear data for systemic and antibiotic lock therapy salvage
duration
Antibiotic Lock Special Situation
Multiple positive catheter blood culture BUT concurrent negative peripheral
blood cultures
Antibiotic lock therapy without systemic therapy for 10–14 days
guide wire
Start Empirical Antibiotics as in salvage pathway
Reassess after 2-3 days: Clinically (fever) & Lab (WBC, CRP)
Improving?
Yes
Exchange on guide wire
Continue antibiotics
Pathway 3: Surveillance
No
Pathway 4: Catheter removal
Pathway 2: Exchange on guide wire
Duration of Systemic and
Antibiotic Lock
Duration of Systemic and Antibiotic Lock
If catheter is exchanged for a patient with any organism
No clear data for systemic and antibiotic lock therapy salvage
duration
Pathway 2: Exchange on guide wire
Pathway 3: Surveillance
bloodstream infection that continuesdespite >72 h of antimicrobial therapy
to which the infecting microbes are susceptible
2 sets of blood cultures obtained on a given day
Pathway 3: Surveillance If the catheter has been retained
Surveillance blood cultures 1 week after completion of an antibiotic course
If blood cultures +ve → the catheter should be removed
New, long term dialysis catheter after additional –ve blood cultures
Pathway 4: Catheter removal
Remove catheter and culture tip (5 cm)
Start empirical antibiotics as in salvage pathway
Is access is needed urgently for dialysis?
Yes
Insert temporary catheter in
another site for short
period of time
No
Continue antibiotics
Insert long term catheter ONLY if:
1- afebrile for 48-72 hours
2- CRP is normal
3- Blood cultures are -ve
Duration?
Pathway 4: Catheter removal
Persistent fungemia or bacteremia >72 h after catheter
removal
4 to 6 weeks of antibiotic therapy
should be administered
Additional TEE should be obtained
Catheter Removal Special Situation (1)
Catheter Removal Special Situation (2)
Catheter tip grows S. aureus
but
Initial peripheral blood cultures -ve
5–7-day course of antibiotics
Close monitoring for signs and symptoms of ongoing infection, including additional blood cultures, as indicated
Talk Outline
• Diagnosis
• Management
• Prevention
Talk Outline
• Diagnosis
• Management
• Prevention
Prevention - Catheter
• Strict aseptic circumstances.
• Avoid as much as possible:
– using non-tunneled catheters.
– using femoral
• Monitor the catheter:
– visually when changing the dressing
– or by palpation through an intact dressing on aregular basis.
Prevention – Exit Site
• Application of antibiotic ointment at the exitsite until the insertion site has healed
• The catheter exit site should be covered by adressing as long as the catheter remains inplace.
Prevention – Antimicrobial Lock
• Its use is debated.
• Its use may be saved to patients with:– history of multiple CRBSI – those with high risk of severe sequelae (patients
with pacemakers, prosthetic valve or IV devices).
• Citrate locks have, for the time being, most extensively been studied. (The 4% solution seems to offer at present the best benefit/risk ratio).
Prevention – Staphylococcus
• Eradication of Staphylococcus carriage (nasal mupirocin cream).
• Consider IV antibiotics at insertion for patients with Staphylococcal skin colonisation.
Always re-evaluate for alternative access
(AVF or AVG).
References
References
Thank You