Healthcare-Associated Infections _ ______________________________________________________________
Treatment The management of an intravascular device-related blood- stream infection does not always include removal of the device. Authors of consensus-based treatment guidelines advise that the decision to remove a tunneled catheter or implanted device suspected to be the source of bacteremia or fungemia should be based on the following factors [259]: • Underlying health status of the patient • Type of catheter • Strength of the evidence that the catheter is the source of the infection • Responsible pathogens • Presence of local or systemic complications Nontunneled central venous catheters should be removed in most cases of bacteremia or fungemia [259]. Antibiotic therapy alone has resolved 80% of infections caused by coagulase- negative staphylococcal bacteria, but in cases of infection with S. aureus or Candida , infection has persisted when the catheter has been maintained [259; 260]. One strategy was developed in an attempt to retain the catheter. With so-called antibiotic lock therapy, antibiotics are instilled through the catheter after injection of an anticoagulant, lock- ing a high concentration of the antibiotic in the lumen [260]. This approach is used in combination with systemic antibiotic therapy, and the antibiotics used have included vancomycin, cefazolin, and clindamycin. Fluconazole and amphotericin B have been used occasionally for infection with Candida spp., and another flush solution (low concentrations of minocycline and EDTA) has demonstrated activity against staphylococci, gram-negative bacilli, and Candida spp. [260]. Early empiric antifungal therapy is important if infection with Candida is suspected, as delayed treatment has been associated with higher mortality [261].
• Compliance with appropriate hand hygiene • Use of maximal barrier precautions • Use of 2% chlorhexidine solution for skin antisepsis • Selection of optimal site for the catheter, with the subclavian vein as the preferred site for nontunneled catheters • Daily review of the need for the line, with prompt removal if line is deemed unnecessary Diagnosis As defined by the CDC, bloodstream infections fall into two categories: laboratory-confirmed infection and clinical sepsis. Clinical sepsis is no longer used in reporting on adults and children and is restricted to use for neonates and infants [129]. For a diagnosis of laboratory-confirmed bloodstream infection, one of the two following criteria must be met [129]. Criterion 1 Recognized pathogen found on one or more blood cultures and organism cultured from blood is not related to an infec- tion at another site Criterion 2 At least one of the following signs or symptoms : • Fever (>38 degrees Centigrade) • Chills (with no other recognized cause) • Hypotension (with no other recognized cause) and signs and symptoms and positive laboratory results are not related to an infection at another site and common skin contaminant (e.g., diphtheroids, Bacillus spp., Propionibacte- rium spp., coagulase-negative staphylococci, viridans group streptococcus, Aerococcus spp., or Micrococcus spp.) is cultured from two or more blood cultures drawn on separate occasions. Criterion elements must occur within the seven-day infection window period, which includes the collection date of the posi- tive blood specimen, the three calendar days before and the three calendar days after [257]. There are several approaches to diagnosing an intravascular device-related bloodstream infection. A meta-analysis of 51 studies published between 1966 and 2004 was designed to identify which method was the most accurate [258]. The stud- ies had involved the eight most commonly used diagnostic methods: culture (qualitative, semiquantitative, or quantita- tive) of a catheter segment; culture (qualitative or quantitative) of blood obtained through the catheter; paired quantitative cultures (blood obtained through the catheter as well as from a peripheral site); differential time to positivity (monitoring of cultures of blood obtained through the catheter and from a peripheral site); and acridine orange leukocyte cytospin. The paired cultures method was the most accurate, with a pooled specificity of 99%, followed by qualitative culture of blood drawn through the catheter and acridine orange leukocyte cytospin [258].
The Centers for Disease Control and Prevention recommends using a chlorhexidine/silver sulfadiazine- or minocycline/rifampin-impregnated central venous catheter in patients whose catheter is expected to remain
in place longer than five days if, after successful implementation of a comprehensive strategy to reduce rates, the central line-associated bloodstream infection rate is not decreasing. (https://www.cdc.gov/infection-control/media/pdfs/ Guideline-BSI-H.pdf. Last accessed January 26, 2025.) Strength of Recommendation/Level of Evidence : IA (Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies)
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