_______________________________________________________________ Healthcare-Associated Infections
Guideline Adherence and Quality Improvement As is the case with guidelines for other HAIs, adherence to prevention guidelines is suboptimal. A survey of more than 500 hospitals showed that, while adherence to the two most strongly recommended prevention strategies—maximal sterile barrier precautions and antisepsis with chlorhexidine gluco- nate—was good at VA hospitals (84% and 91%, respectively), the rates were lower at non-VA hospitals (71% and 69%) [263]. Adherence to a combination of maximal sterile barrier precau- tions, chlorhexidine gluconate, and avoidance of central line changes was even lower: 62% and 44%, respectively [263]. In another study, central venous catheters were routinely changed to prevent infection in about 15% of hospitals [264]. Implementing a prevention bundle has significantly reduced intravascular device-related bloodstream infections: the decrease was from 5.9 per 1,000 catheter-days to 3.1 per 1,000 in one study and from 7.7 per 1,000 catheter-days to 1.4 per 1,000 in another [59; 240]. A how-to guide developed by the IHI provides practical suggestions for implementing the bundle ( Table 15 ) [265]. A checklist should be developed for use when inserting a catheter to ensure adherence to all prevention strategies [37].
The guidelines for treatment of intravascular device-related bloodstream infection (being updated as of 2025) suggest antimicrobial selection according to the known or suspected pathogen ( Table 14 ) [259]. Empiric antibiotic therapy should be selected according to clinical features and context, with due consideration for the local prevalence of resistant pathogens. Vancomycin is recommended as initial treatment for coagulase- negative staphylococci and for S. aureus until the sensitivity to methicillin is determined, at which point treatment should be changed to semisynthetic penicillin if the identified patho- gen is sensitive [259]. Vancomycin should not be used as a front-line treatment for infections with methicillin-sensitive S. aureus . If fever or other signs of infection persist after removal of the catheter, the patient should be evaluated for complications such as septic phlebitis, distant abscess, and endocarditis. Bacterial endocarditis has been found in 25% of patients with intravascular device-related bloodstream infection caused by S. aureus [260]. The findings of one study suggested that patients with MRSA bacteremia and underlying chronic liver disease were at higher risk for endocarditis [262].
TREATMENT OF INTRAVASCULAR DEVICE-RELATED BLOODSTREAM INFECTIONS IN ADULTS Pathogen Preferred Antimicrobial Agent Staphylococcus aureus
Sensitive to methicillin Resistant to methicillin Resistant to vancomycin
Penicillinase-resistant penicillin Vancomycin Daptomycin or linezolid
Coagulase-negative staphylococci Sensitive to methicillin Resistant to methicillin
Penicillinase-resistant penicillin Vancomycin
Enterococcus spp.
Sensitive to ampicillin Resistant to ampicillin/sensitive to vancomycin Resistant to ampicillin/resistant to vancomycin Escherichia coli and Klebsiella spp. ESBL negative ESBL positive Enterobacter spp. and Serratia marcescens
Ampicillin or (ampicillin or penicillin) + aminoglycoside Vancomycin + aminoglycoside
Linezolid or daptomycin
Third-generation cephalosporin Carbapenem
Carbapenem
Acinetobacter baumannii Pseudomonas aeruginosa
Ampicillin/sulbactam or carbapenem
Fourth-generation cephalosporin or carbapenem or antipseudomonal beta-lactam plus aminoglycoside
Burkholderia cepacia
SMZ-TMP or carbapenem Echinocandin or fluconazole
Candida albicans or Candida spp.
Corynebacterium spp. Mycobacterium spp.
Vancomycin
Susceptibility varies by species
SMZ-TMP: sulfamethoxazole/trimethoprim. Source: [259]
Table 14
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