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Managing bloodstream infections in patients who have short-term central venous catheters

Cleveland Clinic Journal of Medicine. 2011 January;78(1):10-17 | 10.3949/ccjm.77a.10015
January 1, 2011|Cleveland Clinic Journal of Medicine
Naomi P. O'Grady, MD;Daniel S. Chertow, MD
Author and Disclosure Information

Naomi P. O’Grady, MD
Staff Clinician, Critical Care Medicine Department; Medical Director, Procedures, Vascular Access, and Conscious Sedation Services, National Institutes of Health, Bethesda, MD. Co-author of the 2009 Infectious Diseases Society of America’s Guidelines for Management and Treatment of Catheter-Related Infections

Daniel S. Chertow, MD
Critical Care Medicine Department, National Institutes of Health, Bethesda, MD

Address: Naomi P. O’Grady, MD, Critical Care Medicine Department, National Institutes of Health, Building 10 Room 2C142, 10 Center Drive MSC 1662, Bethesda, MD 20892; e-mail nogrady@mail.cc.nih.gov

ABSTRACTCatheter-related bloodstream infections can be complicated to manage, but a growing body of evidence supports specific recommendations. In 2009, the Infectious Diseases Society of America published updated guidelines for the diagnosis and management of all intravascular catheter-related infections. Here we provide a focused review on the management of bloodstream infections in adult patients with short-term (not surgically implanted and not tunneled) central venous catheters, including peripherally inserted central catheters. This review should serve as a ready reference for providers (eg, hospitalists, surgeons, physician assistants, nurse practitioners, intensivists) managing adult patients with short-term central venous catheters in place.

KEY POINTS

  • Most bloodstream infections related to central venous catheters occur in patients with short-term central venous catheters; these infections result in significant morbidity and health care costs.
  • Initial management of suspected cases requires decisions about whether to retain or remove the catheter and the choice of empiric antibiotic therapy.
  • Management should be based on the specific pathogen isolated.
  • An infectious disease specialist should be consulted in complicated cases or when multidrug-resistant bacteria or uncommon pathogens are isolated.

Vascular catheters are very common in everyday inpatient and, increasingly, outpatient care. Nearly 300 million catheters are estimated to be used annually in the United States, and approximately 3 million of these are central venous catheters (CVCs).1

Although significant gains have been made in preventing CVC-related bloodstream infections, these infections continue to occur, with estimated rates ranging from 1.3 per 1,000 catheter days on inpatient medical-surgical wards to 5.6 per 1,000 catheter days in intensive care burn units.2

CVCs are classified as either long-term or short-term. Long-term CVCs are surgically implanted or tunneled and used for prolonged chemotherapy, home infusion therapy, or hemodialysis. Short-term CVCs do not require surgical implantation. They are more common than long-term CVCs and account for most CVC-related bloodstream infections. Given the frequency of short-term CVC use, a growing number of health care providers from mid-level practitioners to intensivists are faced with deciding how to manage bloodstream infection related to short-term CVCs.

At baseline, management decisions about bloodstream infections from short-term CVCs can be challenging. Questions that regularly arise include:

  • Should a potentially infected catheter be removed?
  • Which empiric antibiotic therapy should be started pending a microbiologic diagnosis?
  • How should therapy be tailored (eg, antibiotic choice and course and whether to remove or retain the catheter) based on the specific pathogen identified?

Adding to the complexity of these decisions are increasingly resistant microorganisms, heterogeneity of affected patient populations, and variability in the quality and availability of evidence.

This review provides a concise guide to managing bloodstream infections related to short-term CVCs in adults, based on updated guidelines from the Infectious Diseases Society of America (IDSA).3

DEFINITION AND DIAGNOSTIC CRITERIA

We have adapted the following definition and diagnostic criteria from the general definition and diagnostic criteria for catheter-related bloodstream infections proposed by the IDSA.

Bloodstream infection related to a short-term CVC is defined as bacteremia or fungemia in a patient with the CVC in place, clinical manifestations of infection (eg, fever, chills, hypotension), and no apparent source of the bloodstream infection aside from the catheter. At least one of the three diagnostic criteria should be met:

  • Cultures of the catheter tip and of the peripheral blood grow the same organism. Catheter tip culture should be quantitative, with more than 102 colony-forming units (cfu) per catheter segment, or semiquantitative, with more than 15 cfu per catheter segment.
  • Blood drawn from the catheter lumen grows the same organism as blood drawn from a peripheral vein (or less optimally, a different lumen), but at three times the amount by quantitative culture.
  • Blood drawn simultaneously from the catheter lumen and from a peripheral vein (or less optimally, a different lumen) grows the same organism, and growth from the CVC lumen sample is detected (by automated blood culture system) at least 2 hours before growth from the peripheral vein sample.

MANAGING BLOODSTREAM INFECTIONS IN PATIENTS WITH SHORT-TERM CVCs

Figure 1.
The following section addresses specific questions in the order they arise in the management of bloodstream infections related to short-term CVCs. Figure 1 and Figure 2 are flow diagrams to guide initial and pathogen-specific management of suspected and confirmed cases and may serve as a quick reference for busy providers.

When to remove a potentially infected short-term CVC

Figure 2.
Not all patients with a suspected bloodstream infection related to a short-term CVC need to have the catheter removed. A number of studies4–6 have shown that a substantial portion of clinically suspected cases are actually not catheter-related.

In a nonneutropenic intensive care population, Bouza et al4 found that, of 204 episodes of clinically suspected bloodstream infection from a short-term CVC, only 28 (14%) were confirmed to be catheter-related, 27 (13%) were bloodstream infections that were not catheter-related, 36 (18%) involved catheter-tip colonization with negative blood cultures, and the remainder were cases with negative catheter-tip and blood cultures.

Rijnders et al,5 in a study of 100 adult medical-surgical intensive care patients with a clinically suspected bloodstream infection related to a short-term CVC, found only three confirmed cases.

A randomized clinical trial comparing early removal of short-term CVCs and watchful waiting in an adult intensive care population with clinically suspected bloodstream infections showed no difference between treatment groups in length of stay in the intensive care unit or in the mortality rate.6 This trial included a low-risk subset of adult medical-surgical intensive care patients (ie, immunocompetent, no intravascular foreign body, no evidence of severe sepsis or septic shock, no evidence of infection at the catheter insertion site, no proven bacteremia or fungemia). These results suggest that a similar subset of patients can be safely monitored without catheter removal while being assessed for possible catheter-related bloodstream infection.

Empiric catheter removal vs watchful waiting has not and likely will not be studied in higher-risk populations. In this group, clinical judgment should outweigh any specific management algorithm. In patients who are in shock or who are otherwise hemodynamically unstable, early catheter removal should be a priority; however, in some circumstances the risks of immediate catheter removal (eg, coagulopathy with risk of bleeding diathesis, or lack of site to replace the catheter) may outweigh the potential benefits.

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