Rapid Review·Cardiovascular
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Vascular: Venous
T1Must knowCatheter-Related Bloodstream Infection
Focus on
Fever in a patient with a central line and no other source. Paired cultures from the catheter and a peripheral vein before antibiotics; empiric vancomycin (plus gram-negative and fungal cover for femoral lines and the very sick); and pull the line for S. aureus, Pseudomonas, enterococci, fungi, sepsis, suppurative thrombophlebitis, endocarditis, or bacteremia that persists past 72 hours. Prevention is chlorhexidine, full barriers, ultrasound, no femoral lines, and taking the line out the day it is no longer needed.
Key takeaways
Definitions and central lines
Catheter-related bloodstream infection (CRBSI)
a primary bloodstream infection attributable to an intravascular catheter accessed over 48 hours before, or removed within the previous 48 hours, proven by paired cultures.Central line-associated bloodstream infection (CLABSI)
the surveillance definition: a primary bloodstream infection with a central line in place, source not proven.
What this shows
Short-term lines (14 days or less)
non-tunneled lines in the internal jugular (ultrasound-guided) or subclavian (landmark-guided); femoral lines carry the highest infection and thrombosis risk.
What this shows
Long-term lines (over 14 days)
peripherally inserted central catheters (PICC lines), tunneled catheters, implanted ports.
What this shows
Indications
large-volume resuscitation, long-term intravenous therapy, poor peripheral access, vesicant or irritant drugs (chemotherapy), hemodynamic monitoring, total parenteral nutrition, dialysis.Contraindications
infection or thrombosis at the site, superior vena cava syndrome for subclavian or jugular lines (use a femoral line), coagulopathy for the subclavian route (not compressible), allergy to an antibiotic coating.Tip position
the lower superior vena cava (at the level of the tracheal bifurcation and sternal angle); confirm with a chest film if not ultrasound-guided (Approach to Fluid Replacement).- A tip in a smaller vein (subclavian, jugular, azygos) risks perforation.
Insertion complications
pneumothorax or hemothorax, arterial puncture, arrhythmia, air embolism, perforation with tamponade.Organisms, risk factors and clinical features
Organisms
Staphylococcus aureus (most common) and coagulase-negative staphylococci; Candida; Pseudomonas aeruginosa.Risk
femoral or inguinal sites, multiple lumens, central lines (higher than PICC lines), immunosuppression, bone marrow transplant, burns.Clinical features
fever, hemodynamic instability or altered mentation with no other source after examination, urinalysis and a chest film.- Local swelling, pain, redness or purulence at the insertion site in a minority.
Diagnosis
Before antibiotics, draw cultures from two sites simultaneously
the catheter lumen and a peripheral vein (or two different lumens).CRBSI needs the same organism from both
plus one of two findings.- Differential time to positivity: the catheter culture turns positive 2 hours or more before the peripheral sample.
- Quantitative cultures: the catheter sample has 3 times the colony count of the peripheral sample (or of the other lumen).
Other tests
blood count, inflammatory markers, chemistry; echocardiography for Staphylococcus aureus or persistent bacteremia; ultrasound for suppurative thrombophlebitis.| Catheter | Remove if |
|---|---|
| Any peripheral venous catheter | Any sign of local infection |
| Short-term central access (under 14 days) | Confirmed infection with S. aureus, enterococci, fungi, mycobacteria or gram-negative bacilli |
| Long-term central line or arterial catheter (14 days or more) | Severe sepsis or septic shock; suppurative thrombophlebitis; endocarditis; persistent bacteremia despite 72 hours of appropriate therapy; obvious site infection; infection with S. aureus, P. aeruginosa, enterococci, fungi or mycobacteria; catheter dysfunction |
| Any line | Hemodynamic instability or end-organ damage from the infection: remove immediately; place a new line at a new site, or salvage only when venous access is precious |
Management
All patients get gram-positive coverage
vancomycin (high methicillin-resistant Staphylococcus aureus risk).Add gram-negative and Pseudomonas coverage
a carbapenem, cefepime, or piperacillin-tazobactam, with or without an aminoglycoside, for femoral lines, neutropenia or severe sepsis.Add an echinocandin (caspofungin)
for likely Candida (fluconazole as the alternative).Narrow to cultures
S. aureus needs at least 14 days after clearance (4 to 6 weeks if complicated); Candida 14 days after the first negative culture with the catheter removed.Prevention and complications
Choice of line
prefer PICC and tunneled catheters; avoid femoral lines in adults (subclavian or jugular instead).At insertion
chlorhexidine-alcohol skin prep, hand hygiene, full barrier precautions (mask, sterile gloves, gown, drape), ultrasound guidance.Afterward
replace emergently placed lines within 2 days, limit the duration, remove promptly when no longer needed, and do not routinely replace or exchange central lines.Complications
infective endocarditis (especially Staphylococcus aureus), septic emboli, suppurative thrombophlebitis, osteomyelitis and epidural abscess, endophthalmitis with Candida.A patient in intensive care with a 5-day-old femoral central line develops fever with no other source. How is CRBSI proven, and what is the empiric regimen?
Draw paired cultures (catheter lumen and a peripheral vein) before antibiotics; CRBSI needs the same organism in both plus a catheter culture positive 2 or more hours earlier or with 3 times the colony count. A femoral line gets empiric vancomycin, gram-negative and Pseudomonas cover, and an echinocandin.
How it's tested
Fever of 39 °C and rigors in an ICU patient with a 6-day-old femoral line, no other source: suspected CRBSI — paired cultures from the line and a peripheral vein, then empiric vancomycin plus cefepime plus an echinocandin (femoral site), and remove the line.
The catheter culture turns positive 3 hours before the peripheral culture with the same S. epidermidis: differential time to positivity confirms the catheter as the source.
Tunneled dialysis catheter, S. aureus bacteremia, patient stable: remove the catheter anyway (S. aureus mandates removal), TEE, at least 14 days of antibiotics; new access at a new site.
Coagulase-negative staph from a tunneled chemotherapy port in a stable patient with terrible venous access: catheter salvage with systemic antibiotics plus antibiotic lock therapy is acceptable; remove if bacteremia persists past 72 hours.
Which insertion site has the lowest infection rate and which the highest: subclavian lowest (but most pneumothorax); femoral highest.
Go deeper
Guidelines: IDSA Clinical Practice Guideline for Intravascular Catheter-Related Infection · CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections
Related Step 2 pages: Superficial Thrombophlebitis, Approach to Fluid Replacement, Infective Endocarditis, Distributive Shock, Chronic Venous Insufficiency
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