Page 861 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

592 PART 5: Infectious Disorders

that for patients in the ICU with a new onset of fever but without severe Device-related infections due to Candida species should have the
sepsis or evidence of bloodstream infection, percutaneous and blood device removed and be treated with a 14-day course of an azole such as
cultures from a nontunneled central line should be obtained without fluconazole, amphotericin B or a lipid formulation of amphotericin B,
routine catheter removal but if the patient has unexplained sepsis or ery- or an echinocandin as appropriate based on susceptibility. In the sus-
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thema overlying the catheter insertion site or purulence at the catheter ceptible patient population most often found in the ICU, a thorough
insertion site, the catheter should be removed and cultured. For patients evaluation for metastatic candidal infection, including careful fundo-
with unexplained fever, if blood culture results are positive, the central scopic examination, is necessary. The finding of persistently positive
catheter should be exchanged over a guide wire, and if the subsequent blood cultures after catheter removal and initiation of antifungal therapy
catheter tip culture has significant growth, then the catheter should be or the finding of metastatic candidal lesions would necessitate more pro-
removed and a new catheter placed in a new site. longed therapy. An option for the management of uncomplicated bacte-
Device-related bacteremia that is suspected to arise from cuffed central remia due to coagulase-negative staphylococci in the setting of a cuffed
long-term indwelling catheters or totally implanted devices does not neces- long-term central catheter or implantable port, without removal of the
sarily require removal of the device. 53,55 If there is obvious local purulence, device, is the use of systemic antimicrobials and the antibiotic-lock
a tunnel infection or tunnel-associated cellulitis, port-associated abscess, technique, with careful monitoring for evidence of relapse.
septic thrombophlebitis, endocarditis, persistent bacteremia, metastatic
infection, or bacteremia due to S aureus or Candida species removal of PREVENTIVE STRATEGIES
the device is required with surgical dissection as appropriate. Retention
of a cuffed long-term central catheter with catheter-related S aureus Attention to detail in all aspects of the placement and care of intravascular
bacteremia has been associated with a higher relapse rate of bacteremia devices is necessary to minimize the risks of device-related infection. This
and higher sepsis-related mortality. In the setting of bacteremia due to attention to detail is particularly important in the ICU, where the use of
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other microorganisms and in the absence of complications, a course of lines is intensive and patients, by nature of their underlying illnesses, are
parenteral antimicrobial therapy with or without antibiotic-lock therapy, at high risk of device-related infections. This attention to detail with a
based on the susceptibility of the identified microbe, without removal of focus on quality improvement was demonstrated in a large multicentre
the cuffed central catheter or implantable device may be sufficient in as trial involving 375,757 catheter-days in 108 ICUs in a state-wide study in
many as two-thirds of cases. Following treatment, these patients should the United States. An infection control bundle consisting of five anti-
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be monitored carefully for recurrences of bacteremic infection. septic techniques highly recommended by the US Centers for Disease
Definitive antimicrobial therapy for device-associated bacteremia Control and Prevention (CDC) guidelines (emphasis on appropriate
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depends on appropriate identification and susceptibility testing of the hand hygiene, use of maximum sterile barrier precautions during insertion
infecting microorganism. Empirical therapy prior to the identification of the CVC, use of chlorhexidine for skin antisepsis prior to placement, use
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and susceptibility results will be influenced by local microbiologic patterns of the subclavian vein as the preferred insertion site, and the removal of
of line-related infection and susceptibilities. However, a combination of unnecessary CVCs) resulted in a highly significant decrease in the mean
an intravenous antistaphylococcal penicillin (vancomycin if methicillin- rate of CLABSIs from 7.7/1000 catheter-days to 1.4 infections at 16 to 18
resistant S aureus is prevalent) and an aminoglycoside or a third-generation months follow-up, with the reduction persisting after implementation. 57
cephalosporin will provide adequate empiric coverage for most gram- The processes to which preventive strategies may be applied may be
positive and gram-negative microorganisms. Any device-related bactere- divided conveniently into the catheter itself, catheter insertion, catheter
mic infections caused by S aureus should be managed by device removal site care, catheter care, and the delivery system (Table 66-4). Major pre-
and treated for 4 to 6 weeks with parenteral antimicrobial therapy. 53 ventive strategies that have been recommended are presented, 31,51 as well

TABLE 66-4 Strategies for Prevention of Vascular Device–Related Infections
Process or System Preventive Strategy Rationale
Device itself Institute careful needs assessment prior to insertion of any Avoid unnecessary insertions
intravascular device Use of peripheral catheter, midline, or PICC line should be considered if appropriate
Choose least thrombogenic material for type of device being Polyvinylchloride > polyurethane > silicone > steel with respect to thrombogenecity and
inserted based on the needs assessment colonization with certain microorganisms
Consider use of antiseptic-antimicrobial impregnated devices in May be useful in selected settings where institutional goals for device-related infection rates cannot
selected circumstances be achieved by other means or in specific high-risk patient populations
Minimize the number of accesses whenever possible Increased frequency of entry into the system is associated with a greater risk of device-related infection
Device Educate health care providers involved in the insertion, care, Enhanced knowledge about infection prevention strategies related to intravascular devices facili-
insertion and maintenance of intravascular devices tates the importance of the process
Use a checklist to ensure adherence to infection prevention Ensures compliance with aseptic technique
practices at the time of device insertion
Choose site associated with least risk for local and systemic Risk of local and systemic device-related infection is independently associated with density of flora
device-related infection. at the catheter insertion site; femoral > jugular > subclavian
Use aseptic technique with maximal barrier precautions Good hand washing and use of maximal barrier precautions (masks, sterile drapes, gloves, gown)
are associated with less risk of device-related bacteremia than minimal barrier precautions (mask,
sterile gloves, small drapes)
Use a chlorhexidine-based antiseptic for skin preparation Controlled trials have demonstrated a benefit over other skin antiseptics
Insertion is done by skilled operators. Organized, specifically trained IV teams have been associated with lower catheter infection rates,
but the key ingredient is highly skilled operator with excellent technique; difficulty of insertion has
been associated with higher local device-related infection rates.
Place device in as controlled an environment as possible Emergency catheter insertions are associated with a higher risk of infection than elective placement.
(Continued)

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