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ARTICLES
INTRAVASCULAR CATHETER annually by clinics and hospitals in the USA. 1 This includes
more than 5 million central venous and pulmonary artery
SEPSIS catheters.
Catheter-related infections (CRI) remain among the top three
Mervyn Mer causes of hospital-acquired infections, with a mortality of up to
25%, and result in prolonged hospitalisation (mean of 7 days)
and increased medical costs.HO The estimated cost of treating
lntravascular devices are an integral component of modem-day
one episode 01 catheter-related bloodstream infection (CRBS1)
medicaJ practice. They are used to administer intravenous
in the USA ranged from 58 000 in 1988 to more than 528 000 for
fluids, medications, blood products and parenteral nutrition. In
intensive care patients in 1994. On the basis of these figures, the
addition, they serve as a valuable monitor of the haemo-
economic burden from CRBSl is substantial.
dynamic status of critically ill patients.
Central venous catheters (CVCS) account for an estimated
90% of all CRBSl.lI Rates of bloodstream infection range from 4
BACKGROUND AND HISTORY to 13 per 1 000 central catheter days,n with lower rates in
Only a century ago, no means of vascular access existed for the respiratory intensive care units and higher rates in bums units.
lile-sustaining support 01 critically ill patients. In the late 1800s Given the magnitude and seriousness of the problem of CRI,
steel needles became available, and with the advancing it is essential for health care workers to have a clear
knowledge of electrolyte physiology the therapeutic use of understanding of the diagnosis, pathogenesis, prevention and
intravenous fluid became established. In 1945, following the treatment of this problem and the new developments in the
advent of penicillin and the need for multiple intravenous field. Most of these infections can be reversed with appropriate
injections, plastic catheters for continuous vascular access were diagnosis and treatment, and many can be prevented.
describedY A further technological advance took place in 1%7
when the placement of long nylon catheters into central veins,
FORMS OF CATHETER SEPSIS
to limit medication-associated phlebitis, was described in
oncology patients.) These catheters were initially inserted by Definitions
peripheral cutdown techniques and later via percutaneous
approaches into the subclavian and jugular veins. Over the past Definitions relating to intravascular catheter sepsis have been
15 years the focus of research and development has been on the put forward by various workers, but many have complicated
physicochemical properties 01 catheters, looking at such aspects matters and been confusing. This has in part related to the fact
as improved catheter materials, tensile strength, rupture that definitions used for surveillance and research purposes
resistance, biocompatibility and the creation of catheter micro- have diffened from those used lor clinical diagnosis. The
environments hostile to invading organisms. Centers for Disease Control and Prevention in Atlanta, Georgia,
have suggested sensible definitions1J which allow for the use of
Intravascular devices have therefore been a major advance in
both clinical and laboratory evidence of catheter sepsis. These
terms of patient comfort and care, but with them has come the
should be universally used in the definition of intravascular
burden of complications, including a variety of local and
catheter sepsis and are documented in modified form in
systemic infectious complications.
Table I.
In general, intravascular devices can be divided into those
used lor short-term (temporary) vascular access and those used
for long-term (indwelling) vascular access. Long-term
intravascular devices usually require surgical insertion. while
T~le L Definitions for Gltheter-re.lat:ed infections
short-term devices can be inserted percutaneously. The main
focus of this review relates to short-term catheters. Catheter colonisation.: growth of:;e 15 colony-forming units
(semi-quantitative culture) &om a proximal or distaI catheter
segment in the absence of local or systemic infection
~GNTnJDEOFTHEPROBLEM Local infection: erythema, tenderness,. induration or purulence
within 2 cm of the skin insertion site of the catheter
El Although no Specific local statistics are available, more than Catheter-re1ated bloodstre.a.m. infection: isolation of the same
150 million intravascular devices are currently purchased organism (i.e. the identical species as per antibiogram) &om
culture (semi-quantitative or quantitative) of a catheter segment
and from the blood (preferably drawn from a peripheral vein)
of a patient with accompanying clinical symptoms and signs of
lntmsitv Can' Unit, johanntsburg Hospital, and Departmmt of Medicine, bloodstream.infection and no other apparent source of sepsis
Unrverslty of the Wittl'atersrand, Johannesburg
Mervyn Mer, MB BCh, Dip PEC (SA), FCP (SA)
October 1999, VolIS, No. 2 SAICC
P ATHOGENESIS OF CATHETER-RELATED DIAGNOSIS OF CATHETER-RELATED SEPSIS
INFECTIONS
Establishing a diagnosis of CRI involves both clinical and
The skin around the insertion site is the most common portal of laboratory components. The clinical features are generally
entry. I .. ,.. The current Wlderstanding is that a fibrin sheath nonspecific and indude fever, rigors, hypotension and
develops around the catheter which promotes the adherence of confusion. If there is no apparent source of sepsis in a patient
pathogens. This is referred to as the biofiJrn layer. Skin with an intravascular line (especially a central venous catheter)
organisms then migrate from the skin insertion site along the and if the sepsis appears to be refractory to antimicrobial
external surface of the catheter to colonise the distaI therapy or is of abrupt onset and associated with shock. the
intravascular tip and ultimately cause bloodstream infection. possibility of line-related sepsis needs to be considered.
Contamination of the catheter hub during its manipulation by Fundoscopy should always form part of the clinical
medical and nursing personnel is the second most common examination as focal retinal lesions are common in patients
portal of entry of micro-organisms. These organisms migrate \vith CVC-derived Candida infection, even when blood cultures
along the internal surface of the catheter leading to luminal
l are negative. Inflammation or purulence at the catheter
colonisation and thence to bloodstream infection. u,.l7-1!1 Although insertion site is seen in less than hall the cases.
much less common than either of the above two mechanisms, The laboratory components include culture of blood and the
haematogenous dissemination from a distal infectious focus or catheter. Blood cultures ;,re central to the diagnosis of CRBSI.
administration of contaminated infusate may also cause CRI.1lUl Two to three 10 m.l samples, ideally from separate peripheral
Other sources such as contaminated transducer kits, venipuncture sites, should be sent to the laboratory. Paired
disinfectants and infusion lines are also rare causes. quantitative cultures, which involve taking blood from both the
catheter and a peripheral site, may be particularly useful where
MICROBIOLOGICAL PROFILE OF CATHETER- luminal colonisation is predominant. The diagnosis is
RELATED INFECTIONS (TABLE m suggested when fivefold or more colonies are isolated from the
blood drawn from the vascular catheter as compared with the
The microbiology of CRI reflects a predominance of skin
concurrent peripheral sample.1i1:UJ
organisms such as Staphylococcus epidermidis, S. aureus, Bacillus
species and Corynebacterium species (especially JK strains). jK The most widely used laboratory teduUque for culturing the
bacteraemia occurs almost exdusively in severely catheter is the semiquantitative roll-plate metho(pt In this
immunosuppressed patients who are or have been receiving method, cultures are obtained from a segment of the catheter
broad-spectrum antibiotics and who have indwelling after it has been removed from the patient by rolling the
intravascular devices. catheter segment across the surface of a blood-agar plate at
least four times and then determining the number of colonies
present after a period of incubation. Growth of ;;;: 15 colony-
Table n. Common organisms ~ed with atheter--re1at:ed forming units from a proximal or distal catheter segment is
infections . regarded as significant. Quantitative teduUques for culturing
Staphyloa>ccus epidmnidis Enterobactu species the catheter include the sonication and vortexing methods,
5. aulTUS Serratia rrrtlTasan5 which involve extracting micro-organisrns from the catheter
Cmuiida species Citro/><ldrr Jmutdii surface into a medium for culturing. This entails either flushing
Arinetobocter species Enterococcus species
out the catheter segment and immersion in culture medium or
Pseudomoruls tletUginosa Bacitlus species
placement of the segment in culture medium with
Stenatrophomonas maltoplu1ia Caryntbaderium (especially JK
Klebsiella species strains) sonication.m73 Quantitative culture is the most sensitive
technique for diagnosis of catheter-related infection. Other
techniques such as Gram staining of the catheter surface and
culture of the tip in broth are associated with high false-
positive rates. A newer diagnostic culture technique is that of
Contamination from the hands of medical and nursing
the endoluminal brush. This allows samples to be taken via the
personnel is frequently responsible for infection with such
lumen of the catheter with a brush while the catheter remains
organisms as Pseudomonas aeruginosa, Acinetobacter species,
in situ. A sensitivity of 95% and a specificity of 84% in the
Stenotrophomonas mllitaphilia and Candida species.c.:~
diagnosis of CRI has been reported with this teduUque. 3 -" This
Emerging pathogens, including species of Enterococcus, technique does not require sacrifice of the cathet~ but there is
Micrococcus and Achromobacter, rapidly growing mycobacteria still a delay before culture results are known. There are also
such as Mycobacterium Jorhlitum and M. chelonei, and fungal concerns that the process of brushing may lead to embolisation
organisms such as Malassezia furfur, Rhodotorula species, of infected. biofilm. The place of the endoluminal brush in
Fusarium species, Trichosporin species and Hansenula anomala clinical practice is still to be determined.
have also caused catheter infections.l~
ARTICLES J
PREVENTIVE STRATEGIES FOR CRI Silver-chelated subcutaneous collagen cuffs
Strict adherence to halldwashing and aseptic technique remains the These cuffs may be attached to percutaneously inserted CVCs
comeTstone of prevention of CRI. However, other measures may and are designed to act as both a mechanical barrier to the
confer additional protection and need to be considered in the migration of micro-organisms and an antimicrobial deterrent
preventive strategy. These include infusion therapy teams, use (through the effect of silver ions). They have been shown to
of barrier precautions during catheter insertion, cutaneous lower the risk of catheter colonisation and CRBSI in critically ill
antimicrobials and antiseptics, site of catheter insertion, patients.X'.JI The anti-infective effect is short-lived, however, as
tunnelling of eves, silver-chelated subcutaneous collagen the collagen to which the silver ions are chelated is
cuffs, antiseptic hubs, catheter-site dressings and the use of biodegradable. Other drawbacks include cost and the need for
antimicrobial impregnated catheters. specialised training.
Infusion therapy team Antiseptic hubs
The presence of an experienced infusion therapy team whose These have been designed to protect against hub colonisation.
task is to insert and maintain catheters has been shown to A fourfold decrease in catheter-related sepsis has been
decrease the rate of eRBSI up to eightfold and limit overall demonstrated with their use.:J9 A major limitation, however, is
costs.J1.J::! Similarly, strict adherence to peotocals for catheter that protection is only conferred against organism migration
insertion in the intensive care unit (lCU) and theatre are also along the internal surface of the catheter. They do not protect
beneficial in decreasing the rates of CRI. against the migration of skin organisms along the external
surface.
Maximum sterile barriers
Dressings
Careful hand washing together with the use of sterile gloves, a
mask. gown and cap and a large drape have been associated There has been ongoing debate concerning the best method of
with a greater than sixfold decrease in eve-related sepsi? catheter dressing. This has essentially revolved around the
and a fourfold decrease in the rate of bacteraemia related to relative merit of gauze and tape dressings versus transparent
pulmonary artery catheters." The use of this practice cannot be films. In a meta-analysis of catheter dressing regimens, eves
over-emphasised. on which a transparent dressing was used were assoriated with
a significantly higher incidence of catheter tip colonisation but
Cutaneous antimicrobials and antiseptics a non-significant increase in CRBSI..jD
Given the important role of cutaneous microflora in the The preference in our unit is an adhesive gauze dressing
pathogenesis of catheter-related infections, measures to reduce with a central non-adherent pad.
cutaneous colonisation of the insertion site are of vital
importance. Antimicrobial coating of catheters
For skin decontamination before catheter insertion in a three- In recent years, antimicrobial substances have been effectively
group trial.il comparing the efficacy of treatment, 2% bonded to catheters, especially those designed for short-term
ch10rhexidine gluconate was associated with a fourfold use. Two coated cves are currently available, a
decrease in CRBSI as compared with 10% povidone-iodine and chlorhexidine/ silver sulphadiazine catheter and a
70% alcohoL The use of PNB ointment (polymixin-neomycin- minocycline/rifampicin catheter. Several studies have shown
badtradn) at the skin entry site has been associated with a potential benefits of such catheters in terms of reduction of
lower rate of CRBS!; however, the overall protective effect is catheter colonisation as well as CRBSLuo,.u-c
offset by a higher risk of fungal colonisation and infecti.on.l3 A potential drawback of the chIorhexidine/silver
It is the practice in our unit to use a chlorhexidine gluconate- sulphadiazine catheter, however, is that the coating is applied
containing solution for skin preparation. only to the external surfaces and does not protect against
endoluminal colonisation as a result of hub contamination. The
Tunnelling of evCs minocycline / rifampicin catheter is coated on both the external
lIB This involves placing the proximal segment of the catheter and internal surfaces and may therefore be more effective."
One of the concerns about the use of antimicrobial-
under the skin at a distance from the point of entry to the vein.
impregnated catheters relates to the possible development of
A lower rate of CRBSI has been reported in one study in
antimicrobial resistance, and where they are used continued
critically ill patients.J6 More data are required to support this
observation. surveillance for resistance is required.
October 1999. Vol. 15. No. 2 SAJCC
ARTICLES
TREATMENT PRINCIPLES OF CATHETER- Central venous catheters
RELATED INFECnON
cves account for an estimated 90% of all CRBSI. on-
Treatment depends on the stage of infection and the pathogen. tunnelled (percutaneously) inserted CVCS are the most
As a general rule if CRBSI is suspected the catheter must be
l
commonly used central catheters. A host of risk factors for
removed and replaced only if necessary. Most of the infectious evC-related infections have been reported, induding duration
complications are sell-limited and resolve after removal of the of catheterisation,. location of the catheter (the internal jugular
catheter. having a higher rate of CRI than the subclavian vein), the
Indications for antibiotic therapy include persistent sepsis presence of sepsis, type of dressing, multi-lumen catheters
despite catheter removal, evidence of septic thrombosis of the (increased frequency of manipulation), less stringent barrier
great veins, clinical or echocardiograpruc evidence of precautions during placement, experience of personnel
endocarditis, metastatic foci of infection.. underlying valvular inserting the device, and the administration of parenteral
heart disease (especially prosthetic valves), and an underlying nutrition.
immunosuppressed state. The duration of evc use remains controversial. Despite this,
In terms of specific pathogens and CRBSI, S. aUTellS and however, no catheter should be left in place longer than
Candida species require special mention. In the setting of absolutely necessary. ThE:' duration of catheterisation has been
shown to be a risk factor for infection in several studies!C·S!; and
uncomplicated S. Qureus eRBSI, the cathe~er should be
removed and 2 weeks of parenteral antibiotics given. There is a scheduled replacement remains widely practised in most ICUs.
high relapse rate if these are given for a shorter time.e.~ In a recently performed study in mainland Britain, where 165
ICUs were surveyed,>6 catheters were routinely replaced, the
Systemic antifungal therapy (together with removal of the
mean time being 6.5 days.
catheter) should be given in all cases of catheter-related
candidaemia in view of the potentially significant sequelae. 11 We have recently completed and analysed a evc study in
Amphotericin B or fluconazole (except for fluconazole-resistant the multidisciplinary lCV at Johannesburg Hospital. The study
organisms such as Candida glabrata and C. krllsei) should be was a prospective randomised double-blind study which
commenced. Fluconazole 400 mg daily for at least 14 days has entailed comparison of a 14-day placement of standard triple-
lumen versus antimicrobial-impregnated (chlorhexidinelsilver
been shown to be as effective as amphotericin B 0.5 mg/kg/d
sulphadiazine) cves on the rates of CRI. Our aim was to
for 14 daysl with fluconazole being less toxic.-li
determine whether we could safely increase the duration of
insertion time from 7 days to 14 days and the influence of the
SPECIFIC CATHETER TYPES AND INFECT10 antimicrobial-impregnated catheter on the incidence of CRI.
One hundred and eighteen critically ill patients were
Short peripheral intravenous catheters
included in the study, which spanned 3-1951.5 catheter hours (1
These remain the most commonly used intravascuJar devices. 456 catheter days). Sixty-two patients received a standard
There is a significant risk of contamination 72 hours after catheter and 56 an antimicrobial·impregnated catheter.
insertion.fi The insertion site should be an upper extremity or Eighteen of the patients developed a CRBSI, 1 of whom died,
the external jugular vein. There is a greater risk of infection and 5 patients demonstrated catheter colonisation. This rate of
with lower extremity sites and "vith cutdowns. CRBSI compares favourably with those previously reported, in
which many of the catheters were in place for shorter periods
Peripheral arterial catheters of time than in our study.lU9
Peripheral arterial catheters are associated with less infection The most frequent source of infection was the skin.. followed
than pulmonary artery catheters (PACsl, CVCs and short by hub and infusate contamination and lastly haematogenous
peripheral catheters.~ This may be explained by high arterial seeding. The source; and organisms were identified with the
flow around the catheter, which probably decreases the aid of restriction-fragment length DNA subtyping.
adherence of micro-organisms.sl The Centers for Disease We were unable to show any difference in CRJ rates behveen
Control and Prevention guideline u suggests that replacement the two types of catheters in the study. Most importantly we
of catheters and relocation of insertion sites need take place no were able to condude that standard cves can safely be left in
more frequently than every 4 days. place for 14 days (with stringent infection control measures).
It is our unit policy to keep peripheral arterial catheters in Parenteral nutrition was not noted to be a risk factor for
place for up to 30 days prior to replacement and relocation, catheter sepsis, and neither was the site of insertion (internal
unless otherwise indicated. jugular vein versus subclavian vein).
On the basis of the results of this study, it is now our practice
to keep standard cves in place for 14 days unless there is an
ARTICLES
Peripherally inserted central venous catheters
Table ID. Protocol for inse.rt:ion of central venous catheters (PICes)
• Oean the skin around the insertion site over a wide area by
rubbing for 2 minutes with sterile gauze or rottonwool PICCs provide an alternative to subclavian or jugular vein
soaked in a ch.Iorhexidine gIuconate-containing solution. catheterisation and are inserted into the superior vena cava or
Sterile gloves must be worn.. right atrium \ria the cephalic and basilar veins of the
• The doctor,. wearing a mask and Gip, scrubs up (using a antecubital fossa. Compared with other cves they are
chImhexidine gluconate-rontaining scrub solution) and then associated with few mechanical complications, an apparent
dons a sterile gown and gloves.
lower rate of infectionl',oll and decreased cost. The length of
• 1he doctor then deans the area again and drapes widely to
time that these catheters can be left in place safely has not yet
include the patienrs head, neck. chest,. limbs and torso down
to the pelvis. Only the portion necessary for catheter insertion been determined, although they have been used successfully
should be left exposed. for extended periods.
• The 'flush' (heparin 1 (XX) ill in 19 ml sterile saline) is drawn
up avoiding any contamination by the doctor after cleansing G uidewire exchanges
of the stopper on the heparin container. The doctor draws up
the 'flush' with a sterile syringe and needle, while the A recent meta·analysis of evc replacement strategies revealed
assistant holds the vials. that guidewire exchanges were associated with greater risk of
• Once the line has been inserted, a sterile piece of gauze CRI but fewer mechanical complications than new-site
soaked in a chlorhexidirle gluconate-containing solution is replacement.51 If guidewire exchange is used. metirulous
applied over the insertion site and adjacent area for aseptic technique is necessary. This procedure should not be
approximately 30 seconds. perfonned in the setting of confirmed or clinically suspected
• The area is then dried with sterile gauze and an adhesive
sepsis. In our unit we do not practice guidewire exchanges.
gauze dressing with a central non-adherent pad applied.
• The dressings are changed daily and the insertion site
inspected and cleaned in a sterile manner. Cleaning includes AOOITIONAL RECOMMENDATIONS TO LIMIT
removal of old blood, dots, exudates and crusts and the INFEcrION
application of a chIomexidine gluconate-soa.ked piece of
sterile gauze to the insertion site for approximately 30 On the basis of the results of our study, previous guidelines13
seconds, before drying and dressing the area and the cumulative anecdotal experience in our unit, both
• Any signs uf local infection (red. hot, swollen. painful, nursing and medical, we now have a dedicated policy
purulence) must be reported. regarding the insertion, maintenance and use of intravascular
devices. The basic principle revolves around strict adherence to
aseptic technique at all times. It is our present policy to change
indication for earlier removal. This practice goes hand-m-hand central venous and haemodialysis catheters after 14 days,
with a stringent protocol relating to aseptic insertion technique peripheral venous catheters after 3 days and arterial lines after
and care of the catheter. A modified fonn of this protocol 30 days, unless removal is indicated beforehand. Lines used for
appeiUS in Table ffi. the administration of blood products must be replaced. within
24 hours. [jpid-containing parenteral nutrition solutions
Pulmonary artery catheters should be completed within a 24-hour period. Parenteral
Varying rates of infection have been reported with PACs nutrition must be administered via a single dedicated port with
(Swan.(;anz catheters), but most are similar to CVCs. Where the administration line being replaced at 24-hour intervals
higher percentages have been reported, this has been attributed (performed as a sterile procedure). Administration sets such as
to the number of manipulations performed. The 'Hahds-Off those used. for the delivery of inotropes and antibiotics are
Catheter', which is endosed in a contamination·proof shield replaced at 72·hour intervals, or before if clinically indicated.
enabling the doctor to prepare, test and insert it without The day on which lines are changed should be dearly noted on
exposure to external contamination. has been associated with a the rcv chart
decrease in systemic infection.~ Most PACs are heparin- It is our policy to replace bridges and their attached lines,
bonded, which reduces catheter thrombosis and microbial transducers and continuous flush devices every 7 days. This is
m:I adherence." The current Centers for Disease Control and longer than the recommended %-hour interval,u but it is our
Prevention guideline recommends catheter replacement at least experience that provided there is strict adherence to aseptic
every 5 days. U It is our current practice to keep in PACs for up technique, the infection risk is not increased. Aseptic technique
to 7 days if necessary; by which time the patient &equently no also extends to care of ports and caps attached to intravasrular
longer requires this form of catheter. devices and includes the spraying of a chlomexidine gluconate-
containing solution following manipulations.
October 1999, Vol1S, 0.2 SAJCC
34..Mm DC. Ringer M. Alvando q. Prospective randomised trial of p m ~ 31ooho1
CONCLUSION and chknhexidine for p......."tion of infa1ions ~ with Q5ltral venous and IlI12rial
ca.theters. Lmat 1991; J38: 339-343.
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<J8..V3.
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