Infection associated with catheters

Disadvantages include risks associated with catheter insertion, use, and care. Central venous access has a greater potential for infection. 

Vancomycin and teicoplanin display excellent activity against staphylococci and streptococci, but because of the wide availability of equally effective and less toxic drugs, they are second-line drugs in the treatment of most infections. As antistaphylococcal agents they are less effective than 3-lactam cephalosporin antibiotics, such as nafciUin and cefazoUn. They have attained much wider use in recent years as a consequence of the emergence of methicUlin-resistant S. aureus (MRSA) infections, in particular the growing importance of Staphylococcus epidermidis infections associated with the use of intravascular catheters and in patients with peritonitis who are on continuous ambulatory peritoneal dialysis. 

Silver has long been known to exhibit antibacterial properties, which may have been an unwitting advantage to those who could afford silver vessels and tableware. Silver sulfadiazine is a widely used and very effective bum ointment, and silver-treated catheters greatly reduces the rate of infection associated with their use. The element is not known to be essential, although trace amounts (total body burden) are accumulated, with blood levels typically below lOpgL-. ... 

Gosbell IB, Duggan D, Breust M, Mulholland K, Gottlieb T, Bradbury R. Infection associated with central venous catheters a prospective survey. Med J Aust 1995 162(4) 210-13. 

Reportedly, a bland soap handwash was ineffective in preventing transfer by hand of gram-negative bacteria to catheters following brief contact with a heavily contaminated patient source an alcohol hand rinse was generally effective. Other studies have compared the effectiveness of 10% povidone-iodine, 70% isopropanol, and 2% aqueous CHG for the prevention of infection associated with central venous and arterial catheters [5]. CHG resulted in the lowest incidence of local catheter-related infection (2.3% vs. 7.1% and 9.3% for isopropanol and povidone-iodine, respectively) and catheter-related bacteremia (0.5% vs. 2.3% and 2.6% for isopropanol and povidone-iodine, respectively [5]. 

Dimick JB, Pelz RK, Consunji R, Swoboda SM, Hendrix CW, Lipsett PA. Increased resource use associated with catheter-related bloodstream infection in the surgical intensive care unit. Arch Surg 2001 136 229-34. 

Chopra V, O Horo JC, Rogers MA, et al. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults a systematic review and meta-analysis. Infect Control Hosp Epidemiol September 2013 34(9) 908-18. 

Observational studies The use of chlorhexidine in bathing patients has been studied in an evaluation of the effects on the rates of infections associated with central venous catheters in patients in coronary care units [11 ]. On one 70-bedded unit all consecutive patients admitted during 9 months received daily baths with 2% chlorhexidine. Infections in central venous catheters were compared with infections before and after... 

Yahav D, Rozen-Zvi B, Gafter-Gvili A, Leibo-vici L, Gafter U, Paul M Antimicrobial lock solutions for the prevention of infections associated with intravascular catheters in patients undergoing hemodialysis systematic review and meta-analysis of randomized, controlled trials. Chn Infect Dis 2008 47 83-93. 

In its core interventions for BSI reduction, the CDC advocates patient education. Main components are (1) hand hygiene and basic infection control practices during catheter accessing process (e.g., aseptic technique, masks, hub disinfection), (2) access care at home, (3) role of and risks associated with catheters, and (4) knowing signs and symptoms of infection and when to notify the physician. Despite mixed results in other studies, Cheng et al. [10] described a 40% lower risk of hospitalization due to infection and a 51% mortality reduction in patients with chronic kidney disease who received a multidisciplinary education prior to dialysis onset. We conclude that patient education is a valuable tool in the prevention of CLABSIs. 

Other methods for ICP monitoring include Camino ICP monitors, which are positioned into the brain parenchyma, but do not transverse the hemisphere nearly to the degree that EVDs do, and are associated with a lower risk of intracerebral hemorrhage. The ICP is measured by a fiberoptic transducer at the tip of the cathe-ter. ° ICP monitors, however, are subject to inaccuracy over time, so-called drift, and thus may become less reliable after the first few days post-insertion. Epidural and subarachnoid bolts/catheters are the least invasive, placed external to or just within the dura, thereby carrying a much lower risk of hemorrhage and infection, but with unfortunately compromised accuracy. 

Complications associated with PD include mechanical problems related to the PD catheter, metabolic problems associated with the components of the dialysate fluid, damage to the peritoneal membrane, and infections (Table 23-10). Strategies to manage infectious complications of PD are discussed below. 

Evaluate the patient for complications associated with dialysis. Does the patient develop hypotension or cramps during hemodialysis Does the patient have symptoms consistent with peritonitis or a catheter infection ... 

Disruption of host defenses owing to intravenous catheters, indwelling Foley catheters, burns, trauma, surgery, and increased gastric pH (secondary to antacids, H2 blockers, and proton pump inhibitors) may place patients at higher risk for infection. Breaks in and entry into the skin provide a route for infection because the natural barrier of the skin is disrupted. Increased gastric pH can allow for bacterial overgrowth and has been associated with an increased risk of pneumonia.18... 

An indwelling catheter is commonly used in various health care settings, and is associated with UTIs. Bacteria may be introduced into the bladder via the catheter in several ways. These include direct infection introduction during catheterization (via colonization and subsequently traveling the length of the catheter through bacterial motility or capillary action). UTIs as a result of an indwelling catheter are common and occur at a rate of 5% per day of catheter presence.25... 

Amphotericin B is the mainstay of treatment of patients with severe endemic fungal infections. The conventional deoxycholate formulation of the drug can be associated with substantial infusion-related adverse effects (e.g., chills, fever, nausea, rigors, and in rare cases hypotension, flushing, respiratory difficulty, and arrhythmias). Pre-medication with low doses of hydrocortisone, acetaminophen, nonsteroidal anti-inflammatory agents, and meperidine is common to reduce acute infusion-related reactions. Venous irritation associated with the drug can also lead to thrombophlebitis, hence central venous catheters are the preferred route of administration in patients receiving more than a week of therapy. 

Parenteral nutrition can be a lifesaving therapy in patients with intestinal failure, but the oral or enteral route is preferred when providing nutrition support ( when the gut works, use it ). Compared with PN, enteral nutrition generally is associated with fewer infectious complications (e.g., pneumonia, intraabdominal abscess, and catheter-related infections) and potentially improved outcomes.1-3 However, if used in appropriate patients (i.e., patients with questionable intestinal function or when the intestine cannot be used), PN can be used safely and effectively and may improve nutrient delivery.4 Indications for PN are listed in Table 97-1.1... 

Central PN refers to the administration of PN via a large central vein, and the catheter tip must be positioned in the vena cava. Central PN allows the infusion of a highly concentrated, hypertonic nutrient admixture. The typical osmolarity of a central PN admixture is about 1500 to 2000 mOsm/L. Central veins have much higher blood flow, and the PN admixture is diluted rapidly on infusion, so phlebitis is usually not a concern. Patients who require PN administration for longer periods of time (greater than 7 days) should receive central PN. One limitation of central PN is the need for placement of a central venous catheter and an x-ray to confirm placement of the catheter tip. Central venous catheter placement may be associated with complications, including pneumothorax, arterial injury, air embolus, venous thrombosis, infection, chylothorax, and brachial plexus injury.1,20... 

The indications for pulmonary artery catheterization are controversial. Because there is a lack of a well-defined outcome of data associated with this procedure, its use is presently best reserved for complicated cases of shock not responding to conventional fluid and medication therapies. Complications related to catheter insertion, maintenance, and removal include damage to vessels and organs during insertion, arrhythmias, infections, and thromboembolic damage. 

Nosocomial UTI is the most common infection in hospitals and nursing homes and 80% is associated with the use of urethral catheters. An incidence of bacteriuria of 3-10%/day makes the duration of catheterization the most important risk factor for bacteriuria. Asymptomatic bacteriuria should not be treated. However, up to 30% of patients with catheter-associated bacteriuria will develop fevers or other symptoms of UTI. In long term catheterization Providencia stmrtii and Candida species are the most common responsible organisms. Exchange of the catheter under therapy is advised in chronic cases. 

An important reduction in gram-negative bacter-aemia was observed after introduction of selective gut decontamination in the neutropenic patient. The most prevalent bloodstream infection on a hematology ward nowadays is the S. epidermidis bacter-aemia associated with the use of intravenous central catheters. After prolonged neutropenia (e.g. after bone marrow transplantation) the patient is at risk for cytomegalovirus infection, candidemia and invasive aspergillosis. 

Side effects, such as headache and jaw pain, are observed, but the major drawbacks with epoprostenol therapy relate to its delivery. Epoprostenol has an extremely short half-life in the blood (2-3 min) and therefore must be administered by continuous intravenous infusion via a surgically implanted central vein catheter. This can lead to complications such as local infections, sepsis, or catheter-associated thrombosis. In addition, interruption of therapy due, for example, to pump failure can lead to a life-threatening rebound of symptoms. The compound itself is unstable at room temperature and must be stored in the refrigerator. Despite these severe drawbacks, i.v. epoprosenol remains a useful treatment for patients presenting with WHO class IV PAH. The problems with epoprostenol have led to the development of alternative agents. 

Biomaterials are materials foreign to the human body that are used in medicine to replace, support or restore body function. Applications range from central venous and urinary catheters to more complex devices such as prosthetic joints and heart valves. The risk of biomaterial centered infection (BCI) is a key factor limiting their use [1]. The incidence of this type of infections varies for each application for instance 4% for hip prostheses [2] and 10-20% for urinary catheters (see Table 1). In BCI microorganisms are present in close association with the biomaterial surface forming a so-called biofilm. Different species of microorganisms are found in BCI that are often commen-... 

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