Download Central Venous Catheter (CVC) Related Infections

Doncaster and Bassetlaw Renal Junior Doctors Handbook 2011
Haemodialysis Catheter-related Infections (CRIs)
1. Introduction:
Some haemodialysis patients rely on central venous catheters (CVCs) for their
dialysis treatment. CVCs are required when emergency haemodialysis treatment is
needed, or whilst patients are waiting for creation or maturation of their arteriovenous fistula (AVF) or graft (AVG). There are two types of CVCs used for
haemodialysis: non-tunnelled catheters which provide short-term access usually for
emergency haemodialysis and/ or plasma exchange, and tunnelled catheters that are
used as a medium- or long-term vascular access.
Thrombosis and infection are the two most common complications related to CVCs
use. Catheter-related infections (CRIs) are regarded as the most serious
complication of CVCs with a significant increase in morbidity and mortality, and
substantial cost implications.
CRIs are classified into local infections such as exit-site and tunnel infections, and
systemic infections referred to as catheter-related blood stream infections (CRBSI).
2. Prevention:
2.1 Minimise catheter use: Arterio-venous fistula is the preferred vascular
access for haemodialysis due to their better flow rates and lower risk of
dysfunction (thrombosis) and infection compared to catheters and grafts. All
patients should have definitive vascular access (AV fistula or graft) before
initiation of haemodialysis where possible. Patients who start haemodialysis
without definitive access should have this formed as a matter of urgency.
2.2 Limit duration of non-tunnelled catheters: Femoral catheters should be
removed after a maximum of 7 days. Jugular and subclavian catheters should
be removed after a maximum of 3 weeks. Where it is anticipated that dialysis
will be required for longer than this, a tunnelled CVC should be sited as soon
as is practicable.
2.3 Minimise risk of contamination:
 Follow sterile technique at the time of catheter insertion and every time the
catheter is accessed. Gowns, Hats and Masks must be worn for
catheter insertion.
 Haemodialysis CVCs should not be used for other venous access purposes
except in emergency situations.
2.4 Regular surveillance of catheter exit site using the catheter exit site visual
scores (Appendix 1).
3. Clinical manifestations:
Clinical manifestations of CRIs are dependent on whether the infection is localised
or systemic. It is important to remember that patients with chronic kidney disease
have impaired immunity and therefore may not mount the full inflammatory
response.
3.1 Exit-site infection:
 Redness or Pain around exit site
 purulent discharge at the exit site
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Doncaster and Bassetlaw Renal Junior Doctors Handbook 2011
 Fever or rigors may/ may not be present.
3.2 Tunnel infection (Tunnelled catheters only):
 Redness or pain extending >2cm from exit-site along the subcutaneous
tunnel.
 Purulent discharge at exit site +/- fluctuant collection along the
subcutaneous tunnel.
 Fever or rigors may be present.

3.3 Catheter-related blood stream infections (CRBSI): All or some of these signs
may be present:
 Fever with no other obvious source of infection.
 Rigors (especially during dialysis)
 Unexplained hypotension and/or the patient is unwell or acutely confused.
 Signs suggestive of exit-site infection is usually present in non-tunnelled
catheters but may be absent in patients with tunnelled catheters.
 Signs suggestive of deep seeding infections (Endocarditis, Osteomyelitis,
Septic arthritis,
4. Management:
4.1 General Measures:

Remember ABCDE approach in all unwell patients.

Examine the patient:
o Assess the catheter exit site for signs of infection using the visual
scores below in Appendix 1.
o Look for signs of systemic sepsis (low blood pressure, confusion,
poor peripheral perfusion, raised early warning score).
o Look for other source of infection (chest, urine, skin ulcers, etc.)
o Look for signs of metastatic infection (back pain, joints pain/
swelling, new murmurs)

Initial investigations:
o Obtain blood for FBC, U&Es, LFTs, CRP, and paired blood
culture (Three sets- One from each catheter lumen and one from a
peripheral vein) if signs of tunnel infection or CRBSI (Patients
with uncomplicated exit site infection and with no systemic signs,
do not require blood culture). Patients who develop rigors during
haemodialysis, one set of blood culture obtained from the dialysis
tubing by nursing staff is adequate. Repeat paired blood culture
should be performed if the patient spiked temperature after dialysis.
PLEASE REMEMBER WHEN OBTAINING BLOOD
CULTURES TO APPLY
ASEPTIC TECHNIQUE TO
AVOID
FLASE
POSITIVE
RESULTS
DUE
TO
CONTAMINATION, AND TO LABEL BC BOTTLES AND
REQUEST FORMS CORRECTLY INCLUDING WHERE
THE BLOOD WAS OBTAINED FROM (This will help the
microbiology lab. to relate the episode of bacteraemia to the
catheter)
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o Consider CXR, MSU, Ulcer swabs if present, etc.

Consider admission to ward 32 for IV anti-biotic treatment and
consideration of catheter removal if:
o The patient has signs of sepsis (hypotension, tachycardia,
tachyponea, confusion, temperature ≥ 38°C or ≤ 35°C). AND/ OR
o The patient has a tunnelled catheter with features of tunnel
infection and subcutaneous pus collection.

Send catheter tip for culture when removed.
4.2 Treatment:
Treatment of CRIs consists of antibiotic treatment with or without catheter
removal. Several factors are taken into account when deciding to remove or
salvage a catheter, and therefore discussion with senior medial staff and
microbiologist is recommended.
4.2.1 Indications for catheter removal:
Non-tunnelled catheters: Any of the following:
 Catheter has been in situ for ≥ 7days (femoral catheters), or ≥ 21 days
(Jugular or subclavian catheters) ,
 Pus is present at exit site,
 Patient has signs of systemic infection (Rigors, temperature ≥ 38°C with
no other obvious source of infection, hypotension, or patient is unwell).
 Microbiology confirmed exit site infection or CRBSI.
Tunnelled catheters: Any of the following
 Patient is haemodynamically unstable.
 Persistent pyrexia despite treatment with the appropriate antibiotics for
>48 hours.
 Tunnel infection with evidence of subcutaneous pus collection.
 Confirmed CRBSI with organisms which are difficult to eradicate
(Meticillin- sensitive Staphylococci aureus “MSSA”, MRSA, Gram-ve
organisms, Fungi).
Attempted salvage of tunnelled catheters infected with MSSA or a Gramve organism other than Pseudomonas aeruginosa can only be considered
if: 1st episode, the patient is responding to treatment, alternative vascular
access is difficult, and the decision is authorised by the patient’s
consultant.
 Evidence of seeding infections such as osteomyelitis, endocarditis, abscess
formation, etc.
 Persistent signs of exit site or tunnel infection despite a complete course of
antibiotic treatment.
 Relapse of CRI defined as positive exit site culture or positive blood
culture with the same organism within 2 weeks after stopping antibiotic
treatment.
 Recurrent CRI defined as episode CRI with the same organism more than
2 weeks after stopping antibiotic treatment.
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4.2.2 Antibiotic treatment:
Uncomplicated exit site infection (Tunnelled catheters only):
 Prescribe oral Flucloxacillin 500mg qds (Clarithromycin 500mg bd for
patients with Penicillin allergy) for 7 days.
 Adjust antibiotic treatment according to sensitivities.
 If symptoms persist despite 7 days on treatment with antibiotics to which
the organism is sensitive, the catheter has to be removed unless other
course of action is recommended by the patient’s consultant.
 Continue antibiotics for a maximum of 5 days after catheter removal
unless advised otherwise by the consultant microbiologist.
Tunnel infection:
 Admit patient to ward 32 for treatment with IV Flucloxacillin 1g qds
pending culture results, and for catheter removal.
 Adjust antibiotic according to sensitivity and continue for a total of 7 days
after catheter removal if blood culture was negative or yielded gram –ve
organism or Coagulase-negative staphylococci, and for 14 days if blood
culture yielded MSSA or MRSA.
Catheter-related blood stream infection (CRBSI):

Non-tunnelled catheters:
 Commence IV Flucloxacillin 1g qds after catheter removal pending
culture results.
 Consider adding Gentamicin IV 1mg/kg (max. 80 mg) if patient is
hypotensive or gram –ve bacteria is suspected
 Duration of treatment should be guided by the type of micro-organism
as per protocol for tunnelled catheters below.

Tunnelled catheters: Follow Flow chart- Appendix 2
5. Prescribing Vancomycin and Gentamicin:
5.1 Vancomycin:
An initial dose of 1g IV should be given during the last hour of dialysis, or
immediately if the patient is not dialysing that day. Subsequent doses are determined
by pre-dialysis Vancomycin levels (Refer to guidance on prescribing and monitoring
Vancomycin levels- Appendix 3).
Level
< 10
10-15
> 15
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Vancomycin dose
1g
0.5 g
None
Doncaster and Bassetlaw Renal Junior Doctors Handbook 2011
5.3 Gentamicin
Discuss indication with a senior medical staff. An initial loading dose of 1mg/kg
(max. 80 mg) IV at the end of dialysis should be given. Subsequent doses should be
1mg/kg (max. 80 mg) at the of each dialysis session if pre-dialysis gentamicin level is
< 2mg/l.
6. Catheter replacement:
6.1 Non-tunnelled catheters:





Assess indication for catheter replacement.
NEVER REPLACE SUPECTED INFECTED/ INFECTED CATHETER
OVER A GUIDWIRE.
Ideally, catheter replacement should be delayed until the patient is afebrile for
≥ 48 hours.
New venotomy site should be used especially if there was an exit site
infection.
If urgent haemodialysis treatment is required whilst the patient remains
febrile, an in/out femoral catheter approach should be adopted (Discuss with a
senior medical staff).
6.2 Tunnelled catheters:
 Catheter replacement should be deferred until the patient is afebrile for ≥
48hours after commencing treatment.
 New venotomy site should be used and new tunnel track should be created if
the patient had exit site infection.
 In patients with tunnel infection, a new anatomical site should be used for
catheter replacement.
 If urgent haemodialysis treatment is required whilst the patient remains
febrile, an in/out femoral catheter approach should be adopted (Discuss with a
senior medical staff).
CVC-related infections
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Doncaster and Bassetlaw Renal Junior Doctors Handbook 2011
Appendix 1- Visual scores for detection and management of CRIs
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Appendix 2: Flow chart for management of CRBSI in patients with tunnelled
haemodialysis catheter.
Appendix 3
DOCTORS GUIDE FOR PRESCRIBING INTRAVENOUS
VANCOMYCIN FOR HAEMODIALYSIS PATIENTS
DETERMINE LENGTH OF TREATMENT (Discuss with patient’s
consultant and/or microbiologist) AND PRESCRIBE VANCOMYCIN
ON JAC (only if inpatient), EMED, AND PATIENTS’S DRUG
CHART ON WARD 28
JAC (If inpatient)
1. Log into JAC
2. Click “Add order”
3. Type “Vancomycin”
and choose
“Vancomycin
injection during
dialysis “ from the
drop-down menu
4. Go to the next
screen and type “1”
in the “Dose” box
5. In the Frequency
box choose the
option which
reflects the patient’s
dialysis days from
the drop-down menu
6. Complete start date
and enter the
number of treatment
days in the “Stop
medication after”
box
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Emed
1. Log into emed
2. Go to current
medication
3. Click “Add drug”
4. Uncheck
“Indefinite” and
enter start and finish
dates
5. Type “Vancomycin”
in the Drug box
6. Choose “1g
injection” in the
Preparation box.
7. Choose “IV” in the
Route box
8. Choose “1 g” in the
Dose box
9. Choose “Variable as
advised” in the
Regime box
10. Tick the “HD” box
and press “OK”
Patient’s drug chart on
ward 28
First Vancomycin dose is 1g
Subsequent doses are
determined according to
Vancomycin level.
When Vancomycin level is
available, the dialysis nurses
will contact you to prescribe
Vancmycin on the patient’s
drug chart.
Level
Dose
<10
10-15
>15
1g
0.5 g
None