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Heatth Care-Associated lnfections Central Li ne-Associated TABLE 57. Mitigation of Risk Factors for Central Line-Associated Bloodstream lnfections Bloodstream I nfestions Modifiable (Extrinsic) lntervention Central line-associated bloodstream infections (CLABSIs), Risk Factor associated with all types of central venous catheters (CVCs), Prolonged Daily review of continued need for are the most preventable HCAI. In the United States, CVC catheterization CVC rates are 55% in ICU patients and 24o/,, in non-lCU patients. Discontinue as soon as practical Pathogens associated with CLABSIs include coagulase- Minimize the number of CVCs as Multiple CVCS negative staphylococci (20. s %), S. o ureus (12.3%), Enterococcus (increases risk 3.4-fold) much as practical faecalis (e.eZ), non-albicans Condido species (8.t%), K. Multilumen CVC Use a catheter with the minimum pneumoniae or oxytoca (7.9%\, Enterococcus faecium number of lumens needed (7o/.), and Candida albicans (0.s2). Antimicrobial resist- Use subclavian site when possible Femoralvein ance is a problem for many of these pathogens. CLABSI risk catheterization; Use ultrasonographic guidance for factors include prolonged hospitalization before catheteri- particularly in patients internal jugu lar catheter insertion with obesity zation, neutropenia, and reduced nurse-to-patient ratio in Remove femoralvein CVCs as soon the ICU. Additional risk factors (modifiable) are shown in as practical; relocate to another site Table 57. (e.g., subclavian, internal jugular vein)when possible

Central Li ne-Associated TABLE 57. Mitigation of Risk Factors for Central Line-Associated Bloodstream lnfections Bloodstream I nfestions Modifiable (Extrinsic) lntervention Central line-associated bloodstream infections (CLABSIs), Risk Factor associated with all types of central venous catheters (CVCs), Prolonged Daily review of continued need for are the most preventable HCAI. In the United States, CVC catheterization CVC rates are 55% in ICU patients and 24o/,, in non-lCU patients. Discontinue as soon as practical Pathogens associated with CLABSIs include coagulase- Minimize the number of CVCs as Multiple CVCS negative staphylococci (20. s %), S. o ureus (12.3%), Enterococcus (increases risk 3.4-fold) much as practical faecalis (e.eZ), non-albicans Condido species (8.t%), K. Multilumen CVC Use a catheter with the minimum pneumoniae or oxytoca (7.9%\, Enterococcus faecium number of lumens needed (7o/.), and Candida albicans (0.s2). Antimicrobial resist- Use subclavian site when possible Femoralvein ance is a problem for many of these pathogens. CLABSI risk catheterization; Use ultrasonographic guidance for factors include prolonged hospitalization before catheteri- particularly in patients internal jugu lar catheter insertion with obesity zation, neutropenia, and reduced nurse-to-patient ratio in Remove femoralvein CVCs as soon the ICU. Additional risk factors (modifiable) are shown in as practical; relocate to another site Table 57. (e.g., subclavian, internal jugular vein)when possible Diagnosis Heavy microbial Chlorhexidine skin antisepsis at colonization at i nseftion time of insertion CLABSI is suspected when a patient with a CVC has bacteremia site and catheter hub Ch lorhexidine-i mpregnated not resulting from infection at another site. Two sets of periph- dressing eral blood cultures (zo mL blood/set) should be obtained from Daily chlorhexidine bathing of different sites before starting antibiotics. Avoid blood cultures patients in ICU drawn directly from CVCs because they have a higher rate of Minimize catheter access false positivity; they may falsely identiSz a CLABSI and lead to unnecessary antibiotic therapy. Hand hygiene before manipulation of lV system; use aseptic technique for all lV access Treatment Use disinfection caps or disinfect Infected CVCs should be removed; this is particularly impor- catheter hub and needleless tant for S. aureus, P aeruginoso, and Candida species infec- connectors ("scrub the hub") before accessing tions. The duration of therapy for most cases of uncompli- cated non-S. aureus CLABSI is 7 to 14 days (Table 58). Lack of maximal sterile Follow CVC insertion bundle barriers for insertion S. oureus CLABSI is usually treated for at least 4 weeks; how- and breaks in aseptic ever, shorter:term therapy may be considered in select tech n iq ue patients who have immediate catheter removal with resolu- Emergent insertion When adherence to aseptic tion of fever and bacteremia within 72 hours of starting technique cannot be ensured, appropriate therapy and who have no implanted prosthetic replace CVC as soon as possible (at least within 48 hours)to a new site devices; no evidence of endocarditis by echocardiography (preferably transesophageal), of suppurative thrombophle- Total parenteral Consider other options for nutrition delivering nutrition when possible bitis, or of metastatic infection; and neither diabetes melli- tus nor immunosuppression. Bacteremia clearance should CVC = central venous catheter; lV = intravenous.

Diagnosis Heavy microbial Chlorhexidine skin antisepsis at colonization at i nseftion time of insertion CLABSI is suspected when a patient with a CVC has bacteremia site and catheter hub Ch lorhexidine-i mpregnated not resulting from infection at another site. Two sets of periph- dressing eral blood cultures (zo mL blood/set) should be obtained from Daily chlorhexidine bathing of different sites before starting antibiotics. Avoid blood cultures patients in ICU drawn directly from CVCs because they have a higher rate of Minimize catheter access false positivity; they may falsely identiSz a CLABSI and lead to unnecessary antibiotic therapy. Hand hygiene before manipulation of lV system; use aseptic technique for all lV access Treatment Use disinfection caps or disinfect Infected CVCs should be removed; this is particularly impor- catheter hub and needleless tant for S. aureus, P aeruginoso, and Candida species infec- connectors ("scrub the hub") before accessing tions. The duration of therapy for most cases of uncompli- cated non-S. aureus CLABSI is 7 to 14 days (Table 58). Lack of maximal sterile Follow CVC insertion bundle barriers for insertion S. oureus CLABSI is usually treated for at least 4 weeks; how- and breaks in aseptic ever, shorter:term therapy may be considered in select tech n iq ue patients who have immediate catheter removal with resolu- Emergent insertion When adherence to aseptic tion of fever and bacteremia within 72 hours of starting technique cannot be ensured, appropriate therapy and who have no implanted prosthetic replace CVC as soon as possible (at least within 48 hours)to a new site devices; no evidence of endocarditis by echocardiography (preferably transesophageal), of suppurative thrombophle- Total parenteral Consider other options for nutrition delivering nutrition when possible bitis, or of metastatic infection; and neither diabetes melli- tus nor immunosuppression. Bacteremia clearance should CVC = central venous catheter; lV = intravenous. be confirmed with follow-up blood cultures. If bacteremia persists after CVC removal and appropriate antimicrobial therapy, evaluation for a deeper source of infection, includ- drape covering patient), and optimal catheter site selec- ing endocarditis, should be performed. All patients with tion (subclavian site preferred, avoid femoral site). See candidemia should be evaluated by an ophthalmologist to Table 57 for further modifiable factors to prevent CLABSI. rule out the presence of candida endophthalmitis within 1to Insertion bundles, checklists, and staff education have 2 weeks. significantly reduced CLABSIs. If CLABSI rates remain high despite adherence to these strategies, patient chlor- Prevention hexidine bathing and antimicrobial-impregnated cathe- CVCs should be inserted only by experienced personnel ters (silver-sulfadiazine-chlorhexidine, minocycline- using the insertion bundle of hand hygiene, chlorhexidine rifampin) may be considered. Routine CVC exchange or skin antisepsis of the insertion site using recommended replacement or administration of systemic antimicrobial application methods and contact time, maximal barrier prophylaxis at time of insertion or during CVC use should precautions (mask, cap, gown, sterile gloves, large sterile be avoided.

be confirmed with follow-up blood cultures. If bacteremia persists after CVC removal and appropriate antimicrobial therapy, evaluation for a deeper source of infection, includ- drape covering patient), and optimal catheter site selec- ing endocarditis, should be performed. All patients with tion (subclavian site preferred, avoid femoral site). See candidemia should be evaluated by an ophthalmologist to Table 57 for further modifiable factors to prevent CLABSI. rule out the presence of candida endophthalmitis within 1to Insertion bundles, checklists, and staff education have 2 weeks. significantly reduced CLABSIs. If CLABSI rates remain high despite adherence to these strategies, patient chlor- Prevention hexidine bathing and antimicrobial-impregnated cathe- CVCs should be inserted only by experienced personnel ters (silver-sulfadiazine-chlorhexidine, minocycline- using the insertion bundle of hand hygiene, chlorhexidine rifampin) may be considered. Routine CVC exchange or skin antisepsis of the insertion site using recommended replacement or administration of systemic antimicrobial application methods and contact time, maximal barrier prophylaxis at time of insertion or during CVC use should precautions (mask, cap, gown, sterile gloves, large sterile be avoided. 84

Health Care-Associated lnfections TABLE 58. Management of CentralVenous Catheter- Bacteremia caused by methicillin sensitive S. aureus Related Bloodstream lnfection Based on Pathogen" (MSSA) should be treated intravenously with a penicillinase- Organism Treatment resistant semisynthetic penicillin (such as oxacillin) or first generation cephalosporin (such as cefazolin) at maximal Uncomplicatedb doses. Vancomycin should be avoided in patients with MSSA Coagulase-negative Remove catheter, anti microbial staphylococci therapy for 5-7 days who are not allergic to B-lactam antibiotics. Vancomycin is associated with higher rates of relapse and microbiologic fail- lf catheter is not removed, systemic antimicrobials and ure in the treatment of MSSA bacteremia. antimicrobial lock treatmenf For methicillin resistant S. aureus (MRSA) bacteremia, for 10-14 days vancomycin and daptomycin are the preferred antibiotics. Sta phyl ococcus aureus ( no Remove catheter, Vancomycin trough monitoring is no longer recommended for active malignancy or antimicrobials for 214 days severe MRSA infections. Instead, dosing and monitoring should immunosuppression) (usually 4 weeks) be guided by the area under the curve (AUC) to minimum Enterococcus species Remove catheter, inhibitory concentration (MIC) ratio (AUC/MIC), which pro- antimicrobials for 7 -14 days vides enhanced accuracy and safety. AUC guided dosing Gram-negative bacilli Remove catheter, antimicrobials for 7 -14 days requires pharmacist consultation and an AUC calculator. Patients with concomitant S. oureus pneumonia should not Candida species (no retinitis) Remove catheter, antifu ngal agent for 14 additionaldays receive daptomycin because it is inactivated by surfactant. The after first negative blood clinical and microbiologic response (clearance of bacteremia) culture determines whether to continue vancomycin or change to dap Complicated tomycin when the MRSA isolate has a vancomycin minimum Suppurative Remove catheter, inhibitory concentration of <2 pglmL. Persistent bacteremia thrombophlebitis, antimicrobials for 4-6 weeks may be the result of slow bactericidal activity of vancomycin, endocard itis, osteomyelitis, (6-8 weeks for osteomyelitis) inadequate dosing, poor tissue penetration, or inadequate other site of metastatic or deep-seated infection source control. Higher-dose daptomycin (g-tO mg/kg/d) is sometimes used if bacteremia persists despite adequate source "Short-term catheters. control. Vancomycin should not be used when the isolate has a t'Bloodstream infection and fever resolve in 72hours, no intravascular hardware, no endocarditis or suppurative thrombophlebitis. minimum inhibitory concentration greater than 2 trig/ml; dap- tomycin is an acceptable alternative if the isolate is susceptible. 'Antimicrobial solution (such as vancomycin) instilled into the lumen of a catheter and removed after a specified period of time. The median time to clearance of MRSA bacteremia is 7 to 9 days. Uncomplicated infection should be treated with intrave- nous antibiotics for 2 weeks. Bacteremia that persists beyond KEY POIl{TS 72 hours of starting appropriate antibiotic treatment suggests . A central line-associated bloodstream infection should a complicated S. aureus infection and requires additional be suspected when a patient with a central venous cath- evaluation and a longer course of antibiotics (4-6 weeks). eter has bacteremia not resulting from infection at Management of persistent MSSA and MRSA bacteremia also another site. includes a thorough search for and removal of all foci of infec- o The duration of therapy for most cases of uncomplicated tion, including surgical debridement of infected wounds and non- Stoph Alococcus aureus central line -associated abscess drainage. A new focus of infection may develop with bloodstream infection is 7 to 14 days, although S. oureus persistent bacteremia and should always be considered in the infection is usually treated for at least 4 weeks. evaluation of persistent bacteremia. Deep seated infections (endocarditis, embolic phenomena, or vertebral osteomyelitis) require a longer course of antibiotics (4-6 weeks). Staphylococcus au reus Bacterem ia S. aureus is a leading cause of hospital acquired bacteremia. IEY POIl{I5 Endocarditis and vertebral diskitis or osteomyelitis are two o Bacteremia caused by methicillin-sensitive important complications of S. aureus bacteremia, although Staphylococcus aureus (MSSA) should be treated with they are less likelywhen the infection is hospital acquired. The an intravenous penicillinase resistant semisynthetic source of bacteremia and possible metastatic infection should penicillin or first-generation cephalosporin at maximal be determined, starting with a detailed history and examina doses; vancomycin should be avoided in patients who tion. All patients should undergo endocarditis evaluation with are not allergic to B-lactam antibiotics because it is echocardiography, preferably transesophageal. Source control associated with higher rates of relapse and microbio- with removal or drainage of any focus of infection is important logic failure in the treatment of MSSA bacteremia. for treatment success. Blood cultures should be repeated every (Continued) 2to 4 days until results are negative to document clearance.

TABLE 58. Management of CentralVenous Catheter- Bacteremia caused by methicillin sensitive S. aureus Related Bloodstream lnfection Based on Pathogen" (MSSA) should be treated intravenously with a penicillinase- Organism Treatment resistant semisynthetic penicillin (such as oxacillin) or first generation cephalosporin (such as cefazolin) at maximal Uncomplicatedb doses. Vancomycin should be avoided in patients with MSSA Coagulase-negative Remove catheter, anti microbial staphylococci therapy for 5-7 days who are not allergic to B-lactam antibiotics. Vancomycin is associated with higher rates of relapse and microbiologic fail- lf catheter is not removed, systemic antimicrobials and ure in the treatment of MSSA bacteremia. antimicrobial lock treatmenf For methicillin resistant S. aureus (MRSA) bacteremia, for 10-14 days vancomycin and daptomycin are the preferred antibiotics. Sta phyl ococcus aureus ( no Remove catheter, Vancomycin trough monitoring is no longer recommended for active malignancy or antimicrobials for 214 days severe MRSA infections. Instead, dosing and monitoring should immunosuppression) (usually 4 weeks) be guided by the area under the curve (AUC) to minimum Enterococcus species Remove catheter, inhibitory concentration (MIC) ratio (AUC/MIC), which pro- antimicrobials for 7 -14 days vides enhanced accuracy and safety. AUC guided dosing Gram-negative bacilli Remove catheter, antimicrobials for 7 -14 days requires pharmacist consultation and an AUC calculator. Patients with concomitant S. oureus pneumonia should not Candida species (no retinitis) Remove catheter, antifu ngal agent for 14 additionaldays receive daptomycin because it is inactivated by surfactant. The after first negative blood clinical and microbiologic response (clearance of bacteremia) culture determines whether to continue vancomycin or change to dap Complicated tomycin when the MRSA isolate has a vancomycin minimum Suppurative Remove catheter, inhibitory concentration of <2 pglmL. Persistent bacteremia thrombophlebitis, antimicrobials for 4-6 weeks may be the result of slow bactericidal activity of vancomycin, endocard itis, osteomyelitis, (6-8 weeks for osteomyelitis) inadequate dosing, poor tissue penetration, or inadequate other site of metastatic or deep-seated infection source control. Higher-dose daptomycin (g-tO mg/kg/d) is sometimes used if bacteremia persists despite adequate source "Short-term catheters. control. Vancomycin should not be used when the isolate has a t'Bloodstream infection and fever resolve in 72hours, no intravascular hardware, no endocarditis or suppurative thrombophlebitis. minimum inhibitory concentration greater than 2 trig/ml; dap- tomycin is an acceptable alternative if the isolate is susceptible. 'Antimicrobial solution (such as vancomycin) instilled into the lumen of a catheter and removed after a specified period of time. The median time to clearance of MRSA bacteremia is 7 to 9 days. Uncomplicated infection should be treated with intrave- nous antibiotics for 2 weeks. Bacteremia that persists beyond KEY POIl{TS 72 hours of starting appropriate antibiotic treatment suggests . A central line-associated bloodstream infection should a complicated S. aureus infection and requires additional be suspected when a patient with a central venous cath- evaluation and a longer course of antibiotics (4-6 weeks). eter has bacteremia not resulting from infection at Management of persistent MSSA and MRSA bacteremia also another site. includes a thorough search for and removal of all foci of infec- o The duration of therapy for most cases of uncomplicated tion, including surgical debridement of infected wounds and non- Stoph Alococcus aureus central line -associated abscess drainage. A new focus of infection may develop with bloodstream infection is 7 to 14 days, although S. oureus persistent bacteremia and should always be considered in the infection is usually treated for at least 4 weeks. evaluation of persistent bacteremia. Deep seated infections (endocarditis, embolic phenomena, or vertebral osteomyelitis) require a longer course of antibiotics (4-6 weeks). Staphylococcus au reus Bacterem ia S. aureus is a leading cause of hospital acquired bacteremia. IEY POIl{I5 Endocarditis and vertebral diskitis or osteomyelitis are two o Bacteremia caused by methicillin-sensitive important complications of S. aureus bacteremia, although Staphylococcus aureus (MSSA) should be treated with they are less likelywhen the infection is hospital acquired. The an intravenous penicillinase resistant semisynthetic source of bacteremia and possible metastatic infection should penicillin or first-generation cephalosporin at maximal be determined, starting with a detailed history and examina doses; vancomycin should be avoided in patients who tion. All patients should undergo endocarditis evaluation with are not allergic to B-lactam antibiotics because it is echocardiography, preferably transesophageal. Source control associated with higher rates of relapse and microbio- with removal or drainage of any focus of infection is important logic failure in the treatment of MSSA bacteremia. for treatment success. Blood cultures should be repeated every (Continued) 2to 4 days until results are negative to document clearance. 85