Central venous catheter-related infections: Pathogenesis, predictors, and prevention

ISSUES IN INFECTIOUS DISEASE

Central venous catheter-related infections: Pathogenesis, predictors, and prevention

B r e n d a H o p p e , MSN, RN, CCRN, Lake Charles, La.

INSTRUCTIONS TO CE ENROLLEES The closed-book, multiple-choice examination that follows this article is designed to test your understanding of the educational objectives listed below. To enroll in Single Topics, see the instructions at the end of this article.

EDUCATIONAL OBJECTIVES Based on the content of the article, the enrollee should be able to: 1. Describe the purpose and impact of central venous catheter (CVC) use on hospitalized patients. 2. Discuss the pathogenesis of CVC use. 3. Identify preventive measures in the use of CVC.

Central venous catheters are used widely for a variety of therapeutic purposes and have an increased incidence of infections related to their use, The purpose of this article is to address the issue of central venous catheter-related infections, including pathogenesis, predictors and diagnosis, and prevention, (HEART LUNG| 1995;24:333-9)

Copyright 9 1995 by Mosby-Year Book, Inc. 0147-9563/95/$3.00 + 0 2/2/65149

with a 10% to 20% fatality rate. 6 Nosocomial infections add substantially to the cost of hospitalization because they prolong length of stay by approximately 7 days, which increases costs approximately $6000. 6 This article will address the issue of CVC-related infections, including pathogenesis, predictors and diagnosis, and prevention. CVC-related infection has been defined in various terms by the Centers for Disease Control, researchers, and authors, but generally it includes any of the following conditions: a catheter colonized with more than 15 colony-forming units, according to the Maki technique, 7 with symptoms of sepsis (hyperthermia, hypothermia, or hypotension); purulent drainage at the catheter site with or without bacteremia; symptoms of sepsis with or without bacterernia, unrelated to infection at another site, in the presence of an indwelling CVC; and bacteremia, unrelated to in-

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Central venous catheters (CVCs) are used widely in hospitals for reliable access to the central circulation for purposes of fluid, drug, and nutrition administration, hemodynamic monitoring, and hemodialysis. 1 Potential for CVC-related infections and sepsis is ever present, 2 particularly in patients who are critically ill s The mortality rate for patients in intensive care units (ICU) nationwide is more than 25%? and nosocomial infections are a major cause of morbidity and death for these patients. 4 An estimated 50,000 to 100,000 cases of CVC-related infection occur each year in the United States, 5 From Lake Charles Memorial Hospital, Lake Charles. Reprint requests: Brenda Hoppe, MSN, Case Management Coordinator, Lake Charles Memorial Hospital, 1701 Oak Park Blvd., Lake Charles, LA 70601.

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fection at another site, in the presence of an indwelling CVC. s

PATHOGENESIS Several theories have been proposed delineating the source of the organisms that colonize an intravascular device in a given situation. These theories point to the patient's skin, a contaminated catheter hub, hematogenous seeding from a remote site of infection, or contaminated intravenous fluid. 5 The first potential source of infection is the patient's skin. Current research indicates that most eVe-related infections are caused by organisms that colonize the skin at the insertion site and migrate down the extraluminal surface of the catheter through the transcutaneous tract created by insertion of the device. 9' 10 This is supported by the data of investigators who found that organisms that normally colonize h u m a n skin also are found most often to colonize intravascular devices, n The theory of extraluminal migration of organisms is supported also by the concordance between organisms detected by culture of the skin at the insertion site and those found on intravascular catheters implicated in CVC-related infection.12, 13 The coagulase-negative staphylococci, particularly Staphylococcus epidermidis, are part of the normal skin flora. 14 S. epidermidis is the agent most frequently found to cause CVC-related infection.15, 16 It is thought by some researchers that the high proportion of infections caused by this organism is secondary to its ability to adhere to the exterior of the catheter and form a biofilm slime layer that is protective against phagocytosis and antibiotics.17, 18 In addition, eVe-related infections are frequently caused by Staphylococcus aureus, Micrococcus, Corynebacterium, and yeasts, particularly Candida, also commonly part of the skin flora.19-21 The second potential source of infection is a contaminated catheter hub. Results of several studies by Sitges-Serra e t a l . 22-24 have led to the " h u b hypothesis," which holds that a contaminated catheter hub is the most likely source of organisms causing eVe-related infection and resulting sepsis. Salzman et al. 25 found that more than half of eVe-related infections were preceded by or coincided with positive catheter hub cultures. When it is implicated in CVC-related infections, colonization of the hub frequently is associated with more severe infections. 26 Conversely, data

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from other research have implicated the catheter hub infrequently and do not support the " h u b hypothesis" as the primary cause of eVe-related infections.27, 28 The third potential source of infection is hematogenous seeding. By this mechanism intravascular devices may become colonized by hematogenous seeding from remote sites of infection. 12,29,3~ This occurs less frequently than colonization by organisms from the insertion site. 31 The fourth potential source of eVe-related infections is contamination of intravenous fluid. This mechanism rarely results in bacteremia a2 but has been implicated in cases of epidemic nosocomial infections.33 Organisms frequently implicated are Klebsiella, Enterobacter, Serratia, Pseudomonas, and

Citrobacter.5 PREDICTORS AND DIAGNOSIS Several intrinsic and extrinsic risk factors for infection have been delineated. Intrinsic to the patient system are the following predisposing factors that increase the chance of infection and sepsis: extremes of age, 3 impaired host defense mechanisms,34, a5 remote infections,36 severity ofillnessF increased length of hospitalization before catheter insertion, ~8 malnutrition, 3,39 and presence of other invasive lines. 4~ With the exception of malnutrition, most intrinsic risk factors cannot be modified but should be considered When assessing the probability of nosocomial infections. Deterioration in nutritional status is c o m m o n among critically ill patients 41 and frequently is assessed subjectively by estimation of loss of subcutaneous fat or muscle. Assessment should be based on objective data such as prealbumin level,42' 43 albumin level,44 and total lymphocyte count. 45A major goal of nutritional support is the prevention of infection by providing protein needed to sustain and rebuild the immune system.41 Nutritional deficits can occur within 5 or 6 days in a critically ill patient, 46 and should be anticipated and prevented if possible by early nutritional support. 47 Extrinsic or hospital-related risk factors for CVCrelated infection include admission to an ICU, 4' 5, 48 catheterization for more than 3 days,49, 5o and the skill of catheter inserter. 51, 52 Other extrinsic risk factors are multilumen catheters, 53-55 internal jugular vein insertion site, 26, 28, 56, 57 and infusion of total parenteral nutrition. 58-6~ General signs and symptoms of CVC-related

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infection are nonspecific and difficult to distinguish from other infections, particularly in ICU patients. 5 The diagnosis of CVC-related infection is made by use of clinical assessment, exclusion of other sources of infection, and cultures of blood or the catheter tip. Local inflammation of the catheter insertion site frequently is absent, 6~especially in patients with neutropenia. 35 When local inflammation is present, however, especially with purulent drainage, a high correlation exists between catheter colonization and CVC-related infection. 7, 61 A presumptive diagnosis of CVC-related infection can then be made.6, 21 Definitive diagnosis of CVC-related infection is made on the basis of fever or local inflammatory signs when the results from cultures of the catheter are positive, s Hnafiuk et al. 62 suggest that a number of infections are not identified because of loss of organism viability in specimen handling. Their data support the practice of bedside plating of catheter tips rather than transporting the catheter tip to the laboratory for plating. In the absence of documented catheter colonization, a diagnosis of CVC-related infection can be made if peripheral blood cultures are positive and if there are clinical signs of infection, s, 17, 63 In instances in which catheter removal for culture is impractical, Capdevila et al. 64 recommend simultaneously obtaining blood samples for culture from a peripheral site and through the suspected infected catheter. Their data revealed that a fourfold higher bacterial colony count in blood drawn through the catheter as compared with the peripheral sample was a sensitive and specific determination for catheter-related infection. Guider et al. 65 compared cultures of CVC tips and skin at insertion sites. They found positive skin cultures in all instances of colonized CVC tips, which led them to recommend site cultures as a noninvasive method for prediction of CVC colonization.

PREVENTION The preponderance of evidence indicates the transcutaneous tract is the major mode of colonization of intravascular catheters 5 and has tended to emphasize the importance of aseptic CVC insertion and care of the insertion site. Researchers also have given attention to the catheter hub. In a prospective randomized study of 343

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patients, a significant reduction in CVC-related infections was found in the group in which maximal sterile barrier precautions were used during catheter insertion, including mask, cap, sterile gloves, gown, and large patient drape. 66 Skill of the physician inserting the device was an important factor in infection rate in a review of 169 catheters. 51 Data from Maki et al. ~1 indicated that skin preparation with chlorhexidine compared with povidone-iodine and alcohol, reduced infections significantly. It has been well documented that dwell time of catheters in situ results in increased risk of CVC-related infection.15, 49, 67 It is prudent to minimize catheter dwell time when possible; however, other issues of therapeutics and patient safety are considered in making this decision. Cobb et al. 6s, in their trial of scheduled catheter replacement in 160 subjects, recommended the placement of CVCs u n d e r optimal aseptic procedures. Catheters should then remain in place until there is a clinical indication for change to a new site, such as fever without a known source or a catheter malfunction. In their study they found that routine replacement of CVCs every 3 days as has been advocated did not prevent infection. Catheter exchanges over a guidewire increased the risk of infection; this is attributable to innoculation of the new catheter by the guidewire. Insertion of replacement catheters at new sites increased the risk of mechanical complications such as pneumothorax, bleeding, and arrhythmia. 6s Norwood et al. 69 recommend aseptic insertion followed by indefinite catheter dwell time in the absence of absolute or relative indications for removal, such as positive blood culture, grossly infected insertion site, clinical suspicion of CVC-related sepsis, or others. Catheters placed during routine guidewire exchanges should be removed in the event of a positive culture of an intracutaneous segment obtained from the previous catheter. 69 Data from Olson et al. 7~and Hilton et al. 71 point to increased risk of infection with guidewire exchanges of catheters. In situations in which it is advantageous to avoid catheter replacement, attempts occasionally are made to treat CVC-related infections with the colonized catheter in place. Raad et al. 18and Guggenbichler et al. 72 have reported successful treatment of gram-positive infections without removal of the catheter, However, in experiments with in vitro treatment of CVCs contaminated with gram-negative rods, Penner et al. 7~ concluded that it is prob-

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ably not possible to successfully eliminate colonization of these organisms without removal of the CVC. Research on site care has centered on antimicrobial ointments and dressings. Studies on the use of antimicrobial ointment at the insertion site have resulted in varying recommendations. Data from Flowers et al. 13 indicated increased Candida infections were associated with polyantibiotic ointments. Levin et al. 74 found povidone-iodine ointment effective in reducing infections, whereas Prager and Silva6~ reported no benefit. Most research on CVC site dressings has compared transparent dressings with the gold standard of cotton gauze dressings. A meta-analysis of data from seven prospective randomized investigations of transparent dressings versus cotton gauze on CVC insertion sites reported by Hoffmann et al. 75 revealed a statistically significant increase in CVC-related infection rate with transparent dressings. Postulating that a moisture-permeable transparent dressing would reduce moisture accumulation and organism growth, Maki et al. 76 conducted a prospective randomized study of 442 Swan-Ganz catheters (American Edwards Laboratories, Santa Ana, Calif.). They compared a new transparent dressing having an improved moisture vapor transmission rate (OpSite IV 3000; Smith Nephew, Worcester, United Kingdom) with cotton gauze. No differences were found between the OpSite IV 3000 and cotton gauze treatment groups in rates of skin colonization and incidence of infection. A retrospective study of 302 central venous catheters also revealed no difference in infection rate between OpSite IV 3000 and cotton gauze. 77 The role of the catheter hub as an entry site for microorganisms prompted Halpin et al. 7s to investigate the potential benefit of incorporating the catheter hub in a betadine-impregnated connection shield. They found a significantly decreased incidence of eVe-related sepsis in a group that used the shields. A recent innovation that has been shown to decrease the incidence of infection is antimicrobiaMmpregnated catheters.5, 79, 8o Similarly, the addition of Vitacuff (Arrow Corp., Reading, Pa.), a silver-impregnated, tissue-barrier cuff attached to the CVC, has been found to significantly reduce infection rates, la, 27' 81' 82 Investigations of dressings with antimicrobial

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properties also have yielded lower infection rates.83, 84 RECOMMENDATIONS Much attention has been given to the problem of eVe-related infections by researchers. After examination of their findings, the following recommendations are offered to critical care practitioners: 1. Consider risks versus benefits before initiation and continuation of therapy with eVes. Change the catheter on suspicion of infection anc~ discontinue when compatible with therapeutic goals. Follow the guidelines of the Centers for Disease Control. 85 2. Use optimal sterile technique in catheter placement, including maximal barrier precautions and chlorhexidine site preparation. Follow aseptic procedures in site care, use of injection ports and stopcocks, intravenous tubing changes, pressure line manipulations, and blood withdrawal. Avoid the use of impermeable dressing materials. 3. Consider and attempt to modify risk factors for infection in development of the plan of care. For example, give extra attention to site care of jugular catheters. 4. Optimize nutritional status of patients. Early identification of patients with actual or potential nutritional deficiencies is the first step. Equally important is active repletion of nutrient stores through enteral feeding (preferably) and parenteral feeding (if necessary). Support efforts of the infection control department. Surveillance is basic to its effectiveness, which entails systematic collecting, recording, and analyzing of data on the incidence of infections in the institution. Critical care practitioners and managers can improve the efficiency of the infection control department through prompt notification of infections, cooperation in tracking those infections, and implementation of research-based recommendations for prevention. AREAS FOR FURTHER RESEARCH 1. What is the cost-effectiveness of newly developed products intended to reduce eVe-related infections, such as antibiotic-impregnated catheters? 2. How do infection rates vary among institutions? What are the factors influencing this variation?

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I t h a n k Ellen P u c k e r , RN, o f t h e I n f e c t i o n C o n t r o l Departm e r i t o f Lake C h a r l e s M e m o r i a l Hospital, Lake Charles, Louisiana, a n d Curtis Brady o f t h e I n f e c t i o n C o n t r o l Dep a r t m e n t o f East J e f f e r s o n G e n e r a l Hospital, Metairie, Louisiana, for their s u g g e s t i o n s in t h e p r e p a r a t i o n o f this m a n u script.

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CE TEST INSTRUCTIONS Test identification No. H0752 Contact hours/CERPS: 1.0 Passing score: 7 correct answers (70%)

Approved for AACN Category A Florida Content Code: 2501 Iowa Criteria: 1

This continuing education activity is administered and sponsored by Buchanan & Associates, which is accredited as a provider of Continuing Education in Nursing by the American Nurses Credentialing Center's Commission on Accreditation; California Board of Nursing Provider No. CEP9473; Florida Board of Nursing Provider No. 271 1004; and the Iowa Board of Nursing Provider No. 244. This test was written by Jean Buchanan, MS, RN. Single Topics. To receive CE credit for this test, mark your answers on the answer form that follows the test, complete the enrollment information, and submit it with the $9.00 processing fee (In U.S. dollars) to Buchanan & Associates. Answer forms must be postmarked by July 18, 1997. Within 3 weeks of receiving your test form, Buchanan & Associates will send a CE certificate.

1. Which is not a use for central venous catheters (CVC)? a. Hemodynamic monitoring b. Hemodialysis c. Nutrition d. Arterial monitoring 2. What is the mortality rate of CVC-related infections? a. 5% to 10% b. 10% to 20% c. 25% to 30% d. 30% to 40% 3. By how much does the length of stay increase with nosocomial infections? a. 1 to 2 days b. 3 to 4 days c. 5 to 6 days d. 7 days 4. Which is not a condition determining CVC-related infections?

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a.

Colonization of 15 or more colony-forming units and sepsis b. Purulent drainage at the catheter site c. Hypertension, altered mental states d. Symptoms of sepsis or bacteremia 5. The pathogenesis of CVC-related infections does not include: a. Patient's skin b. Contaminated hub c. Contaminated intravenous fluid d. Underlying medical condition 6. What is the most common organism found to cause CVC-related infection? a. Serratia b. Staphylococcus epidermidis c. Klebsiella d. Pseudomonas 7. What organism is identified with CVC-related infections due to intravenous fluid contamination?

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