今日の臨床サポート

カテーテル関連血流感染(CRBSI)

著者: 久保健児 日本赤十字社和歌山医療センター 感染症内科部・救急科部

監修: 山本舜悟 大阪大学大学院医学系研究科 変革的感染制御システム開発学 寄付講座

著者校正済:2022/09/28
現在監修レビュー中
参考ガイドライン:
  1. 米国感染症学会:Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America.
患者向け説明資料

概要・推奨   

  1. CRBSIを疑っていない状況でのルーチンの血管内カテーテル先端培養は、行わないよう推奨される(推奨度3 O)
  1. 中心静脈カテーテル留置患者において、刺入部の所見が陰性であることを根拠に、CRBSIを否定しないよう推奨される(推奨度4 O)
  1. 敗血症・敗血症性ショックを伴わない患者で、CRBSIの事前確率が高くない場合は、血管内カテーテルをただちに抜去せずに血液培養の結果を待つことが推奨される(推奨度2 R)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
久保健児 : 特に申告事項無し[2022年]
監修:山本舜悟 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、血管内カテーテル先端培養、時間差(DTP)、血管内カテーテル抜去の記述について見直し、血管内カテーテル再留置に関する記述を追加した。実際の診療の流れを考慮し、全体の構成を見直すとともに、表を追加した。

病態・疫学・診察

疾患情報  
  1. カテーテル関連血流感染(catheter-related blood stream infection:CRBSI)とは、血管内カテーテルに関連して発生した血流感染を指す。血流感染とは、菌血症または真菌血症のことである。
  1. 代表的な原因微生物は、コアグラーゼ陰性ブドウ球菌(coagulase negative Staphylococcus:CNS)、黄色ブドウ球菌(S. aureus:MRSA )、カンジダ(Candida)、腸球菌(Enterococcus)、グラム陰性桿菌(大腸菌[E.coli]、エンテロバクター[Enterobacter]、クレブシエラ[Klebsiella] などの腸内細菌目、および緑膿菌[P. aeruginosa]など )である。
 
血流感染症とその合併症:
  1. CRBSIは、血管内カテーテルに関連して発生した血流感染(菌血症または真菌血症)であり、以下に示すような合併症を呈し得る。
 
CRBSIに関連した合併症(種類と特徴)

参考文献:
  1. Pearson ML. Guideline for prevention of intravascular device-related infections. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1996; 17:438-73.
  1. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 49:1.

出典

img1:  著者提供
 
 
 
診断基準  
  1. 血管内カテーテルに関連した感染症は、血流感染以外にも種類があり、2009年のIDSAガイドラインの診断基準が参考になる。その中でCRBSIは、「①末梢血からの血液培養結果が1セット以上陽性で、②感染の臨床症状(発熱、悪寒、低血圧など)があり、③血管内にカテーテル等のデバイスが留置中で、④その血管内デバイス以外に原因となる感染巣が明らかではない、菌血症または真菌血症。」と定義されている。
 
 

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文献 

C Brun-Buisson, F Abrouk, P Legrand, Y Huet, S Larabi, M Rapin
Diagnosis of central venous catheter-related sepsis. Critical level of quantitative tip cultures.
Arch Intern Med. 1987 May;147(5):873-7.
Abstract/Text The results of a simplified quantitative broth dilution quantitative tip culture (QTC) of 331 central venous catheters were compared with clinical data prospectively recorded in critically III patients to diagnose bacteremic or nonbacteremic catheter-related sepsis (CRS) (36 catheters), as opposed to contamination (42 catheters) or simple colonization from a distant septic focus (seven catheters). Thirty-five of 36 catheters associated with CRS yielded 10(3) colony-forming units per milliliter (CFU/mL) or more, and 3.8 X 10(2) Candida organisms grew from one. In contrast, 5 X 10(2) CFU/mL or less grew from 37 of 42 contaminated catheters. A QTC of 10(3) CFU/mL or more was 97.5% sensitive and 88% specific for the diagnosis of CRS. The QTC appeared especially useful for the diagnosis of CRS secondary to blood-borne seeding of catheters, or associated with coagulase-negative staphylococci.

PMID 3555377
Leonard A Mermel, Michael Allon, Emilio Bouza, Donald E Craven, Patricia Flynn, Naomi P O'Grady, Issam I Raad, Bart J A Rijnders, Robert J Sherertz, David K Warren
Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America.
Clin Infect Dis. 2009 Jul 1;49(1):1-45. doi: 10.1086/599376.
Abstract/Text
PMID 19489710
Nasia Safdar, Dennis G Maki
Inflammation at the insertion site is not predictive of catheter-related bloodstream infection with short-term, noncuffed central venous catheters.
Crit Care Med. 2002 Dec;30(12):2632-5. doi: 10.1097/01.CCM.0000037966.19604.25.
Abstract/Text BACKGROUND: Noncuffed, percutaneously inserted central venous catheters (CVCs) are widely used and cause at least 250,000 bloodstream infections (BSIs) in U.S. hospitals each year. We report a prospective study to determine whether inflammation at the insertion site is predictive of CVC-related BSI.
METHODS: Percutaneously inserted, noncuffed CVCs inserted into the subclavian, internal jugular, or femoral vein in two randomized trials during 1998-2000 were prospectively studied; most patients were in an intensive care unit. The condition of the insertion site was evaluated daily by research nurses, quantifying pain (0, 1), erythema (0-2), swelling (0, 1), and purulence (0, 1); the lowest possible overall inflammation score was 0 and the highest was 5. CVC-related BSI was confirmed in each case by demonstrating concordance between isolates from the catheter segment and from blood cultures by restriction-fragment DNA subtyping.
RESULTS: Among 1,263 CVCs prospectively studied, 333 (26.3%) were colonized at removal; of these, 35 catheters (2.7%) caused BSIs (5.9 per 1000 CVC days). BSIs were caused by coagulase-negative staphylococci (n = 27), enterococci (n = 4), enteric Gram-negative bacilli (n = 3), or (n = 1). Most insertion sites showed little or no inflammation at the time of removal. There were no significant differences among mean scores for each inflammatory variable examined or overall score among colonized CVCs (0.1 +/- 0.1), catheters causing CVC-related BSI (0.2 +/- 0.4), and noncolonized CVCs (0.1 +/- 0.1). The sensitivity of local inflammation for diagnosis of CVC-related BSI was dismal (0-3%).
CONCLUSION: Local inflammation is uncommon with infected CVCs, probably because most catheter-associated infections are currently caused by coagulase-negative staphylococci, a pathogen that incites little local or systemic inflammation. Whereas overt inflammation of the insertion site should raise suspicion of CVC-related BSI caused by or Gram-negative bacilli, especially if the patient has fever or other signs of sepsis, in general, site appearance cannot be relied on to identify catheter colonization or CVC-related BSI.

PMID 12483050
D J Cotton, V J Gill, D J Marshall, J Gress, M Thaler, P A Pizzo
Clinical features and therapeutic interventions in 17 cases of Bacillus bacteremia in an immunosuppressed patient population.
J Clin Microbiol. 1987 Apr;25(4):672-4.
Abstract/Text We retrospectively examined episodes of Bacillus bacteremia at a hospital with a large proportion of immunosuppressed patients. Seventeen episodes in 9.5 years met our case definition: two of two bottles of one blood culture or one of two bottles of two or more separately obtained blood cultures drawn on the same date. During the same period, there were 59 additional episodes in which a single blood culture had only one of two bottles positive for Bacillus species. Only 2 of 59 such episodes resulted in recurrent bacteremia (3%), as compared with 5 of 17 episodes meeting our case definition (29%) (P = 0.004). In four of five episodes complicated by recurrent bacteremia and in which appropriate antibiotics were used, a Hickman-Broviac catheter was in place and was not removed. We suggest that our case definition permits the differentiation of infection from contamination based on outcome and that patients with Bacillus bacteremia have chronic venous catheters removed as well as receive antibiotic treatment.

PMID 3571476
R Finkelstein, R Fusman, I Oren, I Kassis, N Hashman
Clinical and epidemiologic significance of coagulase-negative staphylococci bacteremia in a tertiary care university Israeli hospital.
Am J Infect Control. 2002 Feb;30(1):21-5.
Abstract/Text OBJECTIVES: To characterize the clinical significance of coagulase-negative staphylococci (CNS) bacteremia.
DESIGN: Prospective cohort study.
SETTING: A 900-bed hospital in Haifa, Israel, from November 1996 to March 1997.
RESULTS: Of 137 episodes of positive blood cultures for CNS, 41 (30%) were considered as true infection. Twenty-seven of 119 episodes associated with only 1 blood culture positive for CNS (23%) met the definition of infection as compared with 14 of 18 episodes (78%) associated with 2 or more blood cultures positive for CNS (P <.001). Methicillin resistance was significantly more frequent among Staphylococcus epidermidis isolates of episodes of true bacteremia than of episodes of contamination (15 of 22 [68%] vs. 11 of 33 [33%], respectively; P =.02). S hominis was isolated only in episodes considered as contamination (P =.01). It was estimated that CNS represents 24% of all nosocomial bloodstream pathogens. When CNS were isolated in the first 48 hours of hospitalization, an intravascular device was more frequently associated with episodes of true bacteremia than in those considered as contamination (7 of 7 [100%] vs. 10 of 57 [18%], respectively; P <.001). The mortality rate among patients with true CNS bacteremia was 16%.
CONCLUSION: Some laboratory parameters may help identify episodes of true CNS bacteremia, which appears to be more common than previously considered.

PMID 11852412
J Ruhe, A Menon, D Mushatt, P Dejace, R Hasbun
Non- epidermidis coagulase-negative staphylococcal bacteremia: clinical predictors of true bacteremia.
Eur J Clin Microbiol Infect Dis. 2004 Jun;23(6):495-8. doi: 10.1007/s10096-004-1134-4. Epub 2004 May 13.
Abstract/Text In order to explore the clinical significance and risk factors for true bacteremia caused by coagulase-negative staphylococci (CNS) other than Staphylococcus epidermidis, a retrospective cohort study of 160 patients with at least one blood culture positive for non- epidermidis CNS was performed. True bacteremia was diagnosed in 32 (20%) of the patients. On multivariate analysis the following factors were associated with true bacteremia: (i) more than one positive blood culture, (ii) presence of a central venous catheter, and (iii) methicillin resistance. The results of this study indicate that non- epidermidis CNS can cause significant bloodstream infections.

PMID 15141334
Issam Raad, Hend A Hanna, Badie Alakech, Ioannis Chatzinikolaou, Marcella M Johnson, Jeffrey Tarrand
Differential time to positivity: a useful method for diagnosing catheter-related bloodstream infections.
Ann Intern Med. 2004 Jan 6;140(1):18-25.
Abstract/Text BACKGROUND: Catheter-related bloodstream infections are associated with recognized morbidity and mortality, especially in critically ill patients. Accurate diagnosis of such infections results in proper management of patients and in reducing unnecessary removal of catheters.
OBJECTIVE: To evaluate differential time to positivity as a method for diagnosing catheter-related bacteremias caused by both short-term and long-term use of central venous catheters.
DESIGN: Prospective study design.
SETTING: M.D. Anderson Cancer Center, Houston, Texas, a tertiary care cancer center.
PATIENTS: All patients, between September 1999 and November 2000, who had the same organism isolated from blood cultures drawn simultaneously through the central venous catheter and the peripheral vein.
MEASUREMENTS: Time necessary for the blood cultures from the central venous catheter and the peripheral vein to become positive, as well as other relevant patient information.
RESULTS: 191 bloodstream infections with positive simultaneous central venous catheter and peripheral vein blood cultures were included. One hundred eight patients had catheter-related bacteremias, and 83 had non-catheter-related bacteremias. Catheter-related bacteremias were more frequently caused by staphylococci and less likely to be associated with underlying hematologic malignant conditions, neutropenia, and longer duration of hospitalization. As a diagnostic tool for catheter-related bacteremia (using a composite definition reference standard according to the Infectious Diseases Society of America guidelines), differential time to positivity of 120 minutes or more was associated with 81% sensitivity and 92% specificity for short-term catheters and 93% sensitivity and 75% specificity for long-term catheters.
CONCLUSION: Differential time to positivity of 120 minutes or more is highly sensitive and specific for catheter-related bacteremia in patients who have short- and long-term catheters.

PMID 14706968
B J Rijnders, C Verwaest, W E Peetermans, A Wilmer, S Vandecasteele, J Van Eldere, E Van Wijngaerden
Difference in time to positivity of hub-blood versus nonhub-blood cultures is not useful for the diagnosis of catheter-related bloodstream infection in critically ill patients.
Crit Care Med. 2001 Jul;29(7):1399-403.
Abstract/Text OBJECTIVE: The differential time to positivity (DTTP), defined as the difference in time necessary for the blood cultures taken by a peripheral puncture and through the catheter to become positive has been suggested to be useful in differentiating between catheter-related bloodstream infection (CR-BSI) and other sources of bacteremia. A DTTP of >120 mins was found predominantly in CR-BSI. The objective of our study was to investigate whether DTTP is useful for the diagnosis of CR-BSI in a medical-surgical intensive care unit.
DESIGN: Prospective clinical study.
SETTING: A 60-bed medical-surgical intensive care unit of a university hospital.
PATIENTS: One hundred consecutive adult patients from whom catheter(s) were to be removed for suspected CR-BSI were studied.
INTERVENTION: A blood culture (using aerobic and anaerobic culture bottles) was first taken from a new puncture site. Next, a blood culture was taken through every intravascular catheter in place.
MEASUREMENTS AND RESULTS: DTTP was calculated using the automated BacT/Alert blood culture system. Three patients had CR-BSI and nine patients had noncatheter-related bacteremia. Five patients had catheter-related sepsis without proven bacteremia. There was no significant difference in median DTTP between patients with CR-BSI and noncatheter-related bacteremia (2.1 hrs and 3.3 hrs, respectively; p =.6). Moreover, catheter-related sepsis in patients without bacteremia could not be detected using DTTP.
CONCLUSION: DTTP seems not to be useful for the diagnosis of CR-BSI in a medical-surgical intensive care unit.

PMID 11445695
Nasia Safdar, Jason P Fine, Dennis G Maki
Meta-analysis: methods for diagnosing intravascular device-related bloodstream infection.
Ann Intern Med. 2005 Mar 15;142(6):451-66.
Abstract/Text BACKGROUND: No consensus exists on the best methods for diagnosis of intravascular device (IVD)-related bloodstream infection.
PURPOSE: To identify the most accurate methods for diagnosis of IVD-related bloodstream infection.
DATA SOURCES: 51 English-language studies published from 1966 to 31 July 2004.
STUDY SELECTION: Studies of diagnostic tests for IVD-related bloodstream infection that described a reference standard and provided sufficient data to calculate sensitivity and specificity.
DATA EXTRACTION: Study quality, diagnostic tests examined, patient characteristics, prevalence, sensitivity, and specificity.
DATA SYNTHESIS: Pooled sensitivity and specificity were calculated for 8 diagnostic methods. Summary measures of accuracy were Q* (the upper leftmost point on the summary receiver-operating characteristic curve) and mean D (a log odds ratio). Subgroup analyses were used to assess heterogeneity. Overall, the most accurate test was paired quantitative blood culture (Q* = 0.94 [95% CI, 0.88 to 1.0]), followed by IVD-drawn quantitative [corrected] blood culture (Q* = 0.89 [CI, 0.79 to 0.99]) and the acridine orange leukocyte cytospin test (Q* = 0.89 [CI, 0.79 to 0.91]). The most accurate catheter segment culture test was quantitative culture (Q* = 0.87 [CI, 0.81 to 0.93]), followed by semi-quantitative culture (Q* = 0.84 [CI, 0.80 to 0.88]). Significant heterogeneity in pooled sensitivity and specificity was observed across all test categories.
LIMITATIONS: The limited number of studies of some of the diagnostic methods precludes precise estimates of accuracy.
CONCLUSIONS: Paired quantitative blood culture is the most accurate test for diagnosis of IVD-related bloodstream infection. However, most other methods studied showed acceptable sensitivity and specificity (both >0.75) and negative predictive value (>99%). The positive predictive value of all tests increased greatly with high pretest clinical probability. Catheters should not be cultured routinely but rather only if IVD-related bloodstream infection is suspected clinically.

PMID 15767623
Kristen C Sihler, Carol Chenoweth, Christy Zalewski, Wendy Wahl, Robert Hyzy, Lena M Napolitano
Catheter-related vs. catheter-associated blood stream infections in the intensive care unit: incidence, microbiology, and implications.
Surg Infect (Larchmt). 2010 Dec;11(6):529-34. doi: 10.1089/sur.2009.084.
Abstract/Text BACKGROUND: Catheter-associated blood stream infections (CA-BSI) and catheter-related blood stream infections (CR-BSIs) differ in the degree of proof required to show that the catheter is the cause of the infection. The U.S. Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN; formerly the National Nosocomial Infections Surveillance [NNIS] group) collects data regarding CA-BSI nationally. We hypothesized that there would be a significant difference in the rates reported according to the definition.
METHODS: Prospective surveillance of CA-BSI (defined as bacteremia with no extravascular source identified) is performed in all intensive care units (ICUs) at our institution and reported as the rate per 1,000 catheter-days. In January 2006, we initiated cultures of all catheter tips to evaluate for CR-BSI (defined as a catheter tip culture with >15 colony-forming units of the same microorganism(s) found in the blood culture) in the surgical, trauma-burn, and medical ICUs.
RESULTS: The CA-BSI rate across all ICUs for the 24-mo study period was 1.4/1,000 catheter-days. The CR-BSI rate was 0.4/1,000 catheter days, for a rate difference of 1.0 infections/1,000 catheter-days (p < 0.001 vs. CA-BSI). The pathogens identified in CA-BSI included many organisms that are not associated with catheter-related BSIs.
CONCLUSIONS: The CR-BSI rate is significantly lower than the CA-BSI rate. The organisms identified in CA-BSI surveillance often are not common in catheter-related infections. Reporting CR-BSI thus is a more accurate measure of complications of central venous catheter use, and this rate may be more sensitive to catheter-specific interventions designed to reduce rates of BSI in the ICU.

PMID 20969471
Miquel B Ekkelenkamp, Tjomme van der Bruggen, David A M C van de Vijver, Tom F W Wolfs, Marc J M Bonten
Bacteremic complications of intravascular catheters colonized with Staphylococcus aureus.
Clin Infect Dis. 2008 Jan 1;46(1):114-8. doi: 10.1086/524077.
Abstract/Text Patients with Staphylococcus aureus colonization of an intravascular catheter but without demonstrated bacteremia within 24 h after intravascular catheter removal had a 24% (12 of 49 patients) chance of subsequent S. aureus bacteremia if they did not receive immediate antistaphylococcal antibiotics. Treatment within 24 h after intravascular catheter removal led to a 83% reduction in the incidence of subsequent bacteremia.

PMID 18171225
K-H Park, S-H Kim, E H Song, E-Y Jang, E J Lee, Y P Chong, S-H Choi, S-O Lee, J H Woo, Y S Kim
Development of bacteraemia or fungaemia after removal of colonized central venous catheters in patients with negative concomitant blood cultures.
Clin Microbiol Infect. 2010 Jun;16(6):742-6. doi: 10.1111/j.1469-0691.2009.02926.x. Epub 2009 Sep 11.
Abstract/Text There are limited data on the clinical significance of positive central venous catheter (CVC) tip cultures associated with concomitant negative blood cultures performed at the time of CVC removal. A retrospective cohort study of all patients who yielded isolated positive CVC tip cultures was conducted in a tertiary-care hospital with 2200 beds during a 10-year period. All patients with isolated positive CVC tip cultures were observed for the development of subsequent bacteraemia or fungaemia between 2 and 28 days after CVC removal. An isolated positive CVC tip culture was defined as a case in which (i) a CVC tip culture yielded > or = 15 colonies using a semiquantitative culture method and (ii) at least two sets of blood samples revealed no organism at, or close to, the time of CVC removal (48 h before to 48 h after CVC removal). During the study period, 312 patients with isolated positive CVC cultures were enrolled. Eight (2.6%; 95% CI 1.2-5.1) of the 312 patients yielding isolated bacterial or fungal CVC tip cultures developed subsequent bloodstream infection (BSI) caused by the same species as that isolated from the tip culture (Staphylococcus aureus, 1: Enterococcus spp.; 2: Pseudomonas aeruginosa; and 3: Candida spp.). Among 125 patients from whose CVC tips the above four organisms were grown, seven (12.3%) of 57 patients who did not receive appropriate antibiotic therapy within 48 h after CVC removal subsequently developed BSI, but only one (1.5%) of 68 patients who did receive appropriate therapy developed BSI (OR 0.11, p 0.02).

PMID 19747217
Bart J Rijnders, Willy E Peetermans, Charles Verwaest, Alexander Wilmer, Eric Van Wijngaerden
Watchful waiting versus immediate catheter removal in ICU patients with suspected catheter-related infection: a randomized trial.
Intensive Care Med. 2004 Jun;30(6):1073-80. doi: 10.1007/s00134-004-2212-x. Epub 2004 Mar 4.
Abstract/Text OBJECTIVE: To find a subset of patients with suspected central venous catheter (CVC)-related infection (CRI) in whom CVC removal is not needed.
DESIGN: Randomized controlled trial.
SETTING: Thirty-three-bed ICU.
PATIENTS AND PARTICIPANTS: One hundred and forty four patients with suspected CRI in which a change of CVCs was planned were evaluated for inclusion.
INTERVENTIONS: Hemodynamically stable patients without proven bacteremia, no insertion site infection, and no intravascular foreign body were randomized to a standard-of-care group (SOC, all CVCs were changed as planned) or a watchful waiting group (WW, CVCs changed when bacteremia was subsequently confirmed or hemodynamic instability occurred).
MEASUREMENT AND RESULTS: Study groups were compared for incidence of CVC-related bloodstream infection (CR-BSI), resolution of fever, C-reactive protein, SOFA score, duration of ICU stay, and mortality. Of 144 patients with suspected CRI, 80 patients met exclusion criteria. Sixty-four were randomized. Forty-seven of 80 excluded patients were shown to be bacteremic, 20 (25%) of whom had a CR-BSI. Five of 64 (8%) included patients had a CR-BSI during their subsequent ICU stay (two in SOC and three in WW group). All 38 CVCs were changed in the SOC group versus 16 of 42 in the WW group (62% reduction, P<0.01). Resolution of fever, C-reactive protein, SOFA score, duration of ICU stay, and ICU mortality did not differ between SOC and WW group ( P>0.1 for all).
CONCLUSIONS: The use of a simple clinical algorithm permits a substantial decrease in the number of unnecessarily removed CVCs without increased morbidity.

PMID 14999442
Vance G Fowler, Anita Justice, Catrin Moore, Daniel K Benjamin, Christopher W Woods, Steven Campbell, L Barth Reller, G Ralph Corey, Nicholas P J Day, Sharon J Peacock
Risk factors for hematogenous complications of intravascular catheter-associated Staphylococcus aureus bacteremia.
Clin Infect Dis. 2005 Mar 1;40(5):695-703. doi: 10.1086/427806. Epub 2005 Feb 4.
Abstract/Text BACKGROUND: The role of both host and pathogen characteristics in hematogenous seeding following Staphylococcus aureus bacteremia is incompletely understood.
METHODS: Consecutive patients with intravascular catheter-associated Staphylococcus aureus bacteremia were prospectively recruited over a 91-month period. The corresponding bloodstream isolates were examined for the presence of 35 putative virulence determinants. Patient and bacterial characteristics associated with the development of hematogenous complications (HCs) (i.e., septic arthritis, vertebral osteomyelitis, or endocarditis) were defined.
RESULTS: HC occurred in 42 (13%) of 324 patients. Patient characteristics at diagnosis that were associated with HC included community onset (relative risk [RR], 2.25; 95% confidence interval [CI], 1.24-4.07; P=.007), increased symptom duration (odds ratio for each day, 1.14; 95% CI, 1.06-1.2; P<.001), presence of a long-term intravascular catheter or noncatheter prosthesis (RR, 4.02; 95% CI, 1.74-9.27; P<.001), hemodialysis dependence (RR, 3.84; 95% CI, 2.08-7.10; P<.001), and higher APACHE II score (P=.02). Bacterial characteristics included sea (RR, 2.03; 95% CI, 1.16-3.55; P=.011) and methicillin-resistant S. aureus (MRSA) (RR, 2.09; 95% CI, 1.19-3.67; P=.015). Subsequent failure to remove a catheter was also associated with HC (RR, 2.28; 95% CI, 1.22-4.27; P=.011). On multivariable analysis, symptom duration, hemodialysis dependence, presence of a long-term intravascular catheter or a noncatheter device, and infection with MRSA remained significantly associated with HC.
CONCLUSIONS: This investigation identifies 4 host- and pathogen-related risk factors for hematogenous bacterial seeding and reaffirms the importance of prompt catheter removal.

PMID 15714415
M Nucci, A L Colombo, F Silveira, R Richtmann, R Salomão, M L Branchini, N Spector
Risk factors for death in patients with candidemia.
Infect Control Hosp Epidemiol. 1998 Nov;19(11):846-50.
Abstract/Text OBJECTIVE: To analyze possible risk factors for death among patients with nosocomial candidemia. To identify risk factors for death in patients with candidemia, we analyzed demographic, clinical, and microbiological data.
SETTING: Six tertiary hospitals in Brazil.
PATIENTS: A cohort of 145 patients with candidemia.
DESIGN: 26 possible risk factors for death, including age, underlying disease, signs of deep-seated infection, neutropenia, number of positive blood cultures, removal of a central venous catheter, etiologic agent of the candidemia, susceptibility pattern of the isolate to amphotericin B, and antifungal treatment were evaluated by univariate stepwise logistic regression analysis.
RESULTS: Non-albicans species accounted for 63.4% of the candidemias. Risk factors for death in univariate analysis were older age, catheter retention, poor performance status, candidemia due to species other than Candida parapsilosis, hypotension, candidemia due to species other than Candida parapsilosis, and no antifungal treatment. In multivariate analysis, older age and nonremoval of a central venous catheter were the only factors associated with an increased risk for death.
CONCLUSIONS: These data suggest that patients with candidemia and a central venous catheter should have the catheter removed.

PMID 9831941
J B Atkinson, K Chamberlin, B A Boody
A prospective randomized trial of urokinase as an adjuvant in the treatment of proven Hickman catheter sepsis.
J Pediatr Surg. 1998 May;33(5):714-6.
Abstract/Text BACKGROUND/PURPOSE: Chronic vascular access catheters have become an important adjunct to the treatment of children with complex medical diseases, particularly malignancy. One of the major complications of chronic venous access devices is bacterial infection of the catheter site and bloodstream. Infusion of systemic antibiotics directly into the catheter has been the standard initial therapy with failure leading to catheter removal and replacement. It has been suggested by a number of investigators that the addition of urokinase as a thrombolytic agent to lyse any accumulated thrombus or fibrin would increase the successful catheter clearance by antibiotics. This study was designed as a prospective, randomized trial to compare treatment of children with positive catheter blood cultures with either antibiotics alone or in combination with urokinase 5,000 U boluses 12 and 24 hours after study entry.
METHODS: A total of 63 patients were entered in the study. Thirty-three received antibiotics and urokinase, and 30 received antibiotics alone.
RESULTS: A total of 45 catheters (71%) were cleared of infection and salvaged. Treatment failures leading to catheter removal occurred in 9 of 33 in the experimental group and 9 of 30 in the control population (no significant difference).
CONCLUSIONS: Urokinase could not be shown to act as an adjuvant in the clearance of infection from chronic central venous access catheters that had no evidence of clot or thrombus. This study required the performance of a dye study and excluded any patient with a known thrombus. This conclusion must therefore be limited to patients with no evidence of a clot or fibrin sheath.

PMID 9607475
M P La Quaglia, C Caldwell, A Lucas, M Corbally, G Heller, L Steinherz, A E Brown, J Groeger, P R Exelby
A prospective randomized double-blind trial of bolus urokinase in the treatment of established Hickman catheter sepsis in children.
J Pediatr Surg. 1994 Jun;29(6):742-5.
Abstract/Text BACKGROUND: The incidence of Hickman catheter sepsis is 10% to 40%, with resultant catheter loss in one third of infections. Urokinase causes dissolution of colonized intracatheter fibrin thrombi and may improve salvage.
STUDY AIMS: To evaluate the efficacy of 12-hour-interval slow-push urokinase infusion in addition to standard antibiotic therapy in the treatment of catheter sepsis in a pediatric oncology population.
METHODS: A two-arm randomized double-blind trial was undertaken, with catheter salvage rate as the end point. Patients with Hickman catheter sepsis were randomized after culture data confirmed the diagnosis. The study drug was administered by a slow intravenous push and given at 12-hour intervals for a total of four doses. The catheters were aspirated after 1 hour.
RESULTS AND CONCLUSIONS: The trial was stopped after 41 patients were entered into the study; 18 patients received a placebo, and 23 received the urokinase. In the placebo group, six catheters were lost; in the urokinase group, eight were lost. The rate of bacterial clearance was equivalent for both. After administration of the study drug, each group had three episodes of fever and chills; two of these resulted in hypotension (one in each group). The authors conclude that slow-push urokinase infusion during established Hickman catheter sepsis does not result in improved catheter salvage or bacterial clearance. Slow intravenous push infusions in this setting may provoke hemodynamic instability even after initiation of antibiotics.

PMID 8078010
Hilmar Wisplinghoff, Tammy Bischoff, Sandra M Tallent, Harald Seifert, Richard P Wenzel, Michael B Edmond
Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study.
Clin Infect Dis. 2004 Aug 1;39(3):309-17. doi: 10.1086/421946. Epub 2004 Jul 15.
Abstract/Text BACKGROUND: Nosocomial bloodstream infections (BSIs) are important causes of morbidity and mortality in the United States.
METHODS: Data from a nationwide, concurrent surveillance study (Surveillance and Control of Pathogens of Epidemiological Importance [SCOPE]) were used to examine the secular trends in the epidemiology and microbiology of nosocomial BSIs.
RESULTS: Our study detected 24,179 cases of nosocomial BSI in 49 US hospitals over a 7-year period from March 1995 through September 2002 (60 cases per 10,000 hospital admissions). Eighty-seven percent of BSIs were monomicrobial. Gram-positive organisms caused 65% of these BSIs, gram-negative organisms caused 25%, and fungi caused 9.5%. The crude mortality rate was 27%. The most-common organisms causing BSIs were coagulase-negative staphylococci (CoNS) (31% of isolates), Staphylococcus aureus (20%), enterococci (9%), and Candida species (9%). The mean interval between admission and infection was 13 days for infection with Escherichia coli, 16 days for S. aureus, 22 days for Candida species and Klebsiella species, 23 days for enterococci, and 26 days for Acinetobacter species. CoNS, Pseudomonas species, Enterobacter species, Serratia species, and Acinetobacter species were more likely to cause infections in patients in intensive care units (P<.001). In neutropenic patients, infections with Candida species, enterococci, and viridans group streptococci were significantly more common. The proportion of S. aureus isolates with methicillin resistance increased from 22% in 1995 to 57% in 2001 (P<.001, trend analysis). Vancomycin resistance was seen in 2% of Enterococcus faecalis isolates and in 60% of Enterococcus faecium isolates.
CONCLUSION: In this study, one of the largest multicenter studies performed to date, we found that the proportion of nosocomial BSIs due to antibiotic-resistant organisms is increasing in US hospitals.

PMID 15306996
Leonardo Lorente, Alejandro Jiménez, Melitón Santana, José Luis Iribarren, Juan José Jiménez, María M Martín, María L Mora
Microorganisms responsible for intravascular catheter-related bloodstream infection according to the catheter site.
Crit Care Med. 2007 Oct;35(10):2424-7. doi: 10.1097/01.CCM.0000284589.63641.B8.
Abstract/Text OBJECTIVE: Current guidelines for the management of intravascular catheter-related bloodstream infection (IVC-RBSI) recommend that empirical antimicrobial therapy must have activity against Gram-positive bacteria, but additional empirical coverage for Gram-negative bacteria may be needed for severely ill or immunocompromised patients, and antifungal therapy may be needed in some situations. We hypothesized that the spectrum of etiological microorganisms responsible for IVC-RBSI and, in relation to that, the choice of empirical antimicrobial therapy depends on the catheter insertion site. We therefore compared the proportion of IVC-RBSI due to Gram-negative bacteria and yeasts according to catheter site.
DESIGN: Prospective cohort study from May 1, 2000, to April 30, 2004.
SETTING: A 24-bed medical-surgical intensive care unit in a 650-bed tertiary hospital.
PATIENTS: Patients requiring a central venous or arterial catheter.
MEASUREMENTS AND MAIN RESULTS: We diagnosed 88 IVC-RBSIs, comprising 36 femoral catheter sites (26 femoral venous and ten femoral arterial sites) and 52 other catheter sites (36 jugular venous, 11 subclavian venous, and five radial arterial sites). No differences were found between IVC-RBSI of femoral vs. other catheter sites for age, sex, Acute Physiology and Chronic Health Evaluation II, diagnosis at admission, use of antimicrobials, the time the catheter responsible for IVC-RBSI had been in place, or the duration of intensive care unit stay before IVC-RBSI. The proportion of IVC-RBSIs due to Gram-negative bacteria was higher in femoral, 14 of 36 (38.89%), than in the other catheter sites, 4 of 52 (7.69%) (odds ratio, 7.48; 95% confidence interval, 2.19-25.54; p = .001). Also, the proportion of IVC-RBSIs due to yeasts was higher in femoral, 6 of 36 (16.67%), than in the other catheter sites, 1 of 52 (1.92%) (odds ratio, 10.20; 95% confidence interval, 1.17-88.85; p = .035).
CONCLUSIONS: Empirical antifungal therapy would seem to be indicated in patients with suspected femoral catheter-related bloodstream infection.

PMID 17717493
Issam Raad, Rawan Kassar, Dany Ghannam, Anne Marie Chaftari, Ray Hachem, Ying Jiang
Management of the catheter in documented catheter-related coagulase-negative staphylococcal bacteremia: remove or retain?
Clin Infect Dis. 2009 Oct 15;49(8):1187-94. doi: 10.1086/605694.
Abstract/Text BACKGROUND: Studies and guidelines recommending the retention of the central venous catheter (CVC) in patients with coagulase-negative staphylococcal bacteremia were based on loose definitions of bacteremia and/or did not evaluate the risk of recurrence. In this study, we used strict definitions of coagulase-negative staphylococcal bacteremia to determine the impact of CVC retention on response to and recurrence of infection.
METHODS: During the period from July 2005 through December 2007, we retrospectively evaluated 188 patients with coagulase-negative staphylococcal bacteremia. Bacteremia was defined using the strict Centers for Disease Control and Prevention criteria of 2 positive blood culture results. Catheter-related bacteremia was confirmed by differential quantitative blood cultures (>or=3:1) or time to positivity (>2 h).
RESULTS: Resolution of infection within 48 h after commencement of antimicrobial therapy was not influenced by CVC removal or exchange versus retention and occurred in 175 patients (93%). Multiple logistic regression analysis showed that infection was 7.0 times (95% confidence interval [CI], 1.5-32.6 times) more likely to fail to resolve in patients with an intensive care unit stay prior to infection ( P = .013 ) and 3.8 times (95% CI, 1.1-13.3 times) more likely to fail to resolve in patients who had other concurrent sites of infection (P = .041 ). Duration of therapy did not affect recurrence. Multiple logistic regression analysis revealed that patients with catheter retention were 6.6 times (95% CI, 1.8-23.9 times) more likely to have a recurrence than were those whose catheter was removed or exchanged (P = .004).
CONCLUSIONS: CVC retention does not have an impact on the resolution of coagulase-negative staphylococcal bacteremia but is a significant risk factor of recurrence.

PMID 19780661
Bart J Rijnders, Eric Van Wijngaerden, Stefaan J Vandecasteele, Marguerite Stas, Willy E Peetermans
Treatment of long-term intravascular catheter-related bacteraemia with antibiotic lock: randomized, placebo-controlled trial.
J Antimicrob Chemother. 2005 Jan;55(1):90-4. doi: 10.1093/jac/dkh488. Epub 2004 Dec 1.
Abstract/Text OBJECTIVES: The use of an antibiotic lock (AB-lock) for the treatment of catheter-related bloodstream infection (CRBSI) has been suggested, but randomized trials have never been performed.
METHODS: A randomized, blinded, multicentre trial was set up to compare an AB-lock-containing vancomycin for Gram-positive or ceftazidime for Gram-negative bacteria-with placebo, in addition to parenteral AB therapy. We included only CRBSI from a long-term intravascular device (LTID) whether tunnelled or totally implanted.
RESULTS: During 30 months, 174 patients with an LTID and bacteraemia were evaluated, of whom 85 had a CRBSI. Forty-six patients were included. Frequent reasons for exclusion were: catheter not vacant for >8-12 h/day for the AB-lock (n =10); yeast infection or mixed Gram-positive/negative infections (n =13); catheter removal preferred by the treating physician (n =7); and CRBSI <14 days after insertion or pocket/tunnel infection (n =10). Forty-four patients met the criteria for modified intention-to-treat analysis. The primary endpoint was failure to cure the CRBSI or relapse with the same strain. On study day 180 by Kaplan-Meier analysis, this occurred in 33% (seven of 21) in the AB-lock arm and in 57% (13 of 23) in the placebo arm (hazard ratio 0.55, P =0.10). A relapse with the same strain occurred in 9/23 with the placebo and 3/21 with the AB-lock (P =0.06).
CONCLUSION: Future studies should take into account the barriers to the use of AB-lock observed in this study. Most importantly, shorter lock dwell times and broader spectrum locks (e.g. antiseptic) should be investigated to target a larger patient population.

PMID 15574481
James Abraham, Craig Mansour, Emir Veledar, Bobby Khan, Stamatios Lerakis
Staphylococcus aureus bacteremia and endocarditis: the Grady Memorial Hospital experience with methicillin-sensitive S aureus and methicillin-resistant S aureus bacteremia.
Am Heart J. 2004 Mar;147(3):536-9. doi: 10.1016/j.ahj.2003.09.018.
Abstract/Text BACKGROUND: Staphylococcus aureus has become the leading cause of endocarditis in most published series, and nosocomial acquisition is becoming more frequent. Previous studies involved community acquired methicillin-sensitive S aureus (MSSA), but recently, methicillin-resistant S aureus(MRSA) infection has increased. This may reflect the growing presence of this microorganism in clinical practice. Few data exist comparing the relative rates of endocarditis with MSSA and MRSA bacteremia. The purpose of this study was to compare these rates in a bacteremic population referred for diagnostic echocardiography.
METHODS: Since July 1999, the demographic and clinical information of 104 consecutive patients with at least 2 blood cultures with positive results for S aureus who were referred for echocardiography to be evaluated for endocarditis at Grady Memorial Hospital (Atlanta, Ga) have been entered into a database. This database has further been restricted to patients who have undergone either a transesophageal echocardiogram or a transthoracic echocardiogram.
RESULTS: Of the 104 patients with S aureus bacteremia, 53 had an infection of MSSA and 51 had an infection of MRSA. There were 33 patients (31.7%) with echocardiographically confirmed endocarditis, 23 patients (43.4%) in the MSSA group versus 10 patients (19.6%) in the MRSA group (P <.009). Community-acquired MSSA bacteremia was the cause of most of the community-acquired S aureus endocarditis (20 patients [87%] vs 3 patients [30%], P =.004), and the nosocomial-acquired MRSA bacteremia was the cause of most of the nosocomial-acquired S aureus endocarditis (3 patients [13%] vs 7 patients [70%], P =.0001).
CONCLUSION: Our study confirms that S aureus bacteremia is associated with high rates of endocarditis. MSSA bacteremia is associated with higher rates of endocarditis than MRSA. Community MSSA is the cause of most of the community endocarditis, whereas nosocomial MRSA is the cause of most of the MRSA endocarditis. Patients with S aureus bacteremia should be aggressively evaluated for endocarditis.

PMID 14999206
V G Fowler, J Li, G R Corey, J Boley, K A Marr, A K Gopal, L K Kong, G Gottlieb, C L Donovan, D J Sexton, T Ryan
Role of echocardiography in evaluation of patients with Staphylococcus aureus bacteremia: experience in 103 patients.
J Am Coll Cardiol. 1997 Oct;30(4):1072-8.
Abstract/Text OBJECTIVES: The purpose of this prospective study was to examine the role of echocardiography in patients with Staphylococcus aureus bacteremia (SAB).
BACKGROUND: The reported incidence of infective endocarditis (IE) among patients with SAB varies widely. Distinguishing patients with uncomplicated bacteremia from those with IE is therapeutically and prognostically important, but often difficult.
METHODS: One hundred-three consecutive patients undergoing both transthoracic (TTE) echocardiography and transesophageal (TEE) echocardiography were prospectively evaluated. All patients presented with fever and > or = 1 positive blood culture and were followed up for 12 weeks.
RESULTS: Although predisposing heart disease was present in 42 patients (41%), clinical evidence of infective endocarditis (IE) was rare (7%). TTE revealed anatomic abnormalities in 33 patients, but vegetations in only 7 (7%), and was considered indeterminate in 19 (18%). TEE identified vegetations in 22 patients (aortic valve in 5, mitral valve in 9, tricuspid valve in 4, catheter in 2 and pacemaker in 2, abscesses in 2, valve perforation in 1 and new severe regurgitation in 1; 26 total [25%]). Using Duke criteria for the diagnosis of IE, definite IE was present in 26 patients (25%). Clinical findings and predisposing heart disease did not distinguish between patients with and without IE. The sensitivity of TTE for detecting IE was 32%, and the specificity was 100%. The addition of TEE increased the sensitivity to 100%, but resulted in one false positive result (specificity 99%). TEE detected evidence of IE in 19% of patients with a negative TTE and 21% of patients with an indeterminate TTE. At follow-up, cure of staphylococcal infection occurred in a similar percentage of patients with and without IE (77% and 75%, respectively). However, death due to sepsis was significantly more likely among patients with IE (4 of 26 [15%]) than among those without IE (2 of 77 [3%]) (p = 0.03).
CONCLUSIONS: Our results suggest that IE is common among patients admitted to the hospital with SAB and is associated with an increased risk of death due to sepsis. TEE is essential to establish the diagnosis and to detect associated complications. Therefore, the test should be considered part of the early evaluation of patients with SAB.

PMID 9316542
Abstract/Text OBJECTIVES: This study was conducted to determine the implications of negative findings on a transesophageal echocardiographic study in which neither a vegetation nor an abscess is identified in patients with clinically suspected infective endocarditis.
BACKGROUND: Echocardiography is the procedure of choice for evaluating suspected infective endocarditis in patients. Transesophageal echocardiography has been shown to be superior to transthoracic imaging. Although the importance of positive results or a diagnostic study is known, the significance of negative findings on a transesophageal study is not clear.
METHODS: All transesophageal echocardiographic studies performed over a 2-year period for suspected infective endocarditis were reviewed and the clinical course of patients with an initially negative study result was assessed to determine their final diagnosis.
RESULTS: Of the 105 patients identified, 65 had a negative transesophageal study result. In the majority of this group (56 of 65), an alternate diagnosis was made or there was no infective endocarditis on follow-up examination, or both. Of the remaining nine patients, four were treated for endocarditis without a definite diagnosis and five had infective endocarditis proved by either repeat transesophageal study (n = 3), pathologic findings (n = 1) or a diagnostic clinical course (n = 1). Gram-positive bacteremia and the presence of a prosthetic valve in the aortic position tended to be more common in the latter group.
CONCLUSIONS: A negative transesophageal study result reduces the likelihood that endocarditis is present. Repeat examination, however, should be considered in high risk patients, such as those with prosthetic valves or unexplained bacteremia, to avoid a missed diagnosis.

PMID 8417064
Abstract/Text Over the last two decades, the optimal duration of therapy for catheter-related Staphylococcus aureus bacteremia has become the subject of controversy. A review of the literature revealed an occasional association between relapse of the infection and a short course of therapy (less than 10 days of iv antibiotic therapy). From records kept between 1983 and 1989 at the University of Florida's affiliated hospitals, we identified 55 patients with catheter-related S. aureus bacteremia. Nine patients (16%) developed acute early complications (e.g., endocarditis or osteomyelitis) while receiving antibiotics. The results of multivariate analysis showed that an early complicated course was characterized by fever and/or bacteremia that persisted for greater than 3 days after catheter removal (P = .02). The remaining 46 patients were followed up for at least 3 months. During follow-up, three of the 18 patients treated for less than 10 days with iv antibiotics developed relapsing septicemia, whereas none of the 28 patients treated for a longer period developed this condition (P = .05). Fever and/or bacteremia that persists for greater than 3 days after catheter removal and initiation of antibiotic therapy suggests an acutely complicated course requiring prolonged treatment. The duration of iv antibiotic therapy in uncomplicated cases should not be less than 10 days but need not be greater than 2 weeks.

PMID 1571466
Nick Daneman, Mark Downing, Brandon M Zagorski
How long should peripherally inserted central catheterization be delayed in the context of recently documented bloodstream infection?
J Vasc Interv Radiol. 2012 Jan;23(1):123-5. doi: 10.1016/j.jvir.2011.09.024.
Abstract/Text The risk of relapsing bacteremia was assessed retrospectively among a cohort of 348 patients who underwent peripherally inserted central catheter (PICC) insertion within 6 weeks of a documented bacteremia. The overall risk of relapsing bacteremia was low (three of 348; 0.9%) when PICC insertion was performed in the context of a recent bloodstream infection. The relapse risk was higher when PICCs were inserted within 2 days (two of 31; 6.5%) versus at least 3 days (one of 317; 0.3%) after documentation of bacteremia (P = .02).

Copyright © 2012 SIR. Published by Elsevier Inc. All rights reserved.
PMID 22221476
Shunji Takakura, Naoko Fujihara, Takashi Saito, Terumi Kimoto, Yutaka Ito, Yoshitsugu Iinuma, Satoshi Ichiyama
Improved clinical outcome of patients with Candida bloodstream infections through direct consultation by infectious diseases physicians in a Japanese university hospital.
Infect Control Hosp Epidemiol. 2006 Sep;27(9):964-8. doi: 10.1086/504934. Epub 2006 Aug 14.
Abstract/Text OBJECTIVE: To examine whether intervention by infectious diseases physicians (IDPs) in the treatment decisions that emphasize adequate antifungal treatment and early removal of central venous catheter for patients with Candida bloodstream infection (BSI) improves prognosis.
DESIGN: Retrospective cohort study of patients with Candida BSI, comparing the prognosis of patients before and after the start of the intervention.
SETTING: A 1,240-bed, tertiary care university hospital.
PATIENTS: Forty patients with Candida BSI during a 2-year period, from January 2001 to December 2002, were included in the study. Twenty-three patients in the first year after the start of intervention by IDPs (intervention group) were compared with 17 patients in the first year before the start of the IDP intervention (baseline group).
INTERVENTIONS: In January 2002, a total of 5 IDPs at Kyoto University Hospital gave unsolicited recommendations on antifungal treatment and advised all physicians treating inpatients who had Candida BSI to remove the central venous catheter.
RESULTS: No significant difference was seen between the 2 groups in patients' clinical background, species, and fluconazole susceptibility of the causative organisms. The 30-day survival rate was significantly better in the intervention group (18 [78%] of 23 patients) than in the baseline group (7 [44%] of 16 patients; P=.04 by Fisher's exact test). More patients in the intervention group than in the baseline group received appropriate antifungal therapy (81% vs 50%) and had their central venous catheter removed at an appropriate time (95% vs 81%).
CONCLUSION: The introduction of an active system of IDP consultation for every case of Candida BSI in our hospital substantially improved patient outcomes.

PMID 16941324
V G Fowler, L L Sanders, D J Sexton, L Kong, K A Marr, A K Gopal, G Gottlieb, R S McClelland, G R Corey
Outcome of Staphylococcus aureus bacteremia according to compliance with recommendations of infectious diseases specialists: experience with 244 patients.
Clin Infect Dis. 1998 Sep;27(3):478-86.
Abstract/Text To determine whether recommendations of infectious diseases specialists affect outcome for patients, we evaluated 244 hospitalized patients with Staphylococcus aureus bacteremia. We offered our management recommendations to each patient's physicians and then assessed the clinical outcome for both patients for whom our consultative advice was followed and those for whom our advice was not heeded. All patients were followed up for 12 weeks after their first positive blood culture. Our management advice was followed for 112 patients (45.9%) and partially or completely ignored for 132 patients (54.1%). Patients for whom our recommendations were followed were more likely to be cured of their S. aureus infection and less likely to relapse (P < .01), despite having significantly more metastatic infections (P < .01) at the outset of therapy, than were those for whom our recommendations were not followed. Failure to follow recommendations to remove an infected intravascular device was the most important risk for treatment failure. After controlling for other factors, logistic regression analysis revealed that patients whose intravascular device was not removed were 6.5 times more likely to relapse or die of their infection than were those whose device was removed. Our findings suggest that patient-specific management advice by infectious diseases consultants can improve the clinical outcome for patients with S. aureus bacteremia.

PMID 9770144
Peter J Pronovost, Christine A Goeschel, Elizabeth Colantuoni, Sam Watson, Lisa H Lubomski, Sean M Berenholtz, David A Thompson, David J Sinopoli, Sara Cosgrove, J Bryan Sexton, Jill A Marsteller, Robert C Hyzy, Robert Welsh, Patricia Posa, Kathy Schumacher, Dale Needham
Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.
BMJ. 2010 Feb 4;340:c309. doi: 10.1136/bmj.c309. Epub 2010 Feb 4.
Abstract/Text OBJECTIVES: To evaluate the extent to which intensive care units participating in the initial Keystone ICU project sustained reductions in rates of catheter related bloodstream infections. Design Collaborative cohort study to implement and evaluate interventions to improve patients' safety.
SETTING: Intensive care units predominantly in Michigan, USA.
INTERVENTION: Conceptual model aimed at improving clinicians' use of five evidence based recommendations to reduce rates of catheter related bloodstream infections rates, with measurement and feedback of infection rates. During the sustainability period, intensive care unit teams were instructed to integrate this intervention into staff orientation, collect monthly data from hospital infection control staff, and report infection rates to appropriate stakeholders.
MAIN OUTCOME MEASURES: Quarterly rate of catheter related bloodstream infections per 1000 catheter days during the sustainability period (19-36 months after implementation of the intervention).
RESULTS: Ninety (87%) of the original 103 intensive care units participated, reporting 1532 intensive care unit months of data and 300 310 catheter days during the sustainability period. The mean and median rates of catheter related bloodstream infection decreased from 7.7 and 2.7 (interquartile range 0.6-4.8) at baseline to 1.3 and 0 (0-2.4) at 16-18 months and to 1.1 and 0 (0.0-1.2) at 34-36 months post-implementation. Multilevel regression analysis showed that incidence rate ratios decreased from 0.68 (95% confidence interval 0.53 to 0.88) at 0-3 months to 0.38 (0.26 to 0.56) at 16-18 months and 0.34 (0.24-0.48) at 34-36 months post-implementation. During the sustainability period, the mean bloodstream infection rate did not significantly change from the initial 18 month post-implementation period (-1%, 95% confidence interval -9% to 7%).
CONCLUSIONS: The reduced rates of catheter related bloodstream infection achieved in the initial 18 month post-implementation period were sustained for an additional 18 months as participating intensive care units integrated the intervention into practice. Broad use of this intervention with achievement of similar results could substantially reduce the morbidity and costs associated with catheter related bloodstream infections.

PMID 20133365

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