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Lecture 14 Related Bloodstream Carr

CATHETER RELATED BLOODSTREAM INFECTIONS (CRBSI): aka line CRBI MANAGEMENT: • Vascular essential part of patient care GRAM • Vancomycin o IV fluid and medication administration EMPIRIC POSITIVE • Many CoNS isolates are resistant to o Renal replacement therapy BASED ON cloxacillin and cefazolin o Monitoring via samples GRAM GRAM • Depends on clinical situation • Nosocomial (hospital-acquired) bloodstream infections STAIN NEGATIVE • /cefotaxime • Cause of and • Pip/tazo for pseudomonas coverage • Mortality: up to 27% • Immunocompromised pts C&S  GRAM • Vancomycin • ** RISK FACTORS: NARROW POSITIVE • Cloxacillin • ** SPECTRUM PATIENT CATHETER (LINE) • Cefazolin • ** IF RESISTANT • Chronic illness • Type of catheter AFFECTED CATHETER • Administer antibiotics through line • Bone marrow transplant o Bare vs. abx-impregnated STILL IN PLACE • If multiple ports, can alternate between • Immunosuppression • Conditions of insertion each port o • Malnutrition o Max barrier precautions NOT evidence-based practice but became gold standard • Parenteral nutrition during insertion DURATION OF THERAPY st • Previous blood stream infxn • Site of placement • 7-14 days following 1 -ve

• Age (infants, elderly) o Femoral or internal jugular >> • Longer if: o Develops • Loss of skin integrity subclavian o Foreign material in body o Burns, SJS, etc • Catheter-site care o Metastatic sites • Presence of bacterial infxn • Skill of person inserting catheter

• Children • Duration

• Admission to ICU with: • Use: REMOVAL OF VASCULAR CATHETER: o GI o Nutrition • Severe sepsis/septic shock o o Cancer • Hemodynamic instability • Swelling or pus at site SIGNS AND SYMPTOMS: • Persistent bacteremia after 72 hours of appropriate antibiotics • Temperature > 38oC ± chills or • Type of bug: • Pathogen cultured from one or more blood cultures Short-term • Staph aureus

• Pathogen not related to an infection from another site catheters • Enterococci o Patient has a vascular catheter (<14 days) • Gram-negative bacilli o No other apparent source of infection • Fungi • In addition, for infants <1 years old: apnea or bradycardia • Mycobacteria Long-term • Staph aureus PATHOPHYSIOLOGY: catheters • SKIN • Most common source (≥ 14 days) • Fungi COLONIZATION • Deposition of biofilm (fibrinogen & fibrin + • Mycobacteria glycocalyx) produced by HEMATOGENOUS • Bloodstream infection originating from another LOCK THERAPY: SEEDING source  bacteria adhere to catheter and propagate • To achieve sufficient therapeutic concentrations at the site • Often from GI site • If catheter cannot be removed • Most common: critically ill, long-term catheters • CoNS or gram negative organisms INFUSATE • Administration of contaminated IV products o Not for Staph aureus, pseudomonas, drug-resistant gram- CONTAMINATION • Contamination during: manufacture, solution, negative bacilli or Candida preparation, or handling by healthcare workers • Evidence of effectiveness is variable • Rare and generally causes epidemic infections • Antibiotic + heparin o Gentamicin-heparin LIKELY PATHOGENS: o Vancomycin-heparin • Coagulase-negative staphylococci (31%) o Cefazolin-heparin • (20%) • Enterococci (9%) PREVENTION: • Candida species (9%) • Aseptic technique: during insertion, w/ dressing changes, w/ site care • Others (mostly gram negatives from GI tract) • Choosing appropriate sites for insertion (subclavian best, femoral worst) • Using PICC lines or surgically inserted catheters when possible IN GENERAL, TREATMENT IS NOT REQUIRED IF: • Catheter materials: antimicrobial impregnated • Positive catheter tip culture with no clinical signs of infection • “Scrub the hub” when accessing the line • Positive cultures from catheter but negative cultures through peripheral • Minimize the need to access the line • Signs of phlebitis with no signs of infection • Changing administration sets every 96 hours RISK FACTORS FOR CANDIDEMIA: • Preventing thrombosis: o • Parenteral nutrition (TKVO) to keep vein open rate o Heparin or citrate locking when not in use • Prolonged use of broad-spectrum antibiotics • Minimizing duration of vascular catheter • Leukemia or lymphoma o Peripheral venous catheter < 4 days • Bone marrow or solid organ transplant o < 6 days • Femoral line o Arterial catheter < 4-6 days • Colonization with Candida species at multiple site o PICC lines & surgically inserted – weeks to months (6-12 months) Lecture 14 Sepsis Carr

SEPSIS: SOURCES OF INFECTION;

• Body’s overwhelming and life-threatening response to infection • • Catheter-related

o Can lead to tissue damage, organ failure, and death • UTI • Endocarditis

• 12th leading cause of death in Canada • Intra-abdominal infection • Infection of unknown source

• CNS • Other • > 50% of deaths from infectious • 30-50% of people who develop sepsis die from it • SSTI

RISK FACTORS: LIKELY PATHOGENS: AGE: • Elderly CNS • Strep pneumonia • N. meningitidis • Neonates and infants • H. influenza DEMOGRAPHICS: • Male PNEUMONIA • Strep. Pneumonia • pneumonia • Non-caucasian • H. influenzas • Chlamydia pneumonia PRE-EXISTING • HIV • Cirrhosis • M. catarrhalis • Mycoplasma pneumonia MEDICAL • Cancer • Alcohol dependence • Staph aureus CONDITIONS • • Pressure sores ENDOCARDITIS • Staph aureus • Staph epi INTRA- • E. coli • Serratia DEFINITIONS: ABDOMINAL • Enterobacter • BACTEREMIA • Presence of bacteria in the blood URINARY • E. coli • Proteus mirrabilis • Presence of virus in the blood TRACT • Klebsiella • Presence of fungus in the blood (candemia) SKIN & SOFT • Staph aureus • Staph species TISSUE • CoNS (S. pyogenes) IV LINE • • SCORING TOOLS: CoNS Staph aureus UNKNOWN • Staph aureus • E. coli SIRS Presence of ≥ 2: SOURCE • Strep pneumonia • Temperature: < 36oC or > 38oC • Heart rate > 90 bpm* • Respiratory rate > 20 bpm* EMPIRIC ANTIBIOTICS: • WBC < 4 or > 12 x 106 CNS • Ceftriaxone or cefotaxime • +/- vancomycin * in children, based on age normal, can also be bradycardic /apnea PNEUMONIA • Ceftriaxone or cefotaxime SOFA • Sequential Organ Failure Assessment Score • + vancomycin (Staph aureus) • Have to look up scoring tool • +/- azithromycin or clarithmoycin qSOFA • Quick SOFA ENDOCARDITIS • Vancomycin o Respiratory rate ≥ 22/min = 1 point INTRA- • Meropenem or imipenem o Change in mental status = 1 point ABDOMINAL • /tazobactam o Systolic BP ≤ 100 mmHg = 1 point • Metronidazole • Score ≥ 2 = organ dysfunction URINARY • Fluoroquinolones (ciprofloxacin)

TRACT • Ceftriaxone or cefotaxime +/- aminoglycosides SEPSIS DIAGNOSIS: • Meropenem or imipenem SEPSIS • A life threatening organ dysfunction caused by a SKIN & SOFT • Vancomycin dysregulated host response to infection TISSUE • Penicillin + clindamycin (Necrotizing Fasciitis II) • Confirmed or suspected infection + SIRS • Pip/tazo (Necrotizing fasciitis I) • SOFA or qSOFA score IV LINE • Vancomycin SEVERE • Sepsis + sepsis-induced organ dysfunction • Meropenem or imipenem SEPSIS • Most recent guidelines no longer recommend using this UNKNOWN • Vancomycin + pip/tazo term SOURCE • Vancomycin + meropenem or imipenem END CNS • Encephalopathy: agitation, confusion, altered LOC Vanomycin = gram +ve Meropenem/imipenem = gram -ve ORGAN LUNGS • Acute respiratory distress syndrome DYSFXN CVS • Heart failure MANAGEMENT: LIVER • Decreasd clotting (increased INR) • Medical emergency  • Impaired bilirubin metabolism ↑ free bilirubin • IV fluids: at least 30 mL/kg up to max 60 mL/kg GU • Decreased or no urine output o Crystalloid (0.9% NaCl, albumin) • Acute renal failure • Blood cultures SEPTIC • Severe sepsis + low BP despite admin of adequate IV fluids • IV antibiotics (within 1 hour) SHOCK • Severe sepsis + end organ damage • Source control • Requiring vasopressors to maintain adequate perfusion • Goal directed therapy • Subset of sepsis with circulatory and cellular/metabolic dysfunction associated with higher risk of mortality o Vasopressors, corticosteroids, etc…

SUMMARY: SIGNS & SYMPTOMS: • Early identification of sepsis important Shivering, or hypothermia Extreme pain discomfort • Early initiation (within 1 hour) of appropriate empiric antibiotics o Pale skin Decreases mortality Sleepy, difficult to rouse, confused • Surviving Sepsis Campaign I feel like I might die • Targeted therapy once bug identified Short of breath • Adjustment of drug dosage based on organ function • Monitoring and goal directed therapy key