Catheter Related Infections

Catheter-Related InfectionsSecond Edition, Revised and Expanded

INFECTIOUS DISEASE AND THERAPYSeries Editor Burke A.Cunha Winthrop-University Hospital Mineola, and State University of New York School of Medicine Stony Brook, New York 1. Parasitic Infections in the Compromised Host, edited by Peter D.Walzer and Robert M.Genta 2. Nucleic Acid and Monoclonal Antibody Probes: Applications in Diagnostic Methodology, edited by Bala Swaminathan and Gyan Prakash 3. Opportunistic Infections in Patients with the Acquired Immunodeficiency Syndrome, edited by Gifford Leoung and John Mills 4. Acyclovir Therapy for Herpesvirus Infections, edited by David A.Baker 5. The New Generation of Quinolones, edited by Clifford Siporin, Carl L.Heifetz, and John M.Domagala 6. Methicillin-Resistant Staphylococcus aureus: Clinical Management and Laboratory Aspects, edited by Mary T.Cafferkey 7. Hepatitis B Vaccines in Clinical Practice, edited by Ronald W.Ellis 8. The New Macrolides, Azalides, and Streptogramins: Pharmacology and Clinical Applications, edited by Harold C.Neu, Lowell S.Young, and Stephen H.Zinner 9. Antimicrobial Therapy in the Elderly Patient, edited by Thomas T.Yoshikawa and Dean C.Norman 10. Viral Infections of the Gastrointestinal Tract: Second Edition, Revised and Expanded, edited by Albert Z.Kapikian 11. Development and Clinical Uses of Haemophilus b Conjugate Vaccines, edited by Ronald W.Ellis and Dan M.Granoff 12. Pseudomonas aeruginosa Infections and Treatment, edited by Aldona L.Baltch and Raymond P.Smith 13. Herpesvirus Infections, edited by Ronald Glaser and James F.Jones 14. Chronic Fatigue Syndrome, edited by Stephen E.Straus 15. Immunotherapy of Infections, edited by K.Noel Masihi 16. Diagnosis and Management of Bone Infections, edited by Luis E.Jauregui 17. Drug Transport in Antimicrobial and Anticancer Chemotherapy, edited by Nafsika H.Georgopapadakou 18. New Macrolides, Azalides, and Streptogramins in Clinical Practice, edited by Harold C.Neu, Lowell S.Young, Stephen H.Zinner, and Jacques F.Acar

19. Novel Therapeutic Strategies in the Treatment of Sepsis, edited by David C.Morrison and John L.Ryan 20. Catheter-Related Infections, edited by Harald Seifert, Bernd Jansen, and Barry M.Farr 21. Expanding Indications for the New Macrolides, Azalides, and Streptogramins, edited by Stephen H.Zinner, Lowell S.Young, Jacques F.Acar, and Harold C.Neu 22. Infectious Diseases in Critical Care Medicine, edited by Burke A.Cunha 23. New Considerations for Macrolides, Azalides, Streptogramins, and Ketolides, edited by Stephen H.Zinner, Lowell S.Young, Jacques F.Acar, and Carmen Ortiz-Neu 24. Tickborne Infectious Diseases: Diagnosis and Management, edited by Burke A.Cunha 25. Protease Inhibitors in AIDS Therapy, edited by Richard C.Ogden and Charles W.Flexner 26. Laboratory Diagnosis of Bacterial Infections, edited by Nevio Cimolai 27. Chemokine Receptors and AIDS, edited by Thomas R.OBrien 28. Antimicrobial Pharmacodynamics in Theory and Clinical Practice, edited by Charles H.Nightingale, Takeo Murakawa, and Paul G.Ambrose 29. Pediatric Anaerobic Infections: Diagnosis and Management, Third Edition, Revised and Expanded, Itzhak Brook

Catheter-Related InfectionsSecond Edition, Revised and Expanded edited by

Harald Seifert Bernd Jansen Barry M.Farr

MARCEL DEKKER NEW YORK

This edition published in the Taylor & Francis e-Library, 2006 . To purchase your own copy of this or any of Taylor & Francis or Routledges collection of thousands of eBooks please go to http://www.ebookstore.tandf.co.uk/. Although great care has been taken to provide accurate and current information, neither the author(s) nor the publisher, nor anyone else associated with this publication, shall be liable for any loss, damage, or liability directly or indirectly caused or alleged to be caused by this book. The material contained herein is not intended to provide specific advice or recommendations for any specific situation. Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress. ISBN 0-203-99710-7 Master e-book ISBN

ISBN: 0-8247-5854-4 (Print Edition) Headquarters Marcel Dekker, 270 Madison Avenue, New York, NY 10016, U.S.A. tel: 2126969000; fax: 2126854540 Distribution and Customer Service Marcel Dekker, Cimarron Road, Monticello, New York 12701, U.S.A. tel: 8002281160; fax: 8457961772 World Wide Web http://www.dekker.com/ Copyright 2005 by Marcel Dekker. All Rights Reserved. Neither this book nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.

PrefacePublished in 1997, the first edition of Catheter-Related Infections was well received by those with a special interest in this topic because of their work in hospital epidemiology and infection control and/or infectious diseases. Others finding the first edition useful were intensive care specialists whose patients frequently require central venous or pulmonary artery catheters and others who care for patients requiring chronic central venous catheterization. These included hematologists, oncologists, nephrologists, gastroenterologists, cardiologists and physicians in training. The first edition covered topics ranging from the basic science of catheter-related infections, such as factors like fibronectin that mediate the adherence of certain microbes to catheters (more to some catheter materials than to others) to data from epidemiologic studies and recommendations regarding the diagnosis, prevention and management of these infections. The second edition addresses these same topics as well as some new ones, providing five chapters covering basic principles, five chapters focusing on different groups of pathogens implicated in catheter-related infections, and nine chapters discussing infections associated with different types of catheters including peritoneal dialysis catheters and central nervous system shunts as well as different types of vascular catheters. The second edition adds three new chaptersone on the epidemiology and impact of catheter-related infections by Philippe Eggimann and Didier Pittet, a second on the management of vascular catheter-related infections by Leonard Mermel and Barry Farr, and a third focusing on catheter-related urinary tract infections by Carol Chenoweth and Sanjay Saint. Newer methods of diagnosis such as differential time-to-positivity are described in detail. Situations in which removal of the indwelling catheter is essential for cure are also contrasted with those in which the catheter may be salvaged using other types of therapy such as parenteral plus antibiotic lock therapy. Chapter authors include some of the worlds most renowned authorities in the area of catheter-related infections with representation from several continents. Many studies on catheter infections have been published in the seven years that have elapsed since publication of the first edition, so the authors of chapters from the first addition have updated their chapters with additional important references. We hope that this second edition will appeal to the same types of clinicians that found the first edition useful. Harald Seifert Bernd Jansen Barry M.Farr

ContentsPreface Contributors vi ix

I. Basic Principles 1. Epidemiology and Impact of Infections Associated with the Use of Intravascular Devices Philippe Eggimann and Didier Pittet 2. Pathogenesis of Vascular Catheter Infections Robert J.Sherertz 3. Diagnosis of Catheter-Related Infections Franois Blot 4. Management of Intravascular Catheter-Related Infections Leonard A.Mermel and Barry M.Farr 5. Prevention and Control of Catheter-Related Infections Bernd Jansen and Wolfgang Kohnen II. Infections Due to Specific Pathogens 6. Catheter-Related Staphylococcus aureus Infection Barry M.Farr 7. Catheter-Related Infections Caused by Coagulase-Negative Staphylococci Mathias Herrmann and Georg Peters 8. Intravascular Catheter-Related Infections Due to Gram-Negative Bacilli Harald Seifert 9. Fungal Infections of Catheters Sergio B.Wey and Arnaldo L.Colombo 10. Miscellaneous Organisms Tanja Schlin and Andreas Voss III. Infections Associated with Specific Catheter Types 11. Central-Venous Catheters Harald Seifert Bernd Jansen Andreas F Widmer and Barry M Farr 255 125 145 171 201 222 1

23 35 70 80

12. 13.

14. 15. 16. 17.

18.

19.

Harald Seifert, Bernd Jansen, Andreas F.Widmer, and Barry M.Farr Peripheral Venous Catheters C.Glen Mayhall Infectious Complications of PA Pulmonary Artery Catheters, Cordis Introducers, and Peripheral Arterial Catheters Leonard A.Mermel and Dennis G.Maki Long-Term Central Venous Catheters Issam Raad and Hend A.Hanna Infections Associated with Central Nervous System Implants Roger Bayston Infections Associated with Chronic Peritoneal Dialysis Henri Alexander Verbrugh Infections Associated with Hemodialysis Vascular Accesses and with Catheters Used for Hemodialysis Jerome I.Tokars and R.Monina Klevens Catheter-Related Infections in Pediatric Patients Andr Fleer, Tannette G.Krediet, Leo J.Gerards, Tom F.W.Wolfs, and John J.Roord Infections Associated with Urinary Catheters Carol E.Chenoweth and Sanjay Saint Index

285 333

375 392 425 443

458

490

519

ContributorsRoger Bayston, M.Med.Sci., F.R.C.Path. Senior Lecturer, School of Medical and Surgical Sciences, University of Nottingham, United Kingdom Franois Blot, M.D. Service de Ranimation Polyvalente, Institut Gustave Roussy, Villejuif, France Carol E.Chenoweth, M.D. Clinical Associate Professor, Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, U.S.A. Arnaldo L.Colombo Associate Professor, Division of Infectious Diseases, So Paulo Federal Medical School, So Paulo, Brazil Philippe Eggimann, M.D. Medical ICU and Infection Control Program, University of Geneva Hospitals, Geneva, Switzerland Barry M.Farr, M.D., M.Sc. Hospital Epidemiologist, The William S. Jordan, Jr.Professor of Medicine and Epidemiology, The University of Virginia Health System, Charlottesville, Virginia, U.S.A. Andr Fleer, M.D., Ph.D. Medical Microbiologist, Wilhelmina Childrens Hospital and Eijkman-Winkler Center for Medical Microbiology, Infectious Diseases and Inflammation, University Medical Center Utrecht, Utrecht, The Netherlands Leo J.Gerards, M.D., Ph.D. Neonatologist, Department of Neonatology, Wilhelmina Childrens Hospital, University Medical Center Utrecht, Utrecht, The Netherlands Hend A.Hanna, M.D., M.P.H. Assistant Professor, Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D.Anderson Cancer Center, Houston, Texas, U.S.A. Mathias Herrmann, M.D. Professor of Medical Microbiology and Hygiene, and Director, Institute of Medical Microbiology and Hygiene, Institutes of Infectious Disease Medicine, University of Saarland Hospital, Homburg/ Saar, University of Muenster, Muenster, Germany Bernd Jansen Professor and Head, Department of Hygiene and Environmental Medicine, Head of Department of Hospital Hygiene and Infection Control, Johannes Gutenberg University, Mainz, Germany R.Monina Klevens, D.D.S., M.P.H. Medical Epidemiologist, Centers for Disease Control and Prevention, National Center for Infectious Diseases, Division of Healthcare Quality Promotion, Atlanta, Georgia, U.S.A. Wolfgang Kohnen, Ph.D. Departments of Hygiene and Environmental Medicine, and Hospital Hygiene and Infection Control, Johannes Gutenberg University, Mainz, Germany Tannette G.Krediet Head of the Clinical Department of Neonatology, Department of Neonatology, Wilhelmina Childrens Hospital, University Medical Center Utrecht, Utrecht, The Netherlands Dennis G.Maki, M.D. Ovid O.Meyer Professor of Medicine and Head, University of Wisconsin Hospital and Clinics, Madison, Wisconsin, U.S.A.

C.Glen Mayhall, M.D. Professor, Department of Internal Medicine, Division of Infectious Diseases and Hospital Epidemiologist, Department of Healthcare Epidemiology, UTMB Hospitals and Clinics, The University of Texas Medical Branch at Galveston, Galveston, Texas, U.S.A. Leonard A.Mermel, D.O., Sc.M., A.M. (Hon.), F.A.C.P., F.I.D.S.A. Medical Director, Department of Infection Control, Rhode Island Hospital Attending Physician, Division of Infectious Disease, Rhode Island Hospital, and Associate Professor of Medicine, Brown Medical School, Providence, Rhode Island, U.S.A. Georg Peters, M.D. Professor of Medical Microbiology and Chairman, Institute of Medical Microbiology, University of Muenster, Muenster, Germany Didier Pittet, M.D., M.S. Professor of Medicine, and Director, Infection Control Program, University of Geneva Hospitals, Geneva, Switzerland and Honorary Professor, Division of Investigative Science and School of Medicine, The Hammersmith Hospitals, Imperial College of Science, Technology and Medicine, London, United Kingdom Issam Raad, M.D., F.A.C.P. Professor and Chairman (ad interim), Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas M.D.Anderson Cancer Center, Houston, Texas, U.S.A. John J.Roord, M.D., Ph.D. Pediatrician, Professor and Head, Department of Pediatrics, Free University Medical Center, Amsterdam, The Netherlands Sanjay Saint, M.D., M.P.H. Research Investigator and Hospitalist, Ann Arbor VA Medical Center, Associate Professor of Medicine, University of Michigan School Director, VA/UM Patient Safety Enhancement Program, Ann Arbor, Michigan, U.S.A. Tanja Schlin, M.D. Medical Microbiologist, University of Medical Centre St.Radboud, Radboud University, Nijmegen, The Netherlands Harald Seifert, M.D. Professor of Medical Microbiology and Hygiene, Institute for Medical Microbiology, Immunology and Hygiene, University of Cologne, Cologne, Germany Robert J.Sherertz, M.D. Chief, Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, North Carolina, U.S.A. Jerome I.Tokars, M.D., M.P.H. Medical Epidemiologist, Centers for Disease Control and Prevention, National Center for Infectious Diseases, Division of Healthcare Quality Promotion, Atlanta, Georgia, U.S.A. Henri A.Verbrugh, M.D., Ph.D. Professor of Medical Microbiology, and Head, Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands Andreas Voss, M.D., Ph.D. Professor and Chair Infection Control, University of Medical Centre St. Radboud, Department of Medical Microbiology and Nijmegen University Centre of Infectious Diseases, Nijmegen, The Netherlands Sergio B.Wey Associate Professor, Division of Infectious Diseases, So Paulo Federal Medical School, So Paulo, Brazil

Andreas F.Widmer, M.D., M.S. Head, Infection Control, Division of Infectious Diseases and Infection Control, University of Basel Hospitals and Clinics, Basel, Switzerland Tom F.W.Wolfs, M.D. Pediatrician, Wilhelmina Childrens Hospital Utrecht, Utrecht, The Netherlands ]

1 Epidemiology and Impact of Infections Associated with the Use of Intravascular Devices

Philippe Eggimann Medical Intensive Care Unit Department of Internal Medicine University of Geneva Hospitals Geneva, Switzerland Didier Pittet Infection Control Program Department of Internal Medicine University of Geneva Hospitals Geneva, Switzerland

Catheter-related infections

2

INTRODUCTION Nosocomial infections are a leading cause of morbidity and mortality among hospitalized patients. They should not, however, be considered as an inevitable tribute to pay to the continuous progress in medicine, considering in particular the sophisticated diagnostic and management strategies applied to the care of complex diseases. The extent of the problem was recently highlighted in the general medical literature in the late 1990s, following a publication by the Institute of Medicine in Washington, DC. In brief, this report estimated that preventable adverse events in the United States, including nosocomial infections, were responsible for 44,000 to 98,000 deaths annually and represent a cost of $17 to $29 billion (1). Mostly based on extrapolation from two studies only, this report has generated a considerable debate in the scientific community (29). Comparable data were published in the United Kingdom by the House of Commons in November 2000 (10). This official government report estimated that at least 100,000 infections are acquired in hospitals in England each year. These infections may be responsible for at least 5,000 deaths annually, with cost estimates as high as $1.8 billion (11). Nosocomial infections now concern 5% to 15% of hospitalized patients and can lead to complications in 25% to 50% of those admitted to intensive care units (ICUs) (12,13). Globally, urinary tract and surgical site infections are the most frequent infections, followed by respiratory and bloodstream infections (14) (Fig. 1). Most data concerning the epidemiology of these infections concern particular types of infections in specialized wards, and general information is sparse. However, it has been repeatedly shown that intravascular devices are among the most significant risk factors for the development of nosocomial infections (1518). More precise epidemiological data are available for critically ill patients and those admitted to ICUs, in particular. Among these patients, pneumonia related to mechanical ventilation, intra-abdominal infections following trauma or surgery, and bacteremia or sepsis associated with the use of intravascular devices account for more than 80% of ICU-acquired infections (19,20) (Table 1). Bloodstream infections represented 12% of all nosocomial infections reported in 10,038 patients from 1417 ICUs in the European Prevalence of Infection in Intensive Care (EPIC) study (15). The National Nosocomial Infection Surveillance (NNIS) system, which took into account only data from ICUs, reported that most nosocomial bloodstream infections are associated with the use of intravascular access, with rates substantially higher among patients with central venous catheters (CVCs) than among those with peripheral lines (19,20).

Epidemiology and impact of infections

3

Figure 1 Proportion of nosocomial infections (n=472) occurring among 4252 patients from 18 large Swiss general hospitals in 1999. Data adapted from the 2nd Swiss National Prevalence Study (14). Table 1 Epidemiology of Leading Nosocomial Infections in Various Types of ICUs in the 1990sIncidence-densities of nosocomial infections per 1000 patient-days Type of ward No. No No. Overall Blood Respi Urinary Wound Other of . of of stream ratory tract /soft units patients infec tract tissue tions112 181,993 14,177 1 1 1 1,050 180 505 145 12 122 6,290 168 78 19.8 34.0 12.3 25.0 14.1 16.6 15.3 3.8 3.8 3.0 5.4 4.0 3.4 2.1 5.3 12.7 5.1 7.3 4.8 8.8 8.9 6.1 5.2 4.1 7.0 2.1 2.5 2.3 7.0 1.0 1.4 1.2 4.6 2.1 0.0 2.4 1.8 0.7 2.0

Richards (30)a Eggimann (32)b Brooks (91)

Medical Medical Medical

Dettenkofer Neurology (68) Richards (29)a Raymond (92) Gastmeier (62) Pediatric Pediatric Pediatric

61 110,709 5 72 710 515

Catheter-related infections

4

Simon (75) Gilio (93) Legras(63) Kollef (18)d Bradley (94) Brasic(61)e Groot (95) Price (96)f c

Pediatric Pediatric Mixed Mixed Mixed Mixed Mixed Surgical Surgical Oncology Coronary Burn

1 1 5 2 3 1 16 1 1 1

201 500 1,589 2,000 2,734 660 2,795 139 327 623

15 65 344 286 354 688 1,177 49 54 370 6,698 36

15.7 31.7 20.3 32.3 44.3 57.1 42.0 11.5 47.2 91.7 10.6 32.3

4.8 1.5 4.1 2.5 22.8 0.0 9.6 22.1 1.8 1.8

6.8 12.7 5.7 22.7 21.8 9.2 15.8 26.5 2.6 19.7

1.9 4.4 5.2 6.9 12.5 2.3 23.5 3.7 9.0

0.8 4.4 4.5 1.5 0.9

0.0 8.7 5.2 7.1 0.0 18.3 19.6 2.5 0.9

Kollef (97) Velasco (98) Richards (28)a Wurtz (99)a b

93 227,451 1 57

Data adapted from reports of the NNIS database. After implementation of a global program targeted at the reduction of vascular access-related infections. Bloodstream infections include episodes of primary bacteremia (1.2/1000 patient-days) and of clinical sepsis (2.6/1000 patients-days). c Bloodstream infections include episodes of primary bacteremia (1.9/1000 patient-days). d Bloodstream infections include episodes of primary bacteremia (3.0/1000 patient-days). e Patients hospitalized for severe infections over a 6-year period. f Data reported are insufficient to extract details on incidence-densities for each type of infection. Data could not be extracted from the original publication.

Table 2 Definitions of Infections Associated with the Use of Intravascular DevicesaCriteria required for diagnosis of different types of catheter-associated infections for epidemiological surveillancePrimary bloodstream infection Clinical sepsis Bacteremia (or fungemia) without documented distal source of infection

Requires one of the following signs or symptoms with no other recognized cause: - fever (>38C) - hypotension (systolic blood pressure 90 mmHg) - oliguria (