How do I diagnose and manage catheter-related bloodstream infections?

How do I diagnose and manage catheter-related bloodstream infections?

44 How Do I Diagnose and Manage Catheter-Related Bloodstream Infections? Michael Scully INTRODUCTION Since Werner Forssmann first successfully cathet...

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44 How Do I Diagnose and Manage Catheter-Related Bloodstream Infections? Michael Scully

INTRODUCTION Since Werner Forssmann first successfully catheterized the right atrium in 1929,1 central venous access has become an essential component in the management of critically ill patients. Central access is performed to administer vasopressors, parenteral nutrition, and fluids, perform blood sampling and advanced hemodynamic monitoring, and provide renal replacement therapy. Long-term vascular device placement is frequently established for therapeutic reasons in patient groups who are at high risk of developing critical illness, such as for chemotherapy in patients with hematological and oncological malignancies and cases of chronic renal failure requiring access for long-term dialysis. However, central venous catheterization is associated with mechanical, thrombotic, and infectious complications, and given their iatrogenic etiology, intensive efforts have been undertaken by health-care systems to reduce their incidence. Successful control depends on a thorough understanding of the pathophysiology, early recognition, treatment, and crucially, institutional and national adoption of preventative measures supported by surveillance and education.

DEFINITIONS A catheter-related bloodstream infection (CRBSI) is defined as a bloodstream infection that develops in the presence of a vascular access devices such as short or long-term central venous catheters (CVC), peripheral catheters, or arterial lines in the absence of an alternative attributable source.1,2 Definitive confirmation is achieved by isolating the organism by quantitative culture of the catheter tip. A central line is defined as a catheter where the tip comes to lie in a great vein, and the majority of CRBSIs are associated with these devices. For surveillance purposes, the National Healthcare Safety Network (NHSN) in the United States has defined these latter infections as central line-associated bloodstream infections (CLASBIs); they are defined as infections in a patient with a central line in situ or infection within 48 hours of a CVC removal in the absence of any other source of sepsis.2 A number of different potential portals of infection have been identified.3–5 The breech in the integrity of the skin surface at the site of catheter placement provides a tract that can permit bacteria, especially skin commensals, to migrate

alongside the device to infect the extraluminal surface, with the potential for intraluminal migration. Safdar and Maki4 have reported that, in a single-center study from the intensive care unit (ICU) of a large tertiary university hospital of .1200 catheters, this was the dominant mechanism by which a CRBSI was acquired, being implicated in almost half the cases. Therefore, strategies aimed at reducing the burden of skin colonization or extending the subcutaneous passage from skin puncture site to the point of vessel entry may be efficacious in reducing the CRBSI risk. In this regard, bathing patients daily with chlorhexidine-impregnated washcloths initially appeared to be efficacious,6 but further studies have yielded conflicting results and have not confirmed a reduction in CRBSIs.7,8 The apparent reduction in CRBSIs in the early studies appear related to a reduction in false-positive blood cultures.9 In situations where longer-term line placement can be anticipated, such as hemodialysis or chemotherapy administration, the risk of infection through this portal may be reduced by tunneling or implanting the device. Tunneling is the process where a subcutaneous tract, typically about 10 cm in length, is created between the point of skin insertion and the device entry point into the vessel.1,4,5 An alternative portal by which infection is acquired is via the catheter hubs, which can become colonized if health-care staff has breeches in hand hygiene practices. Infection via this route will directly enter the catheter’s luminal surface. This is reportedly a more common mechanism beyond 10 days after catheter placement. Less commonly, the catheter may also become secondarily infected, either endogenously by metastatic hematogenous seeding of infection from another source or very rarely by the administration of a contaminated infusate.2–4

INCIDENCE AND EPIDEMIOLOGY The incidence of a catheter-related infection is typically expressed as the incidence density or incidence rate, and it is the number of infections over the time that the catheter is in situ. This is usually expressed as the number/1000 catheter days, and is calculated as: CRBSI rate/1000 catheter days 5 Number of CVC infections 3 1000/Number of CVC days 307

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There is evidence that meticulous adherence to best practice in infection control measures from the time of catheter placement and throughout the period that the device is in situ can dramatically reduce the incidence rate. In 2006, Maki et al.10 reported that in the United States, the incidence of infection in short-term central catheters was 2.7/1000 catheters days and that overall there were 250,000 CRBSIs, with over 80,000 occurring in the critical care areas. In the same era, Pronovost et al.11 published a practice intervention (discussed later) aimed at reducing the CRBSI incidence. These interventions were subsequently widely adopted, and there is evidence that they have led to a significant improvement in CRBSI rates. Data published in 2018 by the NHSN indicate that the current CRBSI rate in the United States has almost halved in the last decade.12 It is estimated that approximately 30% of hospitalized patients with CVCs in the United States are located in the critical care area, and that now 30,000 CRBSIs occur annually in this patient cohort, with an incidence rate of 0.8/1000 catheter days. This is comparable with data collected during 2007–2012 from 43 countries by the International Nosocomial Infection Control Consortium, which reported an incident rate of 4.9/1000 catheter days from comparable ICUs.13 In Europe, surveillance of CRBSIs is under the aegis of the European Centre for Disease Prevention and Control (ECDC). In 2015, for 11 participating countries, the incident rate for ICU-acquired CLASBIs varied from 1.4 infections/1000 catheter days in Luxembourg to 8.0/1000 catheter days in Slovakia (average across all countries 3.2/1000 catheter days).14 This marked heterogeneity is supported by an international questionnaire of intensive care practitioners in 95 countries. The survey demonstrated marked variation in practices related to the control of CRBSIs and the potential scope for improvement.15 CRBSIs have important consequences. Maki et al.10 reported that based on US data, CRBSIs are associated with an additional 10–20 days in hospital and have reportedly an attributable mortality of 12%–25%. The average additional cost required to treat a CRBSI was in excess of US$70,000. Despite the improvements made, CRBSIs are still associated with substantial morbidity and mortality and continue to impose a substantial added financial burden on healthcare costs.13 Risk factors associated with CRBSIs can be grouped according to patient, catheter, operator, personnel, and environmental factors.1,4,5,10 Severity and duration of illness, immune suppression, malignancy, burns, chronic hepatic and renal dysfunction, and failed source control have been associated with the increased risk. As migration of microorganisms along the catheter underlies the pathogenesis of the majority of CRBSIs, the material’s composition can influence the degree of risk. Impregnating the catheter with an antibacterial agent can attenuate the infection risk (discussed later). The choice of technique to secure the device may also modify the risk as well as the type of dressing used. As one of the mechanisms of infection involves colonization of the catheter hubs, the infection risk increases with increased number of lumens. Selecting a catheter with the minimum number of

lumens appropriate to the device’s purpose is appropriate. Furthermore, the risk of hub contamination can be attenuated by close adherence to infection control measures by staff accessing the catheter for the duration of the device’s placement. Hub decontamination and strict hand hygiene will reduce the infective risk by this mechanism. Femoral placement been associated with the highest risk of infection due to the high burden of bacterial colonization at this site, with an intermediate risk in the neck and lowest risk at the subclavian site; however, this has recently been challenged.16 A metaanalysis published by Marik et al.16 reported that in more recent studies, an increased risk of CRBSI in the femoral site was not seen when compared with subclavian or internal jugular positions. This may be a reflection of the adoption of improved hygiene practices. Operator skill and experience and especially adherence to strict infection control practices are fundamental to minimizing the infection risk. Finally, the risk posed to an individual patient is modified by the ecology of the local flora in the critical care environment. Critical care units where there are high levels of multi-drug resistant organisms, which suffer from overcrowding, staff shortages, and deficits of isolation facilities, and which lack robust antimicrobial stewardship programs present an added risk to patients acquiring nosocomial infections including CRBSIs.3

MICROBIOLOGY Gran-positive organisms are implicated in the majority of CRBSIs followed by gram-negative infections and yeasts. The US data compiled by the NHSN indicated the attributed infecting organisms as follows: 34.1% coagulase-negative Staphylococci, 16% Enterococci, 9.9% S. aureus, 5.8% Klebsiella, 3.9% Enterobacter, 3.1% Pseudomonas, 2.7% E. Coli, 2.2% Acenitobacter, 11.8% Candida, and miscellaneous infections accounting for the remaining 10.5%.1 Gram-positive organisms are particularly likely to occur in hemodialysis patients, while gram-negative infections are associated with a malignancy diagnosis and placement of the device in the femoral site. Line placement at this site and total parenteral nutrition delivery are also risk factors for Candida infections.1,4,10

DIAGNOSIS The diagnosis of CRBSIs can be challenging but must be suspected in any patient who manifests typical clinical markers of an inflammatory illness while a CVC is in situ.17 However, clinicians must remain alert to the possibility that an alternative source of infection is not overlooked and not simply ascribed to the CVC. Indeed, it has been reported that in febrile neutropenic patients who undergo catheter removal because of suspected CRBSI, the catheter is only subsequently confirmed as the source of sepsis on microbiological culture in as few as 20% of cases.18 In the ECDC surveillance data, CRBSIs were confirmed as the cause of bloodstream infections (BSIs) in only 43% cases, although

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the cause was not determined in a further 21.5%, some of whom may have missed CRBSIs.14 Of the remaining approximately 35% cases, the BSIs were secondary to another source, principally respiratory, gastrointestinal, and renal infections. This illustrates the importance of thoroughly evaluating every suspected case of CRBSI for alternative sources of infection.14 The catheter site should be evaluated for redness, induration, pus, and discharge at the skin puncture (exit site infection).17 Soiled dressings may be an early indicator of infection. The inability to draw blood from all ports of the catheter has been identified as a risk factor because it likely indicates thrombosis of a lumen, with the potential this could become a nidus for infection. The simultaneous acquisition of paired samples for blood cultures is mandatory.1,3,10 One set should be via the lumen of the CVC, with another sample acquired from a peripheral vein. There is data that with multilumen devices, the diagnostic accuracy can be enhanced by sampling all the lumens of the central catheter in addition to the peripheral sample.18 If peripheral access is not possible due to tissue edema or poor peripheral venous access, sampling from additional ports on the catheter may be an alternative. Meticulous attention must be paid to antisepsis during blood culture sampling, both from the catheter and peripheral vein, to avoid contamination from commensal organisms. At least 20 mL of blood should be drawn. Growths .15 colony-forming units (CFU)/catheter segment by semiquantitative or .102 CFU by quantitative (sonication) measurement are considered significant.17 Infection is highly likely if the same organism is obtained from the paired peripheral and CVC sampled blood cultures, with a three-fold greater colony count in the sample from the device.1,3 Also, in CRBSI, the concentration of the organism in the device is believed to be many multiples of that in the bloodstream, with concentrations of .1000 CFU cultures. This is termed the differential time to positivity (DTTP). A DTTP of .120 minutes is considered significant. Using a diagnostic strategy incorporating DTTP may increase the diagnostic specificity cultures and reduce the incidence of unnecessary catheter removal. However, considerable caution should be exercised and a local infectious disease specialist should be consulted prior to this approach.1,3,19 Where a catheter is removed from a patient suspected of having a CRBSI, the distal 5-cm tip must be sent for culture. A quantitative growth of .15 CFUs, with the same organisms from the peripheral blood cultures, is also diagnostic. Biomarkers for early line infection have been studied. In a study of pediatric line infection, presepsin proved valuable as an early marker.20 Acridine orange is a fluorescent dye that stains bacteria orange and normal tissues yellow to green under acidic conditions. It has been used in conjunction with fluorescence in situ hybridization (FISH) to establish the presence of early CRBSI in patients with hematological malignancies.19 Real-time polymerase chain reaction (PCR) has been evaluated as a diagnostic tool for the early diagnosis of S. aureus infection.21 However, further research is required to define the potential role of these

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approaches in establishing an earlier CRBSI than is currently possible in most cases.

TREATMENT The standard principles of the management of sepsis apply to a suspected or confirmed CRBSI22,23: prompt acquisition of appropriate samples for microbiological culture (at a minimum two sets of blood cultures, with simultaneously acquired peripheral and CVC samples) coupled with administration of broad-spectrum antibiotics based on knowledge of the local microbiological flora in accordance with local prescription guidelines. Narrow-spectrum therapy should be invoked once the results of cultures and sensitivities become known; supportive treatment of the circulation should be performed with fluid and vasopressors as appropriate. For the majority of CVCs placed for short-term access in the critical care, a suspected or confirmed CRBSI should prompt immediate consideration for removal of the device to achieve source control. If on-going venous access is required following removal of the infected device, a new catheter should be placed at a new site. Exchange of a new catheter over a guidewire is not appropriate, apart from exceptional circumstances where there may be serious concerns about mechanical complications of a new CVC insertion. Local spread of infection producing septic thrombophlebitis and metastatic spread to the heart valves and eye must be considered. These complications have significant implications for the duration of antibiotic treatment. Therapy should be administered in consultation with local infectious disease specialists. In the absence of distant infection spread, the duration of antibiotic treatment is determined by the pathogen once it has been identified. Where the signs of sepsis have resolved within 72 hours following the initiation of antibiotics and removal of the catheter, the recommended duration of antibiotics is as follows1,22,23: Coagulase-negative Staphylococci: 5–7 days Enterococci: 7–14 days Gram-negative bacilli: 7–14 days S. aureus: 14 days in the absence of endocarditis or other evidence of metastatic involvement, such as osteomyelitis, discitis, or epidural abscess. In these cases, 4–6 weeks of treatment may be required in conjunction with surgical debridement of infected tissue. Candida: 14 days from the date of the last negative blood culture and in the absence of retinitis. In selected cases, preservation of the catheter may be attempted by a technique called “antibiotic lock” therapy.1,23 This approach is typically undertaken in patients with longterm access devices (such as tunneled catheters for dialysis) and should be prescribed in consultation with infectious disease specialists. Following identification and sensitivity of the pathogen, supratherapeutic concentrations of appropriate antibiotics are instilled to fill each lumen of the catheter for a 24–48-hour period before being replenished. Systemic antibiotics are simultaneously administered, and treatment is continued for 10–14 days. This approach is

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conventionally used to treat infection caused by coagulasenegative Staphylococci, Enterococci, and gram-negative bacilli (with the important exception of Pseudomonas). Care must be taken that the patient is not inadvertently exposed to toxic antibiotic concentrations. It is recommended that treatment success is confirmed by negative blood cultures drawn via the salvaged catheter 1 week after the completion of treatment. This approach is not considered appropriate for infection with S. aureus, Mycobacteria, Pseudomonas, or Candida. Irrespective of the pathogen, the catheter should be removed if signs of metastatic infection, systemic shock, or new organ failure ascribed to the catheter infection develop.

PREVENTION The experience over the past decade has shown that a protocolized program of meticulous adherence to infection control measures11 can be highly successful in reducing the incidence of CRBSIs at an institutional level.24–27 There is evidence that this approach, when supported by an education program, can be successfully adopted into institutions in different countries leading to sustained reductions in CRBSIs.28 Professional health-care bodies in several countries have endorsed this approach and produced guidelines at national level. The common elements of this approach have been summarized by Shah et al.1 Personnel: Experienced operator/trainee closely supervised. Operator to don cap, face mask, sterile gown, and sterile drape after performing hand hygiene. All personnel in attendance in addition to the operator to wear cap and face mask. Site: Selection of subclavian site over the internal jugular and femoral vein. Device: Select a catheter with the minimum number of lumens appropriate to the role. Select a catheter impregnated with chlorhexidine/silver sulfadiazine or minocycline-rifampicin if otherwise optimal compliance with best infection control practices fails to reduce the CRBSI incident rate. Consider peripheral central catheter if feasible. Technique: Use .0.5% chlorhexidine solution for skin antisepsis (caution with neonates) and allow to dry appropriately. Whole body drape during insertion. If sterile technique compromised during insertion, replace catheter as soon as possible. Do not administer prophylactic antibiotics during insertion. Post-insertion Care: All health-care personnel to perform meticulous hand hygiene prior to performing any procedure involving the catheter. Observe the insertion site closely on a daily basis.

If insertion site is oozing, apply gauze dressing and change every 2 days. Otherwise, place a semipermeable dressing and change every 7 days. For both dressing types, replace it if wet/soiled. Do not change the catheter routinely (e.g. every 7 days). The evidence supporting these recommendations has been evaluated in a series of systematic reviews published by the Cochrane Library.29–32 The specific areas evaluated were skin antisepsis, the types of catheter used (impregnated vs. nonimpregnated), antibiotic lock in long-term tunneled access for hemodialysis patients, and type of dressings. The reader is referred to these texts for a more detailed discussion, but in summary, skin antisepsis with a chlorhexidine containing solution (.0.5%) led overall to a 36% reduction in the incidence of CRBSIs compared with povidone-iodine solutions. The issue of impregnated vs. nonimpregnated catheters and the magnitude of the potential benefit of impregnation is complex. Most of the evaluated studies compared minocycline-rifampicin and chlorhexidine silversulfadiazine catheters in studies with either standard peripheral venous catheter (PVC) devices or in head-to-head comparisons. However, other agents used to impregnate catheters which were studied included heparin, silverplatinum carbon, benzalkonium, 5-fluorouracil, and miconazole-rifampicin. Definitive conclusions have been difficult to make owing to the heterogeneous nature of study design, patient cohorts, and end-points. The main benefit appears to be in ICU patients followed by hematology/oncology and dialysis patients, with lesser efficacy in general ward patients. Minocycline-rifampicin appeared to reduce site colonization and CRBSI, and its performance is broadly superior to other forms of impregnation, which in turn are superior to standard PVC catheters. However, there appears little evidence of reduced all-cause sepsis or mortality between impregnated and nonimpregnated catheters. Also, there is currently little data on the emergence of antimicrobial resistance in association with the use of these types of catheters. Therefore, it does seem prudent that currently the use of impregnated devices be restricted to higher risk environments, such as the ICU and hematology patients. There is limited evidence to support prophylactic antibiotic lock therapy in hemodialysis patients. Chlorhexidine-impregnated dressings reduce site colonization. Sutureless devices may be beneficial in reducing CRBSI, but the current evidence does not support their routine use.

ARTERIAL LINES AND PERIPHERALLY INSERTED CENTRAL CATHETER LINES Arterial lines are possibly an under-appreciated source of CRBSIs. Although perceived as comparatively lower risk of infection than venous access catheter infection, in systematic review and metaanalysis, O’Horo et al.33 found that arterial line infection had an incident rate of 0.7 infections/1000 catheter days, especially with femoral site placement compared with the radial artery.33 Peripherally inserted central catheter (PICC) lines have gained increasing popularity and

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have supplanted the placement of conventional venous access in many institutions. However, although associated with low rates of infection in the outpatient setting, there is limited data that these devices are associated with reduced CRBSI rate compared with more conventional CVCs.34 In summary, it behooves health-care staff to treat these lines with the same level of fastidiousness in terms of hygiene and infection control as CVCs.

CONCLUSIONS Despite considerable advances that have been made, CRBSIs remain a persistent challenge in health care. The mainstay of success in reducing the incidence of CRBSIs is through institutional governance of adherence to strict hygiene practices, supported by an education program and audited compliance.

AUTHOR’S RECOMMENDATIONS • CRBSIs are a common and life-threatening complication of critical care. • The prevalence of CRBSIs is decreasing worldwide due to widespread adoption of “bundles” of simple interventions with meticulous attention to sterility. • Surveillance at local, regional, and national levels is the key to success. • Maintaining a low level CRBSI is now an internationally recognized indicator of quality. • Reduction of CRBSIs leads to shortened hospital stays and cost savings and may improve outcomes in critically ill patients. • Antibiotic-impregnated catheters may reduce the incidence of CRBSIs in critical care, but there is little data to support their use elsewhere in the hospital. • Although CRBSIs most commonly involve CVCs, clinicians should always consider arterial lines/PICC lines as potential sources of infection.

REFERENCES 1. Shah H, Bosch W, Thompson KM, Hellinger WC. Intravascular catheter-related bloodstream infection. Neurohospitalist. 2013; 3(3):144-151. 2. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definitions of health care-associated infections and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36(5):309-332. 3. Gahlot R, Nigam C, Kumar V, Yadav G, Anupurba S. Catheterrelated bloodstream infections. Int J Crit Illn Inj Sci. 2014;4(2):162-167. 4. Safdar N, Maki DG. The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Intensive Care Med. 2004;30(1):62-67. 5. Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore). 2002;81(6):466-479.

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6. Climo MW, Yokoe DS, Warren DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368(6):533-542. 7. Noto MJ, Domenico HJ, Byrne DW, et al. Chlorhexidine bathing and health care-associated infections: a randomized clinical trial. JAMA. 2015;313(4):369-378. 8. Kengen R, Thoonen E, Daveson K, et al. Chlorhexidine washing in intensive care does not reduce bloodstream infections, blood culture contamination and drug-resistant microorganism acquisition: an interrupted time series analysis. Crit Care Resusc. 2018;20(3):231-240. 9. Pittet D, Angus DC. Daily chlorhexidine bathing for critically ill patients: a note of caution. JAMA. 2015;313(4):365-366. 10. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006;81(9):1159-1171. 11. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-2732. 12. Centers for Disease Control and Prevention. Healthcare-associated infections: HAI Data. 2018. Available at https://www.cdc.gov/ hai/surveillance/index.html. Accessed November 13, 2018. 13. Rosenthal VD, Maki DG, Mehta Y, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary of 43 countries for 2007-2012. Deviceassociated module. Am J Infect Control. 2014;42(9):942-956. 14. European Centre for Disease Prevention and Control. Annual Epidemiological Report for 2015: Healthcare-associated infections in intensive care units. 2017. Available at https://ecdc.europa. eu/sites/portal/files/documents/AER_for_2015-healthcareassociated-infections_0.pdf. Accessed November 13, 2018. 15. Valencia C, Hammami N, Agodi A, et al. Poor adherence to guidelines for preventing central line-associated bloodstream infections (CLABSI): results of a worldwide survey. Antimicrob Resist Infect Control. 2016;5:49. 16. Marik PE, Flemmer M, Harrison W. The risk of catheterrelated bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012;40(8):2479-2485. 17. 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):1-45. 18. Guembe M, Rodríguez-Créixems M, Sánchez-Carrillo C, Pérez-Parra A, Martin-Rabadán P, Bouza E. How many lumens should be cultured in the conservative diagnosis of catheterrelated bloodstream infections? Clin Infect Dis. 2010;50(12): 1575-1579. 19. Krause R, Auner HW, Gorkiewicz G, et al. Detection of catheter-related bloodstream infections by the differentialtime-to-positivity method and gram stain-acridine orange leukocyte cytospin test in neutropenic patients after hematopoietic stem cell transplantation. J Clin Microbiol. 2004;42(10): 4835-4837. 20. Tanır Basaranoglu S, Karadag-Oncel E, Aykac K, et al. Presepsin: A new marker of catheter related blood stream infections in pediatric patients. J Infect Chemother. 2018;24(1):25-30. 21. Zboromyrska Y, De la Calle C, Soto M, et al. Rapid diagnosis of staphylococcal catheter-related bacteraemia in direct blood samples by real-time PCR. PLoS One. 2016;11(8):e0161684.

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22. Haddadin Y, Regunath H. Central line associated blood stream infections (CLABSI). StatPearls [Website]. Treasure Island, FL: StatPearls Publishing; 2018. 23. Beekmann SE, Henderson DK. Infections caused by percutaneous intravascular devices. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Disease. 6th ed. Philadelphia, PA: Elsevier; 2005:3347-3361. 24. Walz JM, Ellison RT III, Mack DA, et al. The bundle “plus”: the effect of a multidisciplinary team approach to eradicate central line-associated bloodstream infections. Anesth Analg. 2015;120(4):868-876. 25. Lin KY, Cheng A, Chang YC, et al. Central line-associated bloodstream infections among critically-ill patients in the era of bundle care. J Microbiol Immunol Infect. 2017;50(3):339-348. 26. Shimoyama Y, Umegaki O, Agui T, Kadono N, Komasawa N, Minami T. An educational program for decreasing catheterrelated bloodstream infections in intensive care units: a preand post-intervention observational study. JA Clin Rep. 2017;3(1):23. 27. Ista E, van der Hoven B, Kornelisse RF, et al. Effectiveness of insertion and maintenance bundles to prevent central-lineassociated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. Lancet Infect Dis. 2016;16(6):724-734.

28. Hsin HT, Hsu MS, Shieh JS. The long-term effect of bundle care for catheter-related blood stream infection: 5-year followup. Postgrad Med J. 2017;93(1097):133-137. 29. Lai NM, Lai NA, O’Riordan E, Chaiyakunapruk N, Taylor JE, Tan K. Skin antisepsis for reducing central venous catheter-related infections. Cochrane Database Syst Rev. 2016;7:CD010140. 30. Lai NM, Chaiyakunapruk N, Lai NA, O’Riordan E, Pau WS, Saint S. Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Database Syst Rev. 2016;3:CD007878. 31. Arechabala MC, Catoni MI, Claro JC, et al. Antimicrobial lock solutions for preventing catheter-related infections in haemodialysis. Cochrane Database Syst Rev. 2018;4: CD010597. 32. Ullman AJ, Cooke ML, Mitchell M, et al. Dressings and securement devices for central venous catheters (CVC). Cochrane Database Syst Rev. 2015;10:CD010367. 33. O’Horo JC, Maki DG, Krupp AE, Safdar N. Arterial catheters as a source of bloodstream infection: a systematic review and meta-analysis. Crit Care Med. 2014;42(6):1334-1339. 34. Safdar N, Maki DG. Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128(2):489-495.

e1 Abstract: Vascular access devices are an essential component in the management of many patients in both the outpatient and inpatient setting, including in the intensive care unit. Catheter-related bloodstream infections (CRBSIs) associated with access devices contribute to patient morbidity and mortality and health-care costs. Significant reductions in the incidence of this complication

can be achieved with meticulous adherence to infection control and hygiene practices but requires intensive staff training and on-going education. Arterial lines and peripherally inserted central catheters are often under-recognized as sources of CRBSIs. Keywords: CLASBI, CRBSI, cvc, infection, vascular access device