Intravascular Infections Research Articles

Guideline for Prevention of Intravascular-Device-Related Infections

The “Guideline for Prevention of Intravascular Device-Related Infections” is designed to reduce the incidence of intravascular device-related infections by providing an over view of the evidence for recommendations considered prudent by consensus of Hospital Infection Control Practices Advisor y Committee (HICPAC) members. This two-part document updates and replaces the previously published Centers for Disease Control's (CDC) Guideline for Intravascular Infections (Am J Infect Control 1983;11:183-199). Part I, “Intravascular Device-Related Infections: An Over view” discusses many of the issues and controversies in intravascular-device use and maintenance. These issues include definitions and diagnosis of catheter-related infection, appropriate barrier precautions during catheter insertion, inter vals for replacement of catheters, intravenous (IV) fluids and administration sets, catheter-site care, the role of specialized IV personnel, and the use of prophylactic antimi-crobials, flush solutions, and anticoagulants. Part II, “Recommendations for Prevention of Intravascular Device-Related Infections” provides consensus recommendations of the HICPAC for the prevention and control of intravascular device-related infections. A working draft of this document also was reviewed by experts in hospital infection control, internal medicine, pediatrics, and intravenous therapy. However, all recommendations contained in the guideline may not reflect the opinion of all reviewers.

Guideline for Prevention of Intravascular-Device–Related Infections

The “Guideline for Prevention of Intravascular Device-Related Infections” is designed to reduce the incidence of intravascular device-related infections by providing an over view of the evidence for recommendations considered prudent by consensus of Hospital Infection Control Practices Advisor y Committee (HICPAC) members. This two-part document updates and replaces the previously published Centers for Disease Control's (CDC) Guideline for Intravascular Infections (Am J Infect Control1983;11:183-199). Part I, “Intravascular Device-Related Infections: An Over view” discusses many of the issues and controversies in intravascular-device use and maintenance. These issues include definitions and diagnosis of catheter-related infection, appropriate barrier precautions during catheter insertion, inter vals for replacement of catheters, intravenous (IV) fluids and administration sets, catheter-site care, the role of specialized IV personnel, and the use of prophylactic antimi-crobials, flush solutions, and anticoagulants. Part II, “Recommendations for Prevention of Intravascular Device-Related Infections” provides consensus recommendations of the HICPAC for the prevention and control of intravascular device-related infections. A working draft of this document also was reviewed by experts in hospital infection control, internal medicine, pediatrics, and intravenous therapy. However, all recommendations contained in the guideline may not reflect the opinion of all reviewers.

Candida albicans stimulates cytokine production and leukocyte adhesion molecule expression by endothelial cells

Endothelial cells have the potential to influence significantly the host immune response to blood-borne microbial pathogens, such as Candida albicans. We investigated the ability (of this organism to stimulate endothelial cell responses relevant to host defense in vitro. Infection with C. albicans induced endothelial cells to express mRNAs encoding E-selectin, intercellular adhesion molecule 1, vascular cell adhesion molecule 1, interleukin 6, interleukin 8, monocyte chemoattractant protein 1, and inducible cyclooxygenase (cox2). All three leukocyte adhesion molecule proteins were expressed on the surfaces of the endothelial cells after 8 h of exposure to C. albicans. An increase in secretion of all three cytokines was found after 12 h of infection. Cytochalasin D inhibited accumulation of the endothelial cell cytokine and leukocyte adhesion molecule mRNAs in response to C. albicans, suggesting that endothelial cell phagocytosis of the organism is required to induce this response. Live Candida tropicalis, Candida glabrata, a nongerminating strain of C. albicans, and killed C. albicans did not stimulate the expression of any of the cytokine or leukocyte adhesion molecule mRNAs. These findings indicate that a factor associated with live, germinating C. albicans is required for induction of endothelial cell mRNA expression. Furthermore, since endothelial cells phagocytize killed C. albicans, phagocytosis is likely necessary but not sufficient for this organism to stimulate mRNA accumulation. In conclusion, the secretion of proinflammatory cytokines and expression of leukocyte adhesion molecules by endothelial cells in response to C. albicans could enhance the host defense against this organism by contributing to the recruitment of activated leukocytes to sites of intravascular infection.

New guidelines for intravascular device-related infections.

New guidelines for intravascular device-related infections.

New CDC recommendations target intravascular device-related infections

New CDC recommendations target intravascular device-related infections

Guidelines for Prevention of Intravascular Device-Related Infection

Guidelines for Prevention of Intravascular Device-Related Infection

Intravascular device-related infections in cancer patients.

The successful management of oncology patients entails the safe use of intravascular catheters. Central venous catheters (CVC), particularly long-term silastic catheters, are commonly used in cancer patients to administer chemotherapy, antibiotics, blood products, and parenteral nutrition. Infection is one of the leading complications of these devices, and catheter-related septicemias represent the most frequent life-threatening complication of intravascular catheters [1–7]. The rate of septicemias associated with noncuffed CVC has ranged from 4 percent to 14 percent [8]. For long-term cuffed silastic catheters, a range of 8–43 percent has been reported [5]. More than 5 million CVCs are inserted in the United States annually [9]. Of those, about 0.5 million are cuffed silastic catheters [10]. Assuming a conservative average septicemia rate of only 8 percent, one would expect at least 400,000 CVC-related septicemias per year.

Intravascular device-associated systemic infections: a 2 year analysis of cases in a district general hospital

The increasing use of intravascular devices (IVDs) throughout medicine has been accompanied by significant morbidity and mortality associated with catheter-related sepsis (CRS). Within the South Buckinghamshire district, 330 episodes of bacteraemia/fungaemia were recorded over the 2 year period 1992–1993. Thirty-nine episodes (12%), occurring in 37 patients, were associated with IVDs and these were divided into three groups according to the type and site of device. Six patients died with CRS contributing to mortality whilst one patient suffered serious morbidity, in the form of vertebral osteomyelitis. This analysis highlighted deficiencies in the management of IVDs which are likely to be found in similar district general hospitals in the UK. There is an urgent need for national guidelines on IVD care together with recommendations for the optimal treatment of IVD-associated infection.

Yes, Virginia, Aseptic Technique Is Very Important: Maximal Barrier Precautions during Insertion Reduce the Risk of Central Venous Catheter-Related Bacteremia

Yes, Virginia, there is a Santa Claus. -Frances Pharcellus Church There long has been controversy over the level of sterile barrier precautions that should be used during the insertion of a short-term, noncuffed central venous catheter. Most authorities stress the need for good aseptic technique, stringent asepsis, or asepsis, and many explicitly advocate use of maximal sterile barriers,1-9 namely the use of sterile gloves, a long-sleeved surgical gown, a large sterile drape, and possibly a surgical cap and mask as well. However, most authors have not addressed the issue explicitly or endorsed the widespread practice of using only sterile gloves and drapes.1~19 Even the expert panel that wrote the first Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Intravascular Infections could not bring itself to recommend sterile barriers beyond gloves and drapes.20 No cardiologist performing a cardiac catheterization would use less than complete barrier precautions, despite the fact that the catheter remains in place for only an hour or two in most cases and rarely for more than 24 hours, even when the introducer is left in place for a percutaneous transcoronary angioplasty the following day. Realizing that a short-term, percutaneously inserted, noncuffed central venous catheter is the intravascular device most likely to cause nosocomial bloodstream infection,8,21,22 I have long believedadmittedly without conclusive supportive data-that maximal sterile barrier precautions should be mandat ry during the insertion of any central venous catheter (realizing that such precautions are unnecessary and would not be cost-effective for insertion of peripheral venous catheters or intraarterial catheters used for hemodynamic monitoring in an ICU).8 The problem with imposing such a standard on the 5 million short-term central venous catheters placed in U.S. hospitals each year has been the lack of scientific data affirming clearcut benefits in terms of reduction of device-related infection and, in the maelstrom of impending healthcare reform, economic cost-benefit. As a consequence, central venous catheters currently are inserted by physicians who wear sterile gloves, but often use little else in terms of barrier precautions. Personally having inserted hundreds of central venous catheters and supervised the insertion of several thousand over the past 20 years using a long floppy guidewire (as is the common practice), I would submit that without maximal sterile barriers-including a longsleeved gown and a large sterile sheet-drape-touch contamination of the guidewire, the catheter, or both is very common (but rarely appreciated).

Infections Associated with Prosthetic Devices: Clinical Considerations

The successful development of synthetic materials and introduction of artificial devices into nearly all body systems has been shadowed by the adaptation of microorganisms to the opportunities these devices afford for eluding defenses and invading the host. Clinicians are faced with the task of recognizing the manifestations of device-associated infection, predicting the likely pathogens involved, knowing the appropriate diagnostic methods, and initiating appropriate therapy. Infections associated with prosthetic heart valves are particularly challenging to successfully treat; surgical replacement may be necessary. Infection associated with an artificial joint usually requires removal of the device in addition to appropriate antibiotics. Intravascular associated infections are the leading cause of nosocomial bacteremias and, because of their intravascular location, these infections are often life catheter threatening if not promptly diagnosed and treated. Even contact lenses, external to epithelial surfaces, may give rise to serious sight-threatening infections. Although artificial devices play a paramount role in medicine today, infection is an ever present potential with which clinicians must be familiar.

Enterococcal septicemia in patients with hematological malignancies.

Thirty-six cases of enterococcal septicemia in patients with hematological malignancies were reviewed retrospectively and categorized according to their clinical significance using strict previously described definitions. Overall, most of the infected patients were males (77%), had acute leukemia (64%), had recently received cytotoxic drug therapy (86%), were granulocytopenic at the onset of septicemia (77%), and acquired the infection during hospitalization (77%). The source of septicemia was unknown in 18 (50%) patients, intestinal in 15 (42%) and intravascular in three (8%). Mortality was 19% among 21 inpatients who had clinically significant septicemia and 30% among patients with septicemia of uncertain clinical significance. The fatal outcome could be definitively attributed to enterococcal septicemia in only one of the nine inpatients who died. Clinically significant septicemia appeared somewhat more frequently to be polymicrobial (p = 0.06), whereas septicemia of unknown significance presented more frequently as breakthrough septicemia (p = 0.013). Unless associated with intravascular infection, enterococcal septicemia in patients with hematological malignancies seems to represent a marker of cytotoxic drug damage of the intestinal mucosa rather than a truly invasive infection.

Clinical evaluation of teicoplanin In the treatment of Gram-positive bacterial intravascular infections

Journal Article Clinical evaluation of teicoplanin In the treatment of Gram-positive bacterial intravascular infections Get access L. L. LIVORNESE, L. L. LIVORNESE The Medical College of Pennsylvania3300 Henry Avenue, Philadelphia, PA 19/29, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar M. GOLD, M. GOLD The Medical College of Pennsylvania3300 Henry Avenue, Philadelphia, PA 19/29, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar C. C. JOHNSON, C. C. JOHNSON The Medical College of Pennsylvania3300 Henry Avenue, Philadelphia, PA 19/29, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar R. MEASLEY, R. MEASLEY The Medical College of Pennsylvania3300 Henry Avenue, Philadelphia, PA 19/29, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar D. KAYE, D. KAYE The Medical College of Pennsylvania3300 Henry Avenue, Philadelphia, PA 19/29, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar O. KORZENIOWSKI, O. KORZENIOWSKI The Medical College of Pennsylvania3300 Henry Avenue, Philadelphia, PA 19/29, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar M. L. WALSH, M. L. WALSH The Medical College of Pennsylvania3300 Henry Avenue, Philadelphia, PA 19/29, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar C. SAMEL, C. SAMEL The Medical College of Pennsylvania3300 Henry Avenue, Philadelphia, PA 19/29, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar M. HESSEN, M. HESSEN The Medical College of Pennsylvania3300 Henry Avenue, Philadelphia, PA 19/29, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar M. E. LEVISON M. E. LEVISON The Medical College of Pennsylvania3300 Henry Avenue, Philadelphia, PA 19/29, USA Search for other works by this author on: Oxford Academic PubMed Google Scholar Journal of Antimicrobial Chemotherapy, Volume 31, Issue 1, January 1993, Pages 188–191, https://doi.org/10.1093/jac/31.1.188 Published: 01 January 1993

Reduced intravascular catheter infection by antibiotic bonding. A prospective, randomized, controlled trialKamal GD, Pfaller MA, Rempe LE, Jebson P JR. JAMA 1991;265:2364-8. Reprint requests: Dr. Gagan D. Kamal, De- partment of Anesthesia, Naval Hospital, Bldg. 215, Portsmouth, VA 23708.

Reduced intravascular catheter infection by antibiotic bonding. A prospective, randomized, controlled trialKamal GD, Pfaller MA, Rempe LE, Jebson P JR. JAMA 1991;265:2364-8. Reprint requests: Dr. Gagan D. Kamal, De- partment of Anesthesia, Naval Hospital, Bldg. 215, Portsmouth, VA 23708.

Modulation of interactions of Candida albicans and endothelial cells by fluconazole and amphotericin B.

Using an in vitro model of intravascular infection, we examined the effects of exposure to subinhibitory concentrations of fluconazole and amphotericin B on the ability of Candida albicans to adhere to and damage human umbilical vein endothelial cells. Incubation of the organisms for 18 h in 0.5x the MICs of fluconazole and amphotericin B inhibited endothelial cell adherence by 22 and 91%, respectively (P less than 0.001 for each drug). Candida-induced endothelial cell injury was also decreased by exposing the organisms to the antifungal drugs while in contact with the endothelial cells. Fluconazole inhibited damage by approximately 50% at concentrations ranging from 0.25x to 5x the MIC (P less than 0.01 for each concentration). Exposure to amphotericin B at 0.5x the MIC completely blocked the ability of the organisms to injure endothelial cells. The capacities of the antifungal agents to inhibit endothelial cell injury paralleled their abilities to suppress candidal germination. Organisms exposed to up to 5x the MIC of fluconazole had diminished, but still detectable, germ tube production and elongation, whereas incubation in 0.5x the MIC of amphotericin B completely abrogated germination. In addition to their direct effects on the growth of C. albicans, fluconazole and amphotericin B may decrease the ability of the fungus to disseminate hematogenously by inhibiting the organisms' capacity to adhere to and injure endothelial cells.

Reduced Intravascular Infection by Antibiotic Bonding

To the Editor. —The article by Kamal et al 1 concerns an important issue in hospital care: prevention of intravascular catheter-related infections. However, I think that the title of the article and the wording of the Results section suggest that the incidence of actual infection was reduced. In this study, the authors claim that bonding of antibiotic to the inner luminal and outer surface of the catheter reduced catheter infection ; I think this term is misleading. In the title, abstract, and the body of the article, they repeatedly refer to organisms isolated from catheters as representing infections. In fact, catheters do not become infected, they become contaminated or colonized. People become infected, but there is a conspicuous absence of data demonstrating that infection in the patients in whom these catheters were placed was reduced. Actually, the 13 cases of septicemia in the control group and the 10 in the antibiotic-bonded group

Reduced Intravascular Infection by Antibiotic Bonding-Reply

<h3>In Reply.</h3> —Dr Baltimore brings up an issue that needs to be addressed, namely, standardized definitions for catheterrelated infectious complications. Since there is currently no consensus in the literature,¹investigators are obligated to state clearly the scope and meaning of definitions used by them, as we have done. Whether it is the patient, organ(s) of a patient, or prosthetic devices that get infected is an interesting point of semantics. Our reference to "infected catheter" was in the same vein as a surgeon who takes a patient to the operating room to remove an "infected graft." Baltimore rightly points out that by our definition there was no catheter-related bloodstream infection in our study. As suggested by Maki et al,²15 or more colonies represent the precursor of catheter-related septicemia. As such, we believe that a mean colony count of 252 colony-forming units per catheter has obvious significance. Dr Solomon

Reduced Intravascular Infection by Antibiotic Bonding

To the Editor. —Kamal et al 1 state that their data suggest that antibiotic bonding of catheters would be highly cost-effective, but the technique of cost-effectiveness analysis is never used. Furthermore, the researchers have failed to demonstrate clinically relevant and quantifiable gains in outcome by the intervention group and have not considered direct and indirect costs of the two competing strategies. The article also raises the issue of conflict of interest in cost-effectiveness analysis. Health economists have recently begun to question the practice of conducting cost-effectiveness analyses that are sponsored by third parties who have a vested interest in the outcome, and they have suggested guidelines to maintain high standards. 2 Because Kamal et al promoted a single catheter type and prominently displayed the brand name in the accompanying photograph, the potential for financial gain to the manufacturer cannot be ignored. As questions about medical resource allocation grow in importance,

Reduced intravascular infection by antibiotic bonding

Reduced intravascular infection by antibiotic bonding

Intravascular Plastic Catheters

We tested the hypothesis that long-term intravascular cannulation exacerbates the harmful effects of an infectious challenge. Four groups of rats were initially studied: rats without intravascular catheters or infection (group 1), rats without catheters with a polymicrobial infection (group 2), rats with catheters but no infection (group 3), and rats with catheters and infection (group 4). Infected animals had an increased mortality and generated a significantly increased tumor necrosis factor response compared with noninfected animals. Animals with catheters and infection generated far less cardiac output than animals from the other three groups. No histologic changes differentiated the four groups. Therefore, the presence of a sterile intravascular catheter significantly increases cardiac dysfunction and mortality rates in rats with chronic bacteremia. These results suggest that intravascular plastic catheters potentiate the destructive cascade of events produced by the host in response to bacteremia.

Striving for benchmark infection rates: Progress in control for patient mix

The outcome of clinical events has become the major focus for quality assurance programs in the United States. Assessment of outcome depends on the availability of accurate benchmark rates appropriate to the clinical situation. Although mortality, length of stay, cost, and other resource utilization measures are important outcome events for review, nosocomial infection is one of the best-studied outcome events for which benchmark rates and distributions of rates are available. To monitor nosocomial infection acquisition, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has proposed indicators for wound infections after clean and clean-contaminated surgical procedures, for pneumonia in intensive care units (ICUs), and for intravascular device infections in ICUs. From the National Nosocomial Infections Surveillance (NNIS) system, we know that the mean rate of surgical wound infections (SWIs) for clean-contaminated wounds is 2.7%. However, the range is too broad and depends on the types of surgical procedures and the patient risk factors in each category. As an example, the SWI rate for appendectomies is 2.2% while for colon surgery it is 7.1%. In addition, the patients should be stratified by underlying risk factors. For example, the NNIS risk index is composed of wound class, duration of surgery, and American Society of Anesthesiology score. Other commonly used severity of illness scores could be used, such as a comorbidity score or APACHE II. Other proposed JCAHO indicators are reviewed. Controlling for case mix and for severity of illness will be necessary for the development of benchmark infection rate distributions if clinical indicators are to be used as reliable quality assurance tools in the 1990s.