さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

CRBSI 復習

たびたび、復習
4/23にも取り上げましたが、CRBSIです


60代 女性 110㌔
CRBSI 

内科医と学生が戦略を練りました
グラム陽性球菌の検出から
また、カテ抜去、陰性確認
敗血症の全身マネジメントなど

実習生も、基本プラクティスを押さえてきたかなと思いました。

以下、Up To Dateより復習

INDICATIONS FOR TREATMENT 

In general, for circumstances in which systemic intravenous catheter-related infection diagnostic criteria are met, treatment requires determination regarding catheter management (eg, removal, salvage, or exchange) and antibiotic therapy (eg, selection of empiric therapy with subsequent tailoring to culture and sensitivity data).

In general, systemic antibiotic therapy is NOT required in the following circumstances
•Positive catheter tip culture in the absence of clinical signs of infection
•Positive blood cultures obtained through a catheter with negative cultures through a peripheral vein
•Phlebitis in the absence of infection

Removal

Following diagnosis of catheter-related infection, catheter removal is appropriate in the setting of severe sepsis, hemodynamic instability, suppurative thrombophlebitis, endocarditis, or persistent bacteremia after 72 hours of antimicrobial therapy to which the organism is susceptible.

The type of pathogen is important for guiding decisions regarding catheter management. Long term catheters (indwelling ≥14 days) should be removed in the setting of catheter-related bloodstream infection (CRBSI) due to S. aureus, P. aeruginosa, fungi or mycobacteria. Organisms of relatively low virulence that are difficult to eradicate (eg, Bacillus spp, Micrococcus spp, or Propionibacteria) should also prompt catheter removal if blood culture contamination has been ruled out.

Salvage, guidewire exchange

Catheter salvage may be attempted in the setting of uncomplicated CRBSI of long term catheters due to pathogens other than those outlined above. For circumstances in which catheter removal is necessary and risk for complications during catheter reinsertion is high, guidewire exchange of the catheter may be appropriate.

Antibiotic lock therapy 

Adjunctive antibiotic lock therapy in combination with systemic therapy for intraluminal infections due to coagulase negative staphylococci can be a useful strategy for the treatment of CRBSI when the catheter cannot be removed. Antibiotic lock therapy should not be used for extraluminal infections nor for management of infections due to S. aureus, Pseudomonas aeruginosa, resistant gram-negative bacilli, or Candida. 

Empiric antibiotic therapy

Empiric antibiotic therapy for CRBSI in health care settings should include activity against methicillin resistant S. aureus; vancomycin is a reasonable agent. Patients with neutropenia or sepsis should also receive empiric antibiotic therapy for gram negative organisms (including Pseudomonas). Patients known to be colonized with drug resistant organisms should receive empiric antibiotic therapy selected accordingly; therapy should be tailored based on subsequent culture data.

Tailoring therapy 

Following initiation of empiric treatment, antibiotic therapy should be tailored to culture and susceptibility results as needed once data are available. 

S. aureus 

In general, transesophageal echocardiogram (TEE) should be pursued in the setting of S. aureus bacteremia to rule out infective endocarditis (IE). Possible exceptions include patients whose fever and bacteremia resolve within 72 hours following catheter removal and have no underlying cardiac predisposing conditions or clinical signs of endocarditis.

duration of therapy

In general, for uncomplicated CRBSI with negative blood cultures following catheter removal or guidewire exchange and institution of appropriate antibiotic therapy, the duration of therapy is 10 to 14 days (day one is the first day on which negative blood cultures are obtained). Patients with persistent bacteremia >72 hours following catheter removal should receive treatment for at least 4 to 6 weeks. For patients with complications related to bacteremia (such as suppurative thrombophlebitis, endocarditis, osteomyelitis, metastatic infection) the duration of therapy should be tailored accordingly depending on the nature of infection.

FOLLOW-UP

Patients with CRBSI must be monitored closely during and following therapy to detect relapses or signs of metastatic infection. Blood cultures should be drawn after treatment has been initiated to demonstrate clearance of bacteremia. Repeatedly positive blood cultures and/or persistent symptoms 72 hours after catheter removal with appropriate antibiotic therapy should prompt evaluation for sequelae of CRBSI including suppurative thrombophlebitis, endocarditis, and metastatic foci of infection.

LOCAL SITE INFECTIONS

Management of local site infections depends on the nature of the infection.