Re: CVC Tip culture

Dear Tim,

What does INS stand for, and what would be the bibliographical citation/reference for the text passage you cite?

If I read the text passage correctly, the notion is routinely, i.e. do not routinely culture. But it would seem indicated in cases of clinically suspected CR-BSI, in conjunction with blood cultures, and that seems consistent with what Claire writes and with the Mermel 2009 clinical definitions (as opposed to surveillance definitions) of CR-BSI that Claire attached.

Best regards, Matthias.

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From: ACIPC Infexion Connexion [mailto:AICALIST@AICALIST.ORG.AU] On Behalf Of Tim Spencer
Sent: Thursday, 16 March, 2017 10:23 PM
To: AICALIST@AICALIST.ORG.AU
Subject: Re: CVC Tip culture

Hi Cate,

The current INS Standards of Practice (2016) recommendation not to culture the catheter tip. I have cut & pasted from the standards.
SHEA and APIC dont really address this issue clearly (or at all).
Other standards (IVNNZ, RNAO and RCN) follow the same recommendations as the INS SOP.

Practice Criteria

A. Assess for signs and symptoms of a VAD-related infection which may include, but is not limited to, erythema; edema; any pain or tenderness or drain- age; fluid in the subcutaneous pocket of a totally implanted intravascular device or subcutaneous tunnel for any tunneled catheter; induration at the exit site or over the pocket; spontaneous rupture and drainage; necrosis of the overlying skin at the VAD insertion site; and/or body temperature elevation. Immediately notify the licensed independent practitioner (LIP) when signs and symptoms of a VAD- related infection are present, and implement planned interventions.1 (IV)

B. Consider site selection for VAD placement as a strategy to prevent infection. To minimize the risk of catheter-related infection with a nontunneled central vascular access device (CVAD), the subclavian vein is recommended in adult patients, rather than the jugular or femoral (refer to Standard 27, Site Selection).

C. Remove a peripheral venous catheter if the patient develops symptoms of infection (eg, erythema extending at least 1 cm from the insertion site, induration, exudate, fever with no other obvious source of infection) or the patient reports any pain or tenderness associated with the catheter.1-3 (IV)

D. Do not remove a functioning CVAD based solely on temperature elevation and the absence of confirmatory evidence of catheter-related infection. Use clinical judgment regarding the appropriateness of removing the catheter if an infection is evidenced elsewhere or if a noninfectious cause of fever is sus- pected.2,4 (IV)

E. Collaborate with the LIP and patient to collectively determine if the CVAD can be salvaged. For hemodynamically stable outpatients with catheter-related bloodstream infection (CR-BSI), catheter salvage may be a safe and appropriate strategy. Removal of the CVAD is required if there is clinical deterioration or persisting or relapsing bacteremia. The insertion of a new CVAD at a new site should be a collaborative decision based on the specific risks and benefits for each patient. Factors to consider in the decision to salvage a catheter include:

* The type of VAD (eg, percutaneous versus surgically inserted long-term catheter).
* Difficulty with inserting a new CVAD.
* Presence of bleeding disorders.
* The infecting organism(s) as confirmed by paired
* blood cultures.
* The presence of other complicating conditions
* including, but not limited to, severe sepsis, suppurative thrombophlebitis, endocarditis, or the presence of vascular or other hardware (eg, a pacemaker).1,5-8 (IV)

F. Anticipate the removal of a short-term CVAD (in situ less than or equal to 14 days) in a pediatric patient with an uncomplicated CR-BSI and treat with systemic antibiotics for at least 7 to 14 days based on the pathogen. Infections with Staphylococcus aureus, gram-negative bacilli, or Candida require immediate removal of the infected CVAD and a defined course of systemic antibiotic therapy, except in rare circumstances when no alter- native venous access is available. Patients with a long-term CVAD and an uncomplicated CR-BSI because of coagulase-negative Staphylococcus or Enterococcus may retain the CVAD and complete a course of systemic antibiotics with the use of antibiotic lock therapy. Closely monitor and clinically evaluate pediatric patients treated without catheter removal, including additional blood cultures and the use of antibiotic lock therapy with systemic therapy for catheter salvage.8 (V)

G. Consider the use a prophylactic antimicrobial lock solution in a patient with a long-term CVAD who has a history of multiple CR-BSIs despite optimal maximal adherence to aseptic technique. Aspirate all antimicrobial locking solutions from the CVAD lumen at the end of the locking period (refer to Standard 40, Flushing and Locking).

H. Remove a CVAD from a patient with CR-BSI associated with any of the following conditions: severe sepsis; suppurative thrombophlebitis; endocarditis; bloodstream infection that continues despite greater than 72 hours of antimicrobial therapy to which the infecting microbes are susceptible; or infections due to S. aureus, P. aeruginosa, fungi, or mycobacteria following collaboration with the LIP.1,4 (IV)

I. Do not use a guidewire exchange to replace a non-tunneled catheter suspected of infection.2 (V)

J. Consider a catheter exchange procedure when other vascular access sites are limited and/or bleeding dis- orders are present. Consider an antimicrobial- impregnated catheter with an anti-infective intraluminal surface for catheter exchange.1 (IV)

K. Collect a specimen of purulent exudates from a peripheral or CVAD exit site for culture and gram staining to determine the presence of gram-negative or gram-positive bacteria as ordered by an LIP.1 (IV)

L. Do not routinely culture the CVAD tip upon removal unless the patient has a suspected CR-BSI. Catheter colonization may be detected but does not indicate the presence of a bloodstream infection. This practice results in inappropriate use of anti-infective medications, thus increasing the risk of emergence of antimicrobial resistance. Recognize that the catheter tip culture will identify microorganisms on the external catheter and not microorganisms located on the intraluminal surface.1 (IV)

M. Culture the tip of short-term central vascular and arterial catheters suspected of being the cause of a CR-BSI using a semiquantitative (roll-plate) method or quantitative (sonication) method upon removal. Culture the introducer/sheath tip from a pulmonary artery catheter when a CR-BSI is suspected.1 (IV)

N. Culture the reservoir contents of a port body of an implanted port and the catheter tip when it is removed for suspected CR-BSI.1 (IV)
O. Consider contamination of the infusate (such as par- enteral solution, intravenous medications, or blood products) as a source of infection. This is a rare event, but an infusate can become contaminated during the manufacturing process (intrinsic contamination) or during its preparation or administration in the patient care setting (extrinsic contamination). An infusate-related bloodstream infection is the isolation of the same organism from the infusate and from separate percutaneous blood cultures, with no other identifiable source of infection.2,7-9 (IV) (see Standard 43, Phlebotomy).

P. For a suspected CR-BSI, obtain paired blood samples for culture, drawn from the catheter and a peripheral vein, before the initiation of antimicrobial therapy. Blood cultures from both the catheter and venipuncture must be positive for the same organism with clinical signs and symptoms and no other recognized source. Consider quantitative blood cultures or the differential period of central line culture versus peripheral blood culture positivity >2 hours for the diagnosis of CR-BSI (see Standard 43, Phlebotomy).1,6,10,11 (IV)

REFERENCES
Note: All electronic references in this section were accessed October 5, 2015.

1. 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. Erratum in: Clin Infect Dis. 2010;50(3):457; Clin Infect Dis. 2010;50(7):1079.

2. OGrady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. http:// http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html. Published April 2011.

3. Rickard CM, Webster J, Wallis MC, et al. Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet. 2012;380(9847):1066-1074.

4. Chopra V, Flanders SA, Saint S, et al. The Michigan appropriate- ness guide for intravenous catheters (MAGIC): results from an international panel using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;163(suppl 6):S1-S39.

5. Caroff D, Norris A, Keller S, et al. Catheter salvage in home infusion patients with central line-associated bloodstream infection. Am J Infect Control. 2014;42(12):1331-1333.

6. Chopra V, Anand S, Krein SL, Chenoweth C, Saint S. Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Am J Med. 2012;125(8): 733-741.

7. Kumar A, Kethireddy S, Darovic GO. Catheter-related and infusion-related sepsis. Crit Care Clin. 2013;29(4):989-1015.

8. Huang EY, Chen C, Abdullah F, et al. Strategies for the prevention of central venous catheter infections: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg. 2011;46(10):2000-2011.

9. The Joint Commission. Preventing central line-associated blood- stream infections: a global challenge, a global perspective. http:// http://www.jointcommission.org/preventing_clabsi. Published May 2012.

10. Septimus E. Clinician guide for collecting cultures. http://www.cdc.gov/getsmart/healthcare/implementation/clinicianguide.html. Published April 7, 2015.

11. Garcia RA, Spitzer DE, Beaudry J, et al. Multidisciplinary team review of best practices for collection and handling of blood cultures to determine effective interventions for increasing the yield of true-positive bacteremias, reducing contamination, and eliminating false-positive central line-associated bloodstream infections. Am J Infect Control. 2015;43(11):1222-1237.

APIC Guide 2009 – ASSOCIATION FOR PROFESSIONALS IN INFECTION CONTROL AND EPIDEMIOLOGY
Guide to the Elimination of Catheter-Related Bloodstream Infections

1. A CLABSI as defined by CDC, is a primary (i.e., no apparent infection at another site) BSI in a patient that had a central line within the 48-hour period before the development of the BSI. BSI is defined using either laboratory- confirmed bloodstream infection (LCBI) or clinical sepsis (CSEP) definitions (see Definition of Terms). In the CDC/NHSN definition of CLABSI, there is no minimum period of time that the central line must be in place in order for the BSI to be considered central lineassociated. The culture of the catheter tip is not a criterion for CLABSI.

Timothy R. Spencer, RN, APN, DipAppSci, BHealth, ICCert, VA-BC
Vascular Access Consultant
E: tim.spencer68@icloud.com
M: +1 (623) 326 8889 (USA)
M: +61 (0)409 463 428 (AU)
ABN: 51606547370
http://orcid.org/0000-0002-3128-2034

On Mar 15, 2017, at 10:42 PM, Cate Coffey <Cate.Coffey@NT.GOV.AU> wrote:

Hi everyone
We are updating our policies and I notice that our CVC and Vascath polices recommend culturing the tip of CVC. Could you tell me if there is evidence to support this practice Wouldnt a blood culture be more appropriate to diagnose infection? Can there be a CVC tip infection without bloodstream infection and what is the relevance if there is?
We do not have 24 hour pathology service so it means that tip cultures could only be sent during lab hours?
Can you let me know your thoughts?
Cate Coffey | Clinical Nurse Consultant
Infection Prevention and Control Unit | Central Australia Health Service
Northern Territory Government
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e … cate.coffey@nt.gov.au http://www.nt.gov.au/health

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