National Healthcare Safety Network: Central Line-associated Bloodstream Case Studies Teresa C. Horan, MPH

Transcription

1 National Healthcare Safety Network: Central Line-associated Bloodstream Case Studies Teresa C. Horan, MPH National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

2 Mrs. A 64-year-old female admitted from ED on 7/18 to the surgical intensive care unit with severe abdominal pain. IV catheter (20g) inserted (R) forearm. Lungs clear. Chest x-ray WNL. Abdominal CT demonstrated large mass blocking lower half of colon. PMH: Hypertension, diabetic, 1 pack/day smoker, occasional alcohol use. Admission Vital Signs & Labs: BP 129/62, Temp F, P 105, Na 135, K 3.3, Glucose 202, BUN 22, Cr 0.4,WBC 12.4, HGB 12.6, HCT 37.

3 Mrs. A Continued Surgical Findings/Procedure: To OR on 7/18. Large mass in colon - (R) Hemicolectomy (COLO). Many gallstones - open cholecystectomy (CHOL) Perforated small intestine - SB repair (SB). Duration: 4 hr, 35 min., primary closure, general anesthesia. ASA class 4, wound class contaminated (III). Admitted to SICU on 7/18 following surgery.

4 Mrs. A Continued DATE TEMP DIAGNOSTIC FINDINGS 7/18 Pathology results consistent with adenocarcinoma of the colon. 7/24 Abdominal incision draining purulent drainage. Slight erythema and induration. Wound not cultured. Started on antibiotics. 7/25 Port implanted for chemo and antibiotics on 7/25. 7/ Switched to oral antibiotics and transferred to LTAC. 8/1-8/13 Wound completely healed. 8/14 8/ Port accessed for the first time for chemo x1; patient had reaction to IV chemo was switched to PO chemo. BC x 2 drawn from L arm. Urine collected and sent for urinalysis and culture. Chest x-ray done - WNL. Urinalysis - WNL. Pt started on antibiotics empirically. Port not being used. 8/22-8/23 T Max-99.6 Urine culture no growth in 48 hours. BC positive for MSSA. 8/30 Discharged to nursing home in stable condition on antibiotics.

5 Does this patient have a CLABSI? 1. Yes, this patient has a CLABSI meeting criterion 1. To which location should the CLABSI be attributed? 3. LTAC Transfer Rule: If a CLABSI develops within 48 hours of transfer from one inpatient location to another in the same facility, the infection is attributed to the transferring location. In this case the patient was transferred on 7/31 from SICU to an LTAC and BSI onset was not until 8/21.

6 Mrs. C 45-year-old female, with newly diagnosed stage IIB endometrial cancer, admitted to the Women s Center on 11/2 for a total abdominal hysterectomy, bilateral salpingo-oophorectomy and removal of pelvic and abdominal lymph nodes. Patient is also scheduled to have a PICC placed for participation in a clinical trial. History: 3 month history of new onset pelvic pain and dysmenorrhea. The patient has had two previous C-sections with the last one ten years ago. Admission Vital Signs & Labs: BP 117/70, P 82, T 36.0 C, WBC 5.2, HGB 8, HCT 29.

7 Mrs. C Date Temp Diagnostic Findings 11/2 36 Nursing admission obtained; L arm PICC line placed in interventional radiology. 11/2 Patient typed and cross matched for 2 units packed RBC for treatment of anemia. Blood transfused through PICC. 11/3 Afebrile Surgical procedure performed with no complications reported. Patient transported back to Women s Center from Post-op Recovery Unit. 11/4 Afebrile Post-op antibiotics discontinued. Dressing changed on abdominal incision with no signs of erythema or drainage noted. Foley draining clear yellow urine. 11/5 Afebrile Patient able to ambulate with assistance; Foley d/c d. Dressing remains dry and intact. Patient reported first bowel movement post-op without difficulty. Patient medicated for abdominal pain (8 on 10 scale). 11/ Patient continues to complain of abdominal pain unresolved with pain meds. Slight tenderness noted on palpation of L lower abdomen. 11/7 39 Blood specimens collected x 2. Patient sent for CT scan of the abdomen. Report notes: abscess present in L lower abdominal cavity. Drain placed in the L lower abdominal cavity and drainage obtained for culture. IV placed and antibiotics started.

8 Mrs. C Date Temp Diagnostic Findings 11/ Blood culture positive for VRE and Bacteroides fragilis x 2 and abscess culture positive for Bacteroides fragilis. Patient reports decreased abdominal pain. 11/12 36 Drain removed. Abdominal sounds present. Follow-up CT scan reveals that intra-abdominal abscess is resolved. Patient discharged. Does this patient have an HAI? YES If so, what type? The patient has an organ/space SSI-IAB and a secondary BSI with B. fragilis and VRE. NOTE: Although VRE was not isolated from the culture of the abdominal abscess it is an organism which is logical for the site and so the BSI is considered secondary.

9 Mrs. C Continued

10 Mrs. C Continued

11 Day 1: Mr. D 79-year-old male, admitted with gastric cancer. Central line placed day of admission for TPN. Day 2: Partial gastrectomy performed. Day 6: Patient progressing well until fever spike of F. Blood specimens x 2 obtained for culture. Day 7: Increasing abdominal pain. CT scan of abdomen shows small fluid collection posterior to stomach. Fluid collection fully drained by ultrasound guided needle aspiration and the recovered purulent fluid sent for culture.

12 Mr. D Continued Day 8: Blood cultures 2 of 2 positive for Staphylococcus epidermidis. Abdominal fluid growing Gramnegative rods. Antibiotics begun. Day 9: Abdominal fluid culture: Enterobacter cloacae

13 Does this patient have a CLABSI? 1. Yes, CLABSI with S. epidermidis only. 2. No, SSI-IAB with S. epidermidis and E. cloacae. 3. Yes, CLABSI with S. epidermidis and E. cloacae.

14 Mr. D Continued Cultures collected from sites to determine the primary or secondary status of a concurrent blood culture must contain the same organism as the blood. This patient s blood only grew S. epidermidis so only meets LCBI criterion 2. He also has an SSI-IAB with Enterobacter cloacae.

15 Mr. D Continued

16 Mr. D Continued

17 Ms. E 8/14 8/17 8/19 A 41-year-old female presents to the Emergency Room in diabetic coma and with anemia. She has a subclavian catheter inserted in the Emergency Room. The next day, in the ICU, she has a midline catheter inserted and receives blood transfusions. She develops fever of 39 C and shaking chills. Blood specimens for culture x 3 obtained. All blood cultures are positive for Staphylococcus haemolyticus. Neither insertion site shows inflammation and there is no other documented infection.

18 Is there an LCBI and if so, which criterion of LCBI? 1. LCBI criterion 1 recognized pathogen from 1 or more blood cultures 2. LCBI criterion 2 at least one sign/symptom and common commensal from 2 or more blood cultures 3. No LCBI

19 Ms. E continued Let s change this scenario and say that on 8/17 the patient s subclavian catheter site is red and has a small amount of pus present. Does this change your decision? 1. No, this patient still has a CLABSI. 2. Yes, this is no longer a CLABSI; it is a vascular site infection (CVS-VASC)

20 Ms. E Continued

21 Ms. F 3/11 at 9pm patient presents to ED for pain crisis due to sickle cell disease; vital signs WNL. She states she ran out of her medication. Pan cultures are ordered and collected to rule out infection. L upper arm PICC inserted. PMH: She has a complex medical history which includes liver disease, depression and frequent hospital stays. She has been suspected of injecting her port with contaminants including urine. Her hematologist is no longer seeing her due to manipulative behavior. On day of admission she was seen by her psychiatrist, who suggested that she only take oral medication and will work to coordinate her care.

22 Ms. F Continued 3/12: At 3am she complained of fever and chills upon admission to the unit; actual vital signs were WNL. Nursing notes state patient suspected of crushing up dry wall flakes, mixing with water and injecting into her line. 3/13: 2 of 2 blood cultures from admission grew coagulasenegative staphylococci; all other cultures negative. 3/15: Temp F; blood cultures collected and grew Delftia acidovorans; discarded needles were found in patient s bedside drawer. 3/16: Temp F; blood cultures collected and grew Delftia acidovorans on 3/19; fever resolved without treatment; patient discharged to inpatient behavioral health facility.

23 Is this an HAI? 1. Yes, it was not incubating or present on admission. 2. No, this infection was self-inflicted. 3. No, the patient had positive blood cultures on admission. Note: The means in which an infection develops does not prevent it from meeting the HAI criteria. It may indicate that different or unique prevention strategies may need to be implemented.

24 Is this a CLABSI? 1. Yes, it meets LCBI criterion Yes, it meets LCBI criterion No, it does not meet CLABSI criteria.

25 Baby Z Day 1: One-day-old twin male infant admitted and emergently transferred to Neonatal Intensive Care Unit. Intubated during transport. Admitted with peripheral IV in scalp, IV fluid at 1cc/hr with Prostin (0.05mcg/kg/min) started prior to transport, and umbilical venous catheter present. Neonatal History: Gestational age = term infant, birth wt grams, Apgars 5 & 6. An echocardiogram showed transposition of the great vessels of the heart.

26 Baby Z Day 3: Day 4: Day 5: Repair of Patent Ductus Arteriosus and Atrial Septal Defect performed; later that day the umbilical catheter site was noted to be slightly red. Umbilical catheter site remained slightly red and a low grade fever developed. 1 blood specimen was drawn through umbilical line; line was discontinued and the catheter tip sent for culture. PICC line placed.

27 Baby Z Day 6: Day 7: Continued elevated temp of 38.1 C (core) and antibiotics were started. Blood culture was negative but the umbilical catheter tip was positive for Staphylococcus epidermidis >15 colonies. Antibiotics adjusted.

28 Does this patient have an LCBI? 1. No, this patient does not have an LCBI. 2. Yes, this patient has an LCBI. Catheter tip cultures are not utilized for NHSN LCBI criteria. Note: Catheter tip cultures are part of CVS-VASC criteria but there can be no blood culture done or if done, it must be negative to qualify. (PS Manual Chapter 17, p 318, January 2012)

29 Baby Z Does not meet this criterion x

30 Baby Z continued What if the catheter tip had been negative, but the blood culture was positive for S. epidermidis? Would the baby have a CLABSI? 1. Yes, the baby has a CLABSI with S. epidermidis. 2. No, the baby does not have a CLABSI. Note: There must be positive blood cultures from 2 separate blood draws to meet that portion of the LCBI criterion 2 (common commensals). This baby only had 1 blood draw.

31 If the patient had both the PICC and the umbilical line at the same time, how would the device-day data be recorded? 1. 1 central line day 2. 2 central line days 3. 1 umbilical catheter day 4. 1 central line day and 1 umbilical catheter day NOTE: If a NICU infant has both an umbilical catheter and a nonumbilical central line, count as a single central line day only. (PS Manual Ch.14, p25 dated January 2012)