Venenkatheter-assoziierte Infektionen

Transcription

1 Update Infektionen in der Hämatologie und Onkologie Venenkatheter-assoziierte Infektionen Georg Maschmeyer Potsdam

2 Aktuelle Leitlinie der AGIHO...unter Berücksichtigung von: Ann Hematol 2008; 87:863-76

3 Empfehlungen: Diagnostik One pair of blood cultures from the catheter and one from a peripheral vein (A-II) Semiquantitative culturing after catheter removal (A-II) Quantitative culturing from interior catheter surface, vortex and ultrasound treatment to disengage adhesive bacteria (A-II) Ultrasound imaging along the catheter tunnel (C-III) Blood cultures from all lumina of the catheter (C-III) Cultures from the catheter hub not recommended (D-II) Skin swab not recommended (D-III) Placing the catheter tip in broth and subsequently culturing the pathogen not recommended (E-II) Wolf HH et al (AGIHO), Ann Hematol 2008;87:863-76

4 Empfehlungen: ZVK-Management Primary catheter removal: CRI due to S.aureus (A-II) CRI due to Candida spp. (B-II) Punnel and pocket infection (B-III) Complicated CRI (i.e., metastatic organ or severe soft tissue infections) (B-II) Preservation of CVC attempted in clinically stable patients with: Coagulase-negative staphylococci, C.jeikeium, A.baumannii, S.maltophilia, P.aeruginosa, and Bacillus spp. (B-III) Wolf HH et al (AGIHO), Ann Hematol 2008;87:863-76

5 Empfehlungen: Antimikrobielle Therapie Same principles as treatment of fever of unknown origin Prompt empirical vancomycin therapy not required (A- II) At least 2 weeks of systemic antimicrobial treatment in immunosuppressed patients (B-III) In-vitro susceptible pathogens: penicillinase-resistant penicillin preferable to glycopeptide (B-II) Wolf HH et al (AGIHO), Ann Hematol 2008;87:863-76

6 Patients with Catheter-Related Infections: Response to Empiric Standard Antibiotics + Vancomycin n CR NR ED Only clinically documented % 8% 4% Clinically + microbiologically documented 26 85% 8% 8% Total % 8% 5% Link H et al (PEG Study Group), Ann Hematol 1994;69:231-43

7 Empfehlungen: Prävention (1) Access via the subclavian vein preferred to internal jugular vein (A-I) Compliance with hygiene principles during insertion and standardized aseptic (A-I) Education programs for nurses and physicians (A-II) Ultrasound-guided placement (B-I) Antibiotic lock in addition to systemic antibiotic therapy to reduce the relapse rate of CRI (C-III) Wolf HH et al (AGIHO), Ann Hematol 2008;87:863-76

8 Empfehlungen: Prävention (2) Use alcoholic chlorhexidine solution, alcoholic polyvidone iodine solutions or 70% propanolol for disinfection of insertion site (A-I) No routine catheter replacement (D-I) No systemic prophylactic antibiotic treatment prior to catheter insertion (E-I) No topical antibiotic ointments at catheter insertion site (E-I) Wolf HH et al (AGIHO), Ann Hematol 2008;87:863-76

9 Mermel LA et al (IDSA), Clin Infect Dis 2010;49:1-45

10 Summary of recommendations:... Mermel LA et al (IDSA), Clin Infect Dis 2010;49:1-45

11 Methods for the diagnosis of acute fever for a patient suspected of having short-term central venous catheter infection or arterial catheter infection Mermel LA et al (IDSA), Clin Infect Dis 2010;49:1-45

12 Management of patients with short-term central venous catheter related or arterial catheter related bloodstream infection Mermel LA et al (IDSA), Clin Infect Dis 2010;49:1-45

13 n = 188 patients with CNS bacteremia Resolution of infection within 48 h (93%) not influenced by CVC removal or exchange versus retention Patients with catheter retention were 6.6 times more likely to have a recurrence than were those whose catheter was removed or exchanged (p = 0.004) CVC retention is a significant risk factor of recurrence Raad I et al (MDACC), Clin Infect Dis 2009;49:

14 Treatment of a patient with a long-term central venous catheter or a port-related bloodstream infection Mermel LA et al (IDSA), Clin Infect Dis 2010;49:1-45

15 Concentrations of Antibiotic Lock Solutions Used for the Treatment of Catheter-Related Bloodstream Infection Mermel LA et al (IDSA), Clin Infect Dis 2010;49:1-45

16 Trotz 123 Empfehlungen...: Unresolved Issues Prior guidelines call for negative TEE findings for all patients with S. aureus CRBSI to allow for a treatment duration of only 2 weeks. However, some experts believe that a TEE is not needed for patients without intravascular hardware who have rapid resolution of bacteremia and signs and symptoms of acute infection The true value and optimal duration of antimicrobial lock solutions as an adjunctive to systemic antibiotic therapy administered through the catheter remains unknown Can antimicrobial therapy for CRBSI due to coagulase-negative staphylococci be safely omitted for patients who are at low risk for complications (i.e., those who no intravascular foreign body) when clinical signs and symptoms have resolved promptly after catheter removal? The clinical impact of culturing and reporting colonized catheters for patients without bacteremia or fungemia is unclear What is the optimal duration of therapy for S. lugdunensis CRBSI? It remains unclear which strategy CVC change over a guidewire, insertion of a new CVC at a new site, or watchful waiting is preferred among patients with suspected but unconfirmed catheter-related infection, pending blood culture results How should patients be treated who have positive catheterdrawn blood culture results and negative percutaneous blood culture results? What is the optimal duration of antimicrobial use when an infected CVC is not removed? Is the roll-plate method or the sonication method preferred for the diagnosis of long-term catheter related infection? Should blood cultures be routinely obtained after completing a course of antibiotics for CRBSI? Mermel LA et al (IDSA), Clin Infect Dis 2010;49:1-45

17 Nucci M et al, Clin Infect Dis 2010;51:

18 Subgroup analysis of 2 phase III, multicenter, doubleblind, randomized, controlled trials of candidemia Nucci M et al, Clin Infect Dis 2010;51:

19 Nucci M et al, Clin Infect Dis 2010;51:

20 Nucci M et al, Clin Infect Dis 2010;51:

21 Time to Mycological Eradication Nucci M et al, Clin Infect Dis 2010;51:

22 Nucci M et al, Clin Infect Dis 2010;51:

23 We conclude that early CVC removal in nonneutropenic adults with candidemia does not influence patient outcomes and that the recommendation to remove all CVCs in nonneutropenic patients may not be justified. Instead, CVC management should be individualized. Nucci M et al, Clin Infect Dis 2010;51:

24 Dettenkofer M et al (Freiburg/Basel), Clin Microbiol Infect 2010;16:600-6

25 N = 400; haematology units and one surgical unit of two university hospitals Adult patients with a non-tunnelled CVC randomly assigned to two different skin disinfection regimens at the insertion site: 0.1% octenidine with 30% 1-propanol and 45% 2-propanol, vs 74% ethanol with 10% 2-propanol Skin colonization at the CVC insertion site during the first 10 days significantly reduced by octenidine treatment (relative difference: 0.21; 95%CI: , p <0.0001) Positive culture of the catheter tip significantly less frequent in the octenidine group (7.9%) than in the control group (17.8%): OR = 0.39 (95%CI: , p = 0.009) Patients treated with octenidine had a non-significant reduction in catheter-associated bloodstream infections (4.1% vs. 8.3%; OR = 0.44; 95%CI: , p = 0.081) Side effects similar in both groups Dettenkofer M et al (Freiburg/Basel), Clin Microbiol Infect 2010;16:600-6

26 The Cochrane Library 2009, Issue 1

27 Main Results and Conclusions 9 trials with 588 patients 4 on vanco/teico prior to insertion vs placebo 5 on antibiotic flushing combined with heparin vs heparin flushing only Antibiotic prior to catheter insertion decreases the number of Gram positive CVC infections (odds ratio [OR] = 0.42, 95% CI = not significant) Flushing the CVC with a vanco/heparin lock solution is beneficial (OR = 0.43, 95% CI ) => NNT = 13 (95 % CI 5-23) Conclusion: if the catheter related infection-rate is high, it is justified to flush the catheter with a combination of an antibiotic and heparin The Cochrane Library 2009, Issue 1

28 Risk of Clinically Manifest Catheter- Related Thrombosis Van Rooden CJ et al (Leiden, NL), J Clin Oncol 2005;23:

29 Bloodstream Infections in Acute Leukemia: Port vs Conventional CVC Johansson E et al (Stockholm), Support Care Cancer 2004;12:99 105

30 Incidence of Catheter-Related Infection in Cancer Patients with CVC Hanna H et al (MDACC), J Clin Oncol 2004;22:

31 Thanks for Listening