Lancashire Teaching Hospitals NHS Foundation Trust Haemodialysis central venous catheter-related sepsis management guideline Version 3 AUTHOR APPROVED BY DATE AUTH REF. NO NAME REBG/00018/July12 Michael Heap TITLE Dialysis Access Specialist Nurse INITIATING DIRECTORATE Renal Services IMPLEMENTATION LTHTR hub and satellite dialysis units NAME M. Letheren Chair Clinical Effectiveness Advisory Group TITLE R Asghar Chair Renal Evidence Based s Group 01/12/09 Reviewed July 2012, Apr 2013, Nov 2013 REVIEW DATE April 2016 CLINICAL GUIDELINE The governing principles outlined within this document are fully supported in every respect by the Clinical Governance Sub-Committee. All members of staff are required to adhere to the principles involved as outlined within this document, together with any related procedures, which are enabled by this guideline. This guideline was produced in consultation with: Dr L. Solomon Consultant Nephrologist and Infection Control Champion Dr J. Cheesbrough Consultant Microbiologist Lindsay Innocent Modern Matron Definition of clinical practice guidelines Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. Version: 2.1 Page 1 of 9 Ref: REBG/00018/July12
1. Title Catheter Sepsis Management 2. Adaptation Following local consensus 3. Major Recommendations This guideline is intended for use in patients who haemodialyse either twice or three times per week via a tunnelled central venous catheter (CVC). This can either be a tunnelled internal jugular CVC or tunnelled femoral CVC. Epic 2 (2007) states that Bloodstream infections associated with the insertion and maintenance of central venous catheters (CVC) are among the most dangerous complications of healthcare that can occur, worsening the severity of the patients underlying ill health, prolonging the period of hospitalisation and increasing the cost of care. Every year, almost 6,000 patients in the UK acquire a catheter-related bloodstream infection. According to EPIC 2 (2007) catheter-related bloodstream infection (CR-BSI) can develop in three ways; Micro-organisms that colonise catheter hubs and the skin adjacent to the insertion site. Skin micro-organisms at the insertion site that contaminate the catheter during insertion or migrate along the cutaneous catheter track. Micro-organisms from the hands of healthcare workers that contaminate and colonise the catheter hub during care interventions. Introducing measures such as aseptic non touch technique (ANTT), Personal (staff and patient) protective equipment, antimicrobial catheter locks and chlorhexidine impregnated foam discs have had an impact in reducing contamination during care interventions. When a catheter related bacteraemia has occurred, completing a root cause analysis has helped to focus attention to those areas of care that require change. From these root cause analysis, it appears that there is a small group of patients at high risk of developing CR-BSI; Patients who that have undergone numerous or complex invasive vascular procedures Patients with pre-existing infections. Patients who have had a CVC present for a prolonged period. EPIC 2 (2007) also states that maintaining catheter patency and preventing catheter thrombosis may help prevent infections. This guideline suggests best practice when suspected or confirmed catheter related bacteraemia arises. For patients who haemodialyse via a tunnelled femoral haemodialysis CVC, a chlorhexidine impregnated foam disc should be used from insertion continuously until removal. 4. Clinical Algorithms Haemodialysis Sepsis Management Protocol. 5. Disease/condition/target population Patients who require haemodialysis via a central venous catheter 6. Implementation strategy 7. Interventions Sepsis can be suspected if the patient presents with a red flag NEWS marker: Systolic blood pressure <90 mmhg Lactate >2 mmols/l Heart rate >130 b/min Respiratory rate >25 b/min Oxygen saturations <91% Version: 2.1 Page 2 of 9 Ref: REBG/00018/July12
Altered mental state includes new confusion Purpuric rash Haemodialysis Session 1. (Sepsis Suspected). Take blood cultures from both lumens. To confirm whether the CVC is the source of infection, a peripheral sample should also be obtained if possible. A lactate sample should be taken at the same time and sent to pathology within 15 minutes (on ice). If exit site infection suspected, obtain an exit site and nasal swab for Staph. Aureus. If positive, follow the guideline for haemodialysis catheter exit sites. Obtain a full blood count and CRP. If patient clinically well at beginning and end of the dialysis session, wait for blood culture results before commencing treatment. If patient is clinically unwell at the beginning of the dialysis session, administer intravenous Vancomycin as per the IV Vancomycin Loading Dose regime (which can be found on the attached treatment protocol) at the end of dialysis. The licensed infusion rate is 10mg/min; however, when given on dialysis 1g can be given over 1 hour. For fluid restricted patients a concentration of 10mg/ml can be used i.e. 1g in 100ml sodium chloride 0.9%. If patient severely unwell administer both intravenous Vancomycin (as per the IV Vancomycin Loading Dose) and Gentamicin 2.5mg/kg (maximum 200mg) at the end of dialysis and consider admitting. Haemodialysis Session 2. Review blood culture result: If blood culture negative- no further action If blood culture positive- treat as per the attached twice and three times weekly haemodialysis catheter related sepsis management protocols Future Haemodialysis Sessions. Follow instructions that can be found on the attached treatment protocols. Complete the Lancashire and Cumbria Chronic Haemodialysis Related Infection Surveillance proforma for all blood cultures taken. If repeat blood cultures are being obtained within two weeks of the original culture, a lactate sample does not need to be obtained. 8. Major Outcomes When suspected or confirmed catheter related bloodstream infection occurs, to treat in a timely manner to reduce morbidity, mortality and where possible preserve vascular access. 9. Reference(s) National Kidney Foundation (2006) KDOQI clinical practice guidelines for vascular access. American Journal of Kidney Diseases, 48 (suppl 1), pp. S248-S273. LTHTR (2011) Sepsis flow chart. Pratt, R.J. et al (2007) epic2: National evidence-based guidelines for preventing healthcareassociated infections in NHS hospitals in England. Journal of Hospital Infection, 65s, pp. S1-S64. The Renal Association (2011) Vascular access for haemodialysis. London, The Renal Association. 10. Availability Trust Intranet and satellite units Version: 2.1 Page 3 of 9 Ref: REBG/00018/July12
11. Companion Documents LTHTR (2013) TWICE WEEKLY Haemodialysis catheter-related sepsis management protocol. LTHTR (2013) THREE TIMES WEEKLY Haemodialysis catheter-related sepsis management protocol. Lancashire and Cumbria Chronic Haemodialysis Related Infection Surveillance proforma Version: 2.1 Page 4 of 9 Ref: REBG/00018/July12
Version: 2.1 Page 5 of 9 Ref: REBG/00018/July12
Version: 2.1 Page 6 of 9 Ref: REBG/00018/July12
LANCASHIRE & CUMBRIA HAEMODIALYSIS RELATED INFECTION SURVEILLANCE Incident LOG Form CENTRE Month Year Preston Chorley Accrington Blackpool Burnley Kendal Home HD Please fill in a row on this LOG form & an INCIDENT form for:- Each unplanned hospitalisation of a day patient Each NEW prescription for IV antibiotic therapy in a haemodialysis patient Each patient who has had a blood culture sent to the lab When an exit site swab is taken Patient s Name Date (dd/mm) REASON (please tick) Admission IV given Blood Culture Exit site infection LOG No Form Completed Please sign At the end of each month please send separate copies of this form along with the completed incident forms both to: - Nora Kerigan, Dialysis Unit, RPH & Gosia Clarke, Clinical Audit and Effectiveness, CDH Any problems or queries please contact Nora on 01772 523528 or Gosia on 01257 245318 Version: 2.1 Page 7 of 9 Ref: REBG/00018/July12
Session 1 Sepsis Suspected- presumed or confirmed infection, Temp >38/<36, RR >20, HR >90bpm. Take blood cultures (from both lumens if possible), peripheral blood cultures from blood circuit, lactate sample, FBC, CRP. Swab exit site if inflamed. If clinically stable at end of dialysis, no antibiotics await blood culture results. If clinically unwell with some features of sepsis but not in need of immediate admission, give IV Vancomycin Loading Dose at the end of dialysis. IV Vancomycin Loading Dose- Below 70kgs: 1000mgs, 70kgs or above: 1500mgs. If remains septic at end of HD also give GENTAMICIN 2.5mg/kg mg IV (maximum 200mg). Admit if clinical condition poor. Continue patients line lock solution in all instances Session 2- Chase up blood culture result. If NEGATIVE- no further action. If POSITIVE- treat according to organism and sensitivities. Repeat blood cultures. NORMAL SKIN FLORA (NSF) STAPHYLOCOCCUS AUREUS (MRSA/MSSA) COAGULASE NEGATIVE STAPHYLOCOCCUS (CNS) MRSA- IV Vancomycin for 4 weeks as per IV Vancomycin IV Vancomycin for 2 weeks as per IV Vancomycin Level and Level and Dose Regime) and Oral Rifampicin 300 mg BD for 28 Dose Regime days. MSSA- IV Cefuroxime IV 2250mgs for 4 weeks. Administer IV Cefuroxime at end of dialysis. Version: 2.1 Page 8 of 9 Ref: REBG/00018/July12 IV Vancomycin Level and Dose Regime Vancomycin Level at start HD Vancomycin result at end of HD and dose as below:- > 20 mg/l- omit today s dose. 15-20mg/l- 500 mg. 10-15mg/l- 1000mgs. < 10mg/l- 1500mgs. Continue patients line lock solution in all instances GRAM NEGATIVE BACILLI (GNB) No more Vancomycin. Discuss with Microbiologist 2 weeks antibiotics as per sensitivities. If Gentamicin needs to be continued take a level at start of HD. If concentration < 2mg/L, give 1 mg/kg If concentration > 2mg/L, omit until next dialysis Session 3 Check blood culture results from previous session. If clinically improved continue antibiotics and check blood culture at HD session 4. If repeat blood cultures grow MRSA or MSSA and the patient remains septic- consider line removal. If repeat blood culture grows CNS and patient remains febrile- discuss with microbiology. NSF and CNS- IV Vancomycin as per level and dose regime MRSA- IV Vancomycin as per level and dose regime. Continue Session 4- If clinically improved- repeat blood cultures and continue antibiotics. NSF and CNS- - Last dose of IV Vancomycin as per the level MRSA- IV Vancomycin as per level and dose regime. Continue and dose regime Session 5- Chase up blood cultures from previous session. MRSA- IV Vancomycin as per level and dose regime. Continue Session 6 Session 7 Session 8 TWICE WEEKLY Haemodialysis Catheter Related Sepsis Management Protocol MRSA- IV Vancomycin as per level and dose regime. Continue MRSA- IV Vancomycin as per level and dose regime. Continue GNB- if Gentamicin needs to be continued take a level at start of HD. If concentration < 2mg/L, give 1 mg/kg If concentration > 2mg/L, omit until next dialysis GNB- Continue as per microbiology advice. MRSA- Last dose of IV Vancomycin. Remind patient to complete course of oral anrtibiotics MSSA- Last dose of IV Cefuroxime. AT ANY SESSION-REPEAT BLOOD CULTURES IF PATIENT REMAINS UNWELL. IF FURTHER SIGNS OF SEPSIS- DISCUSS LINE REMOVAL. NO FURTHER BLOOD CULTURES IF INITIAL BACTERAEMIA HAS CLEARED AND PATIENT REMAINS WELL WITH NO EVIDENCE OF SEPSIS
Session 1 Sepsis Suspected- presumed or confirmed infection, Temp >38/<36, RR >20, HR >90bpm. Take blood cultures (from both lumens if possible), peripheral blood cultures from blood circuit, lactate sample, FBC, CRP. Swab exit site if inflamed. If clinically stable at end of dialysis, no antibiotics await blood culture results. If clinically unwell with some features of sepsis but not in need of immediate admission, give IV Vancomycin at the end of dialysis. IV Vancomycin Loading Dose- Below 70kgs: 1000mgs, 70kgs or above: 1500mgs. If remains septic at end of HD also give GENTAMICIN 2.5mg/kg mg IV (maximum 200mg). Admit if clinical condition poor. Continue patients line lock solution in all instances Session 2- Chase up blood culture result. If NEGATIVE- no further action. If POSITIVE- treat according to organism and sensitivities. Repeat blood cultures. NORMAL SKIN FLORA (NSF) STAPHYLOCOCCUS AUREUS (MRSA/MSSA) COAGULASE NEGATIVE STAPHYLOCOCCUS (CNS) MRSA- IV Vancomycin for 4 weeks as per IV Vancomycin IV Vancomycin for 2 weeks as per IV Vancomycin Level and Level and Dose Regime and Oral Rifampicin 300 mg BD for Dose Regime 28 days. MSSA- IV Cefuroxime IV 1500mgs for 4 weeks (if greater than 100kgs give 2250mgs). Administer IV Cefuroxime at end of dialysis. Session 3 Check any blood culture results from previous session. If clinically improved continue antibiotics and check blood culture at HD session 4. If repeat blood culture grows MRSA and patient remains septic- discuss with microbiology but consider line removal If repeat blood culture grows MSSA and patient remains septic- consider line removal. NSF and CNS- IV Vancomycin for 2 weeks as per IV Vancomycin Level and Dose Regime Session 4- If clinically improved- repeat blood cultures and continue antibiotics NSF and CNS- IV Vancomycin for 2 weeks as per IV Vancomycin Level and Dose Regime Session 5 NSF and CNS- IV Vancomycin for 2 weeks as per IV Vancomycin Level and Dose Regime Session 6 NSF and CNS- Last dose of IV Vancomycin. Sessions 7-11 Session 12 THREE TIMES WEEKLY Haemodialysis Catheter Related Sepsis Management Protocol IV Vancomycin Level and Dose Regime. Vancomycin Level at start HD Vancomycin result at end of HD and dose as below:- > 20 mg/l- omit today s dose. 15-20mg/l- 500 mg. 10-15mg/l- 1000mgs. < 10mg/l- 1500mgs. Continue patients line lock solution in all instances. GRAM NEGATIVE BACILLI (GNB) No more Vancomycin. Discuss with Microbiologist 2 weeks antibiotics as per sensitivities. If Gentamicin needs to be continued take a level at start of HD. If concentration < 2mg/L, give 1 mg/kg If concentration > 2mg/L, omit until next dialysis GNB- If Gentamicin needs to be continued take a level at start of HD. If concentration < 2mg/L, give 1 mg/kg If concentration > 2mg/L, omit until next dialysis GNB- Continue as per microbiology advice MRSA- Last dose of IV Vancomycin. Remind patient to complete course of oral antibiotics MSSA- Last dose of IV Cefuroxime. AT ANY SESSION- REPEAT BLOOD CULTURES IF PATIENT REMAINS UNWELL. IF FURTHER SIGNS OF SEPSIS- DISCUSS LINE REMOVAL NO FURTHER BLOOD CULTURES IF INITIAL BACTERAEMIA HAS CLEARED AND PATIENT REMAINS WELL WITH NO EVIDENCE OF SEPSIS Version: 2.1 Page 9 of 9 Ref: REBG/00018/July12