Line sepsis

[bkell101]

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Have a pt just transferred out of ICU

Documented negative bld cultures
Gets picc line placed
27 hrs later fever and positive 2/2 bld culture positive gram positives

My attending says its not line sepsis because it usually takes over 48 hours to develop fevers and positive cultures

Thoughts?

 

[nap$ter]

life is a bell curve.

it's definitely bacteremia. sepsis has a different definition - not sure if your pt met it based on your resentation. if there's no other source ie urine/lungs/bones/wound/sinus etc it likely is from the line placement.

 

[pie944]

Have a pt just transferred out of ICU

Documented negative bld cultures
Gets picc line placed
27 hrs later fever and positive 2/2 bld culture positive gram positives

My attending says its not line sepsis because it usually takes over 48 hours to develop fevers and positive cultures

Thoughts?

Did the culture from the PICC line turn positive first?

 

[urge]

My attending says its not line sepsis because it usually takes over 48 hours to develop fevers and positive cultures

Thoughts?

How does that change anything?

 

[BADMD]

How does that change anything?

CLABSI definition requires the line to be in for greater than 2 calendar days (not quite the same as 48 hours)

http://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf

Plus, no one wants to report CLABSIs if they can find a way to call it anything else.

 

[Idiopathic]

Did the culture from the PICC line turn positive first?

too nonspecific a test, and it really doesnt matter - pull the line, treat with PIVs and get a PICC when blood cultures are negative again

 

[Idiopathic]

Have a pt just transferred out of ICU

Documented negative bld cultures
Gets picc line placed
27 hrs later fever and positive 2/2 bld culture positive gram positives

My attending says its not line sepsis because it usually takes over 48 hours to develop fevers and positive cultures

Thoughts?

i could agree with the fact that it may not be sepsis, if the patient doesnt meet SIRS criteria. however, you can see bacteremia immediately with suboptimal line placement conditions or access and fever could follow soon after. also fever could be unrelated to gram+ bacteremia

 

[bkell101]

So....

Tip cultures came back staph today, which matches my bld cultures

I looked up CDC guidlines line sepsis and saw the 2day thing hat somebody else mentioned, but this is clearly line sepsis although under 48 hrs right? If so what's the thought behind the 48hrs? I know this a little more medicine/ICU related, sorry but just wondering....

 

[bkell101]

Hr and rr met sits criteria upon admission but chalked up to pain from a very recent car accident with spinal fractures ....vitals on floor when I saw him were similar

 

[pie944]

too nonspecific a test, and it really doesnt matter - pull the line, treat with PIVs and get a PICC when blood cultures are negative again

It sounded based on his description that his/her staff wasn't convinced the PICC was the source of the bacteremia. So in this situation it could be used as an argument to his staff to pull the PICC line if he was strongly opposed to it.

The IDSA guidelines on for diagnosis and management of intravascular catheter related infection state that "For DTP, growth of microbes from a blood sample drawn
from a catheter hub at least 2 h before microbial growth is detected in a blood sample obtained from a peripheral vein best defines CRBSI."

DTP - Differential Time to Positivity

The evidence is only A-II, and the citation is a study based on cancer patients from 2004, however there are more recent studies that show utilizing this might be helpful in management of situations like these.

The sensitivities and specificities seem to hang out in the 80s depending where you look, not the best, but what is when it comes to this situation?

 

[Praziquantel86]

So....

Tip cultures came back staph today, which matches my bld cultures

I looked up CDC guidlines line sepsis and saw the 2day thing hat somebody else mentioned, but this is clearly line sepsis although under 48 hrs right? If so what's the thought behind the 48hrs? I know this a little more medicine/ICU related, sorry but just wondering....

Other things to consider - what proportion of the bottled were positive? You'd mentioned 2/2 cultures, but is that 2 bottles from the same set, 2 bottles from different sets, or 2 bottles in each set? If 2 bottles from the same set, it's possible you're detecting contamination resulting from colonization of the line (supported by the cath tip colonization), whereas if its different culture sets your likelihood of a true bacteremia and line-related infection is higher. Also worth considering is the type of Staph involved - if S. aureus, it will always be treated as a true infection regardless of how many/which bottles are positive. If CoNS, that again may or may not be contamination,

Either way, it's probably best to pull the line (as seems to have been done), but antibiotic duration and amount of workup that needs to be done would vary based on the organism and which bottles were positive.

 

[Idiopathic]

It sounded based on his description that his/her staff wasn't convinced the PICC was the source of the bacteremia. So in this situation it could be used as an argument to his staff to pull the PICC line if he was strongly opposed to it.

The IDSA guidelines on for diagnosis and management of intravascular catheter related infection state that "For DTP, growth of microbes from a blood sample drawn
from a catheter hub at least 2 h before microbial growth is detected in a blood sample obtained from a peripheral vein best defines CRBSI."

DTP - Differential Time to Positivity

The evidence is only A-II, and the citation is a study based on cancer patients from 2004, however there are more recent studies that show utilizing this might be helpful in management of situations like these.

The sensitivities and specificities seem to hang out in the 80s depending where you look, not the best, but what is when it comes to this situation?

i get what you are saying about differential times, but there is no benefit to this outside of looking for another source. so in this day and ago, with CLABSI being such a hot button issue, you pull the line, do not culture the tip, and treat the bacteremia. you can also attempt to sterilize the line but unless future access is an issue, i would probably place a CVL, rx with abs until clean cultures, and get another PICC.

what do you gain here by diagnosing a CRBSI, especially when the test isnt foolproof?

caveat: if the patient came to your hospital with an outside PICC or port and had bacteremia then they should ABSOLUTELY get that line cultured when it is pulled.

 

[Per4mer8]

caveat: if the patient came to your hospital with an outside PICC or port and had bacteremia then they should ABSOLUTELY get that line cultured when it is pulled.

Is this just so the transferring hospital and not yours gets dinged with the hospital acquired line infection? If so this is just another example of how all the health care changes involving disincentivizing/penalizing hospitals doesn't really reduce costs. It's just going to transfer the cost by resulting in the performance of further tests that won't change management...... Or am I missing something? (Possible)

 

[pie944]

i get what you are saying about differential times, but there is no benefit to this outside of looking for another source. so in this day and ago, with CLABSI being such a hot button issue, you pull the line, do not culture the tip, and treat the bacteremia. you can also attempt to sterilize the line but unless future access is an issue, i would probably place a CVL, rx with abs until clean cultures, and get another PICC.

what do you gain here by diagnosing a CRBSI, especially when the test isnt foolproof?

caveat: if the patient came to your hospital with an outside PICC or port and had bacteremia then they should ABSOLUTELY get that line cultured when it is pulled.

I presumed this staff was arguing that the source of the bacteremia is unknown(line versus another source).

One doesn't need to pull central access in every case of bacteremia from another source. There are even cases of CLABSI where antibiotic therapy can be utilized without removal of the line, limited as these situations are. It depends on variables including the specific type of access, future access needs, the overall patient condition, as well as the species being cultured.

That was my reasoning for asking the initial question, I read the question as his attending felt the line wasn't the source, so I presumed he might be arguing against it's removal.

The place I'm currently at replaces all central access with fresh sticks for all transfers, including local hospitals under their umbrella. I find that last fact amusing.

 

[Idiopathic]

Is this just so the transferring hospital and not yours gets dinged with the hospital acquired line infection? If so this is just another example of how all the health care changes involving disincentivizing/penalizing hospitals doesn't really reduce costs. It's just going to transfer the cost by resulting in the performance of further tests that won't change management...... Or am I missing something? (Possible)

yes, yes and yes. put simply, CLABSI is a performance metric, and less simply, its a pride metric. if someone comes into your ICU with a blood stream infection, you are going to make sure and document that they came in with it, and not that they got it while they were in your unit

 

[Idiopathic]

I presumed this staff was arguing that the source of the bacteremia is unknown(line versus another source).

One doesn't need to pull central access in every case of bacteremia from another source. There are even cases of CLABSI where antibiotic therapy can be utilized without removal of the line, limited as these situations are. It depends on variables including the specific type of access, future access needs, the overall patient condition, as well as the species being cultured.

That was my reasoning for asking the initial question, I read the question as his attending felt the line wasn't the source, so I presumed he might be arguing against it's removal.

The place I'm currently at replaces all central access with fresh sticks for all transfers, including local hospitals under their umbrella. I find that last fact amusing.

How else would you change out a line?

 

[pie944]

How else would you change out a line?

I meant the fact we even will replace lines for patients who received them at our satellite hospitals.

 

[bkell101]

yes, yes and yes. put simply, CLABSI is a performance metric, and less simply, its a pride metric. if someone comes into your ICU with a blood stream infection, you are going to make sure and document that they came in with it, and not that they got it while they were in your unit

Our attendings in the MICU are very sensitive about this very subject. I've learned to never write VAP or line sepsis in my note because of the metrics for the hospital (unless of course they transferred from outside hospital).

He also explained about DVT being a "never" event in the metric system, even though when looked at in studies some small percent of people develop DVT despite appropriate prophylaxis measures. Thought it was interesting....

 

[Idiopathic]

Our attendings in the MICU are very sensitive about this very subject. I've learned to never write VAP or line sepsis in my note because of the metrics for the hospital (unless of course they transferred from outside hospital).

He also explained about DVT being a "never" event in the metric system, even though when looked at in studies some small percent of people develop DVT despite appropriate prophylaxis measures. Thought it was interesting....

yes, you will find that the problem with "never" events is that they will happen, and nobody will report them. if there was a benchmark other than zero, you would see more truthful reporting and maybe even enact real change.

VAP is a little different because it doesnt rely on culture data but more on clinical impression.