Epidemiology, pathogenesis, and microbiology of intravascular catheter infections
- Robert Gaynes, MD
Robert Gaynes, MD
- Professor, Emory University School of Medicine
- Centers for Disease Control and Prevention
- Jeffrey D Band, MD, FACP, FIDSA
Jeffrey D Band, MD, FACP, FIDSA
- Attending Physician, Section of Infectious Diseases and International Medicine
- Beaumont Hospital-Royal Oak, MI
- Professor of Medicine
- Oakland University William Beaumont School of Medicine
Nosocomial (hospital-acquired) bloodstream infections (BSIs) are an important cause of morbidity and mortality, with an estimated 250,000 cases occurring each year in the United States [1,2]. BSIs may be either primary or secondary. Secondary infections are related to infections at other sites, such as the urinary tract, lung, postoperative wounds, and skin. Most nosocomial BSIs are primary, as illustrated by the United States Centers for Disease Control and Prevention's National Nosocomial Infection Surveillance system, in which 64 percent of the nosocomial BSIs reported were primary BSIs . While some primary BSIs have no identifiable source, most are associated with intravascular catheters, and central venous catheters (CVCs) in particular [3,4].
CVCs are increasingly used in the inpatient and outpatient setting to provide long-term venous access. Infection of CVCs remains a major problem. It is estimated, for example, that approximately 90 percent of annual catheter-related bloodstream infections in the United States occur with CVCs .
The epidemiology, risk factors, pathogenesis, and microbiology of intravascular catheter infections will be reviewed here. The diagnosis, treatment, and prevention of CVC-associated infections are discussed separately. (See "Diagnosis of intravascular catheter-related infections" and "Treatment of intravascular catheter-related infections" and "Prevention of intravascular catheter-related infections".)
Catheter-related bloodstream infections (CR-BSIs) are an important cause of morbidity and mortality worldwide, although they may be decreasing in incidence in some areas, possibly as a result of widespread prevention efforts. As an example, the incidence of CR-BSI associated with central lines among patients hospitalized in intensive care units (ICUs) in the United States decreased from 3.64 to 1.65 infections per 1000 central line days between 2001 and 2009 [6,7]. These decreases in the United States have continued through 2015 and appear to be sustained [8,9]. This amounted to an estimated 18,000 central line–related infections in 2009. A similar trend of decreasing incidence has been observed in Canada . In contrast, the reported pooled incidence of central line–associated BSI across 422 ICUs in 36 countries in Latin America, Asia, Africa, and Europe from 2004 to 2009 was substantially higher, 6.8 events per 1000 central line days . Many of these sites are in resource-limited areas, and the high incidence is thought to be related to a lack of official regulations regarding catheter care.
Although ICU patients are generally exposed to more medical devices and are more severely ill than other hospitalized patients, CR-BSIs remain common in hospital wards outside the ICU. As an example, an estimated 23,000 central line–associated BSIs occurred among patients in inpatient wards in the United States in 2009 . In a prospective analysis from the Surveillance and Control of Pathogens of Epidemiologic Importance (SCOPE) database, which evaluated the characteristics of 24,179 nosocomial BSIs from 49 hospitals in the United States between 1995 and 2002, the following findings were noted :
- Pittet D, Li N, Woolson RF, Wenzel RP. Microbiological factors influencing the outcome of nosocomial bloodstream infections: a 6-year validated, population-based model. Clin Infect Dis 1997; 24:1068.
- Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006; 81:1159.
- Martone WJ, Gaynes RP, Horan TC, et al. National Nosocomial Infections Surveillance (NNIS) semiannual report, May 1995. A report from the National Nosocomial Infections Surveillance (NNIS) System. Am J Infect Control 1995; 23:377.
- Wisplinghoff H, Bischoff T, Tallent SM, et al. Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis 2004; 39:309.
- Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med 2000; 132:391.
- Centers for Disease Control and Prevention (CDC). Vital signs: central line-associated blood stream infections--United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep 2011; 60:243.
- Fagan RP, Edwards JR, Park BJ, et al. Incidence trends in pathogen-specific central line-associated bloodstream infections in US intensive care units, 1990-2010. Infect Control Hosp Epidemiol 2013; 34:893.
- Pronovost PJ, Watson SR, Goeschel CA, et al. Sustaining Reductions in Central Line-Associated Bloodstream Infections in Michigan Intensive Care Units: A 10-Year Analysis. Am J Med Qual 2016; 31:197.
- Dudeck MA, Edwards JR, Allen-Bridson K, et al. National Healthcare Safety Network report, data summary for 2013, Device-associated Module. Am J Infect Control 2015; 43:206.
- Fontela PS, Platt RW, Rocher I, et al. Epidemiology of central line-associated bloodstream infections in Quebec intensive care units: a 6-year review. Am J Infect Control 2012; 40:221.
- Rosenthal VD, Bijie H, Maki DG, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries, for 2004-2009. Am J Infect Control 2012; 40:396.
- Fowler VG Jr, Miro JM, Hoen B, et al. Staphylococcus aureus endocarditis: a consequence of medical progress. JAMA 2005; 293:3012.
- Tokars JI, Cookson ST, McArthur MA, et al. Prospective evaluation of risk factors for bloodstream infection in patients receiving home infusion therapy. Ann Intern Med 1999; 131:340.
- Reunes S, Rombaut V, Vogelaers D, et al. Risk factors and mortality for nosocomial bloodstream infections in elderly patients. Eur J Intern Med 2011; 22:e39.
- Tompkins RG, Burke JF. Infections of burn wounds. In: Hospital Infections, 3rd Ed, Bennett JV, Brachman PS (Eds), Little, Brown, Boston 1992.
- Bodey GP, Buckley M, Sathe YS, Freireich EJ. Quantitative relationships between circulating leukocytes and infection in patients with acute leukemia. Ann Intern Med 1966; 64:328.
- Mollee P, Jones M, Stackelroth J, et al. Catheter-associated bloodstream infection incidence and risk factors in adults with cancer: a prospective cohort study. J Hosp Infect 2011; 78:26.
- Niedner MF, Huskins WC, Colantuoni E, et al. Epidemiology of central line-associated bloodstream infections in the pediatric intensive care unit. Infect Control Hosp Epidemiol 2011; 32:1200.
- Parienti JJ, du Cheyron D, Timsit JF, et al. Meta-analysis of subclavian insertion and nontunneled central venous catheter-associated infection risk reduction in critically ill adults. Crit Care Med 2012; 40:1627.
- Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med 1991; 91:197S.
- Richet H, Hubert B, Nitemberg G, et al. Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients. J Clin Microbiol 1990; 28:2520.
- Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001; 286:700.
- Ronco C. The place of early haemoperfusion with polymyxin B fibre column in the treatment of sepsis. Crit Care 2005; 9:631.
- Wilcox TA. Catheter-related bloodstream infections. Semin Intervent Radiol 2009; 26:139.
- Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol 1994; 15:231.
- Maki DG. Yes, Virginia, aseptic technique is very important: maximal barrier precautions during insertion reduce the risk of central venous catheter-related bacteremia. Infect Control Hosp Epidemiol 1994; 15:227.
- Pessa ME, Howard RJ. Complications of Hickman-Broviac catheters. Surg Gynecol Obstet 1985; 161:257.
- Darbyshire PJ, Weightman NC, Speller DC. Problems associated with indwelling central venous catheters. Arch Dis Child 1985; 60:129.
- Groeger JS, Lucas AB, Thaler HT, et al. Infectious morbidity associated with long-term use of venous access devices in patients with cancer. Ann Intern Med 1993; 119:1168.
- Ross MN, Haase GM, Poole MA, et al. Comparison of totally implanted reservoirs with external catheters as venous access devices in pediatric oncologic patients. Surg Gynecol Obstet 1988; 167:141.
- Carde P, Cosset-Delaigue MF, Laplanche A, Chareau I. Classical external indwelling central venous catheter versus totally implanted venous access systems for chemotherapy administration: a randomized trial in 100 patients with solid tumors. Eur J Cancer Clin Oncol 1989; 25:939.
- Veenstra DL, Saint S, Saha S, et al. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection: a meta-analysis. JAMA 1999; 281:261.
- Barzaghi A, Dell'Orto M, Rovelli A, et al. Central venous catheter clots: incidence, clinical significance and catheter care in patients with hematologic malignancies. Pediatr Hematol Oncol 1995; 12:243.
- Lundgren IS, Zhou C, Malone FR, et al. Central venous catheter repair is associated with an increased risk of bacteremia and central line-associated bloodstream infection in pediatric patients. Pediatr Infect Dis J 2012; 31:337.
- Maki DG. Infections due to infusion therapy. In: Hospital Infections, 3rd Ed, Bennett JV, Brachman PS (Eds), Little, Brown, Boston 1992. p.849.
- Snydman DR, Gorbea HF, Pober BR, et al. Predictive value of surveillance skin cultures in total-parenteral-nutrition-related infection. Lancet 1982; 2:1385.
- Bjornson HS, Colley R, Bower RH, et al. Association between microorganism growth at the catheter insertion site and colonization of the catheter in patients receiving total parenteral nutrition. Surgery 1982; 92:720.
- Cooper GL, Hopkins CC. Rapid diagnosis of intravascular catheter-associated infection by direct Gram staining of catheter segments. N Engl J Med 1985; 312:1142.
- Raad II, Baba M, Bodey GP. Diagnosis of catheter-related infections: the role of surveillance and targeted quantitative skin cultures. Clin Infect Dis 1995; 20:593.
- Guidet B, Nicola I, Barakett V, et al. Skin versus hub cultures to predict colonization and infection of central venous catheter in intensive care patients. Infection 1994; 22:43.
- Armstrong CW, Mayhall CG, Miller KB, et al. Clinical predictors of infection of central venous catheters used for total parenteral nutrition. Infect Control Hosp Epidemiol 1990; 11:71.
- Raad I, Costerton W, Sabharwal U, et al. Ultrastructural analysis of indwelling vascular catheters: a quantitative relationship between luminal colonization and duration of placement. J Infect Dis 1993; 168:400.
- Liñares J, Sitges-Serra A, Garau J, et al. Pathogenesis of catheter sepsis: a prospective study with quantitative and semiquantitative cultures of catheter hub and segments. J Clin Microbiol 1985; 21:357.
- Tenney JH, Moody MR, Newman KA, et al. Adherent microorganisms on lumenal surfaces of long-term intravenous catheters. Importance of Staphylococcus epidermidis in patients with cancer. Arch Intern Med 1986; 146:1949.
- Miller JJ, Venus B, Mathru M. Comparison of the sterility of long-term central venous catheterization using single lumen, triple lumen, and pulmonary artery catheters. Crit Care Med 1984; 12:634.
- Salzman MB, Isenberg HD, Shapiro JF, et al. A prospective study of the catheter hub as the portal of entry for microorganisms causing catheter-related sepsis in neonates. J Infect Dis 1993; 167:487.
- León C, Alvarez-Lerma F, Ruiz-Santana S, et al. Antiseptic chamber-containing hub reduces central venous catheter-related infection: a prospective, randomized study. Crit Care Med 2003; 31:1318.
- Maki DG. Nosocomial bacteremia. An epidemiologic overview. Am J Med 1981; 70:719.
- Kimura AC, Calvet H, Higa JI, et al. Outbreak of Ralstonia pickettii bacteremia in a neonatal intensive care unit. Pediatr Infect Dis J 2005; 24:1099.
- Ostrowsky BE, Whitener C, Bredenberg HK, et al. Serratia marcescens bacteremia traced to an infused narcotic. N Engl J Med 2002; 346:1529.
- Centers for Disease Control and Prevention (CDC). Pseudomonas bloodstream infections associated with a heparin/saline flush--Missouri, New York, Texas, and Michigan, 2004-2005. MMWR Morb Mortal Wkly Rep 2005; 54:269.
- Centers for Disease Control and Prevention (CDC). Update: Delayed onset Pseudomonas fluorescens bloodstream infections after exposure to contaminated heparin flush--Michigan and South Dakota, 2005-2006. MMWR Morb Mortal Wkly Rep 2006; 55:961.
- Tena D, Carranza R, Barberá JR, et al. Outbreak of long-term intravascular catheter-related bacteremia due to Achromobacter xylosoxidans subspecies xylosoxidans in a hemodialysis unit. Eur J Clin Microbiol Infect Dis 2005; 24:727.
- Banerjee SN, Emori TG, Culver DH, et al. Secular trends in nosocomial primary bloodstream infections in the United States, 1980-1989. National Nosocomial Infections Surveillance System. Am J Med 1991; 91:86S.
- Hidron AI, Edwards JR, Patel J, et al. NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007. Infect Control Hosp Epidemiol 2008; 29:996.
- ECDC surveillance report: Surveillance of healthcare-associated infections in Europe, 2007. http://www.ecdc.europa.eu/en/publications/Publications/120215_SUR_HAI_2007.pdf (Accessed on November 28, 2012).
- Ong DS, Bonten MJ, Safdari K, et al. Epidemiology, Management, and Risk-Adjusted Mortality of ICU-Acquired Enterococcal Bacteremia. Clin Infect Dis 2015; 61:1413.
- Haslett TM, Isenberg HD, Hilton E, et al. Microbiology of indwelling central intravascular catheters. J Clin Microbiol 1988; 26:696.
- Chitnis AS, Edwards JR, Ricks PM, et al. Device-associated infection rates, device utilization, and antimicrobial resistance in long-term acute care hospitals reporting to the National Healthcare Safety Network, 2010. Infect Control Hosp Epidemiol 2012; 33:993.
- Boktour M, Hanna H, Ansari S, et al. Central venous catheter and Stenotrophomonas maltophilia bacteremia in cancer patients. Cancer 2006; 106:1967.
- Brusselaers N, Monstrey S, Snoeij T, et al. Morbidity and mortality of bloodstream infections in patients with severe burn injury. Am J Crit Care 2010; 19:e81.
- Mir MA, Anjum S, Mir RA, et al. Prevalence of various bacteria and their susceptibility pattern in burn unit of governmental medical college and hospital Srinagar. The Internet Journal of Microbiology 2012; 10:5580.
- Nørgaard M, Larsson H, Pedersen G, et al. Short-term mortality of bacteraemia in elderly patients with haematological malignancies. Br J Haematol 2006; 132:25.
- Do AN, Ray BJ, Banerjee SN, et al. Bloodstream infection associated with needleless device use and the importance of infection-control practices in the home health care setting. J Infect Dis 1999; 179:442.
- Toscano CM, Bell M, Zukerman C, et al. Gram-negative bloodstream infections in hematopoietic stem cell transplant patients: the roles of needleless device use, bathing practices, and catheter care. Am J Infect Control 2009; 37:327.
- Jarvis WR, Murphy C, Hall KK, et al. Health care-associated bloodstream infections associated with negative- or positive-pressure or displacement mechanical valve needleless connectors. Clin Infect Dis 2009; 49:1821.
- Downes KJ, Metlay JP, Bell LM, et al. Polymicrobial bloodstream infections among children and adolescents with central venous catheters evaluated in ambulatory care. Clin Infect Dis 2008; 46:387.
- Long JG, Keyserling HL. Catheter-related infection in infants due to an unusual lipophilic yeast--Malassezia furfur. Pediatrics 1985; 76:896.