Catheter-Related Infections

A catheter is a flexible tube that is inserted into the body with the purpose of withdrawal of fluids from (or introduction of fluids or a device into) a body cavity. Catheters are often a routine part of medical care in 2022. There are many different types of catheters; some common examples include: urinary catheters (to drain the bladder), intravascular catheters(for delivery of medications intravenously), and dialysis catheters (for administration of hemodialysis or peritoneal dialysis).

Clinical Significance:

Despite often being a necessary part of patient care, catheter-related complications, such as infection, occur routinely, occasionally leading to devastating consequences for the patient. For example, it is estimated that more than 5 million central venous catheters (CVCs) are inserted into patients every year in the US, and the frequency of CVC associated bloodstream infections (also called central line associated bloodstream infection or CLABSI) is estimated at 0.5 - 10 infections per 1000 catheter days. The mortality ranges from 12-40% and up to 70% of these infections may be preventable. A challenge that occasionally faces the clinician when working to establish a diagnosis of CLABSI is that CVCs often become colonized with bacteria. While distinguishing a true CLABSI from Pseudobacteremia (or positive blood cultures as a result of catheter colonization only) is often straightforward, in real world clinical practice, the 2 diagnoses are sometimes confused, occasionally leading patients to be treated for a CLABSI when in fact they do not have one.

Another common type of catheter related infection is a catheter associated urinary tract infection (CAUTI), which is the most common type of hospital acquired infection (HAI),  accounting for  more than 30% of infections reported by acute care hospitals. CAUTI are associated with increased patient morbidity, mortality, cost and length of stay. The diagnosis of CAUTI is not always straightforward, as catheters quickly become colonized with bacteria; the presence of bacteria in a urine specimen collected from a catheter is insufficient to diagnose a CAUTI. It is not uncommon for patients to get misdiagnosed as having a CAUTI when in fact, they more often than not simply have Catheter-Asssociated Asymptomatic Bacteriuria - a condition for which antibiotics are not indicated.

Diagnosis and Management:

Diagnosis and management of catheter related infections varies, depending on the catheter type, and the clinical scenario. For CLABSI, CAUTI and infections related to dialysis catheters, published guidelines exist that describe best practices for diagnosis and management, including recommendations for antimicrobial therapy and whether or not the catheter may remain in place or should be removed. In general, it is best practice to remove a catheter that is no longer needed as soon as possible.

Conclusions:

Catheter-related infections are an unfortunate complication of catheter placement and  continue to occur to patients nationwide. Distinguishing catheter colonization from true infection is not always straightforward, and arriving at the correct diagnosis in a timely manner is crucial for proper management of the patient. A catheter-related infection Expert Witness may be helpful in the evaluation of the care of a patient with suspected or confirmed catheter-related infection.

 

References

1. https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf
2. Boll et al. Central venous catheter–related infections in hematology and oncology: 2020 updated guidelines on diagnosis, management, and prevention by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Annals of Hematology 2021;100: 239-59
3. Mermel at al. Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2009;49:1–45
4. Hooton et al. Diagnosis, Prevention, and Treatment of Catheter- Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clinical Infectious Diseases 2010;50:625–663
5. Timsit et al. Expert consensus-based clinical practice guidelines management of intravascular catheters in the intensive care unit. Ann. Intensive Care (2020) 10:118
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8. Li et al. Peritoneal Dialysis International  2022;42:110-153
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