Betsy: We have none. the reason is that there are so many different
patient scenarios on so many different services. The CDC Guidelines say
that you have to look carefully at every patient, examine them thoroughly,
and then make a judgment about what to do and how. It's very difficult, and
probably NOT in patients' best interest to have a set or relatively rigid
algorithm.
However, given all that, I understand your frustration when you see very
inconsistent practices.
Are you going to AVA? Dr. Ellen Jo Baron, the Director of Microbiology at
Stanford Hospital will be giving a presentation on blood cultures. It might
be worth asking her opinion, although she is not an infectious disease
physician.
I have asked infectious disease docs a similar question as you have posed,
but not as a protocol. I've not gotten a real clear answer.
We do know that the majority of lines that are pulled for suspected CRBSI
come back negative. A lot of that has to do with the fact the the wrong
cultures are done.
1. If a tip culture is sent and no blood cultures are sent, our Micro lab
will just throw it out as it will be meaningless. It doesn't tell us if the
PATIENT is bacteremic.
2. Most people think the distal catheter tip is what a tip culture is all
about. They should really be doing two catheter segments: the distal tip
AND the intracutaneous portion of the catheter because it's the colonization
of skin microbes down the catheter track that is the usual cause of CRI.
3. You still need peripheral blood cultures, preferably two sets to see if
the patient is actually bacteremic. Just because the tip is positive, if
the peripheral BCs are negative, then the MD should NOT institute IV
antibiotics.
4. Tip cultures also do nothing to diagnoize intraluminal infection. This
would best be done with time-to-positivity cultures. Dr. Baron will be
discussing this at AVA.
5. There are differences in concern about different patient populations.
Patients with any type of artificial device implanted are at much higher
risk of serious infection than without. Therefore there should be a higher
level of suspicion and vigilence if a patient has any implants at all.
6. Patients who are immune suppressed are also at much higher risk and
physicians are usually much more conservative in these populations and will
often remove a line and all other invasive devices that are temporary as a
means to prevent rapid deterioration in a fragile patient. That is one
reason why PICC lines are becoming more popular with the leukemic and other
oncology patient populations. The acute leuks can be neutropenic for a
prolonged period of time, and if they develop a CRBSI seriously enough to
get them admitted to the ICU, the mortality is unbelievably high. Instead
they pull the PICC, culture them, and start them on empiric antibiotics.
Usually the cultures come back negative, but they continue with the
antibiotics. Once the patient is afebrile for at least 24 hours and their
WBC is dropping into the normal range (although it won't register at all if
they are profoundly neutropenic), then the docs order another PICC and we
try to put it in the other arm.
7. This is very different for a patient who needs access for other
reasons.
Let's try to ask the ID folks at AVA this question (although I think I keep
trying and get the most vague answers.) Others may have completely
different opinions.
Nadine Nakazawa, Rn
Stanford Hospital
From: "Elizabeth Harmon" <[EMAIL PROTECTED]>
To: [EMAIL PROTECTED], [EMAIL PROTECTED]
Subject: culture protocols/guidelines for suspected CRBSI
Date: Sat, 12 Aug 2006 20:28:52 -0800
Does anyone out there have anyestablished protocols/procedures or
guidelines their facility uses when Central Lines are removed for suspected
CRBSI? Would you be willing to share? If so please e-mail me privately.
We are working on a set protocol for all Physicians to follow for any
suspected CRBSI. It would be done anytime a central line is changed or
pulled and another one is placed. Previously lines would get pulled, no
cultures, nothing and meds changed, and the lines blamed for the problem.
We are looking to have set protocols.
Thanks in advance.
Betsy Harmon RN CRNI
Vascular Access Team
Critical Care Unit
Alaska Native Medical Center
Anchorage, Alaska
[EMAIL PROTECTED]
