CRBSI

Kawana Wamundila
• No hx of headache, confusion,vomiting,diarrhoea, nor known hx of household TB
contact

• Perm cath removed 10/7 post readmission, cath tip sent for m/c/s

• Pmed hx HTN/DM nifedine/Lorsatan,not on hypoglycemics

• No pets/animal contact at home

• SEhx civil servant, Alcohol°,smoking°

Examination
• Vitals: Bp profile good, T =36.5°c, been normal for about 1/52 with TPR
s/p spiking fevers 1/52, Tmax of 39°c, RR normal profile regular, non
bounding radial pulse. RFV temp cath in situ-no exit site infection sign
• Urine out put not documented but pt reports upto about 500mls/24hrs
• Fully conscious, pale(moderate) J° CN° Afebrile level JVP Lipodystrophy

• No uremic frost/flap, MMSE good.

• Chest: clear CVS:S1S2 tachycardic, no Rub MSS: no oedema
ART History
Date ART Regimen VL/CD4
2005 AZT/3TC/NVP ˃ D4t/LPV/r/? ?

2007 TDF/3TC/LPV/r ?

2012 AZT/3TC/DVR/r ?

2017 ABC/3TC/RAL ?
DX
• GROUP DISCUSSION FOR DIFFERENTIALS
• HD CRBSI(line sepsis) 2° poorly/partially treated bacteraemia in
RVD/HTN/?DM on 3rd line ART

• Malaria

• r/o UTI
 Investigations
05/04/2020 27/04/2020 5/05/2020
FBC WBC 3, Hb 5.4,PLT 89 WBC
Blood culture Collected but result indicated Enterobacter spp Sensitive to Enterobacter cloacae
on 27/04/2020 Chlora-/piptazo/Cipro- and (profuse growth) EBSL=
Resistant to negative, AMP C =
CTX/Ampicillin/Sulbactum/Ge Positive[see sensivities slide
ntamycin below]
Yeast cells seen on
microscopy but non viable on
culture
Cath tip pus culture Enterobacter agglomerans
Creatinine/Urinalysis 475umol/L, No M/C/S seen
RDT Malaria/MPS Negative RDT - Positive(4/7 post
admission), MPS negative
after Artesunate Tx
ECHO Normal findings, No
vegetations
Dx/Tx
• HD CRBSI (Enterobacter spp ) with Severe Anaemia in ESRD/DM/HTN s/p Resolved
malaria
Treatment given
• 27/04/2020
• Imipenem 125mg BD IV and Vancomycin @ 15mg/kg initially stopped after MCS
results
• Artesunate IVI/Coartem
• EPO/Iron sucrose
• BT intra HD
• Renal team input
• Emphasise on ABX last hour of HD.
Approach to CRBSI
CRBSI is same(identical species/antibiogram) org. isolation from 2
cultures in pt with signs of sepsis and no alternative source of infection
1. Hx and Exam,plus appropriate investigations

2. Exclude alternative diagnoses even where CRBSI is suspected

(If hx limited to Fever/chills, 85% CRBSI/ 15% alternative diagnoses)
3. Clinical evaluation- out vs in pt care. Prompt stabilises of
unstable/septic patients with fluids/appropriate empiric ABXs therapy-
aim to cover MRSA + Gram negs
• 40-80% - G +ves[S. aureus + CoNs]/ 20-40% - G –ves
• 10-20% - polymicrobial with Fungi ≤10%
• 4. Prompt confirmation of diagnosis
-2 blood cultures prior to Abxs and exclude alternative source of
infection
• Sources of collection include catheters/circuit line[preferred in HD pts
and peripheral vein
• 5. empiric tx (stable vs unstable pt and type of dialyser)
Stable pt, Vancomycin at 20mg/kg IV and 1gm ceftazidime immediately
after session. 3 times/week till cultures ready for definitive tx
Unstable pts start tx immediately, DO NOT WAIT FOR DIALYSIS
• If cephalosporins O/S; gentamycin @ 1-2mg/kg (max 100mg in singe
dose) and tobramycin are alternatives
• For Vanc, initial 20mg/kg,then 1gm if high flux dialyser, 500mg if low
flux dialyser which removes minimal vancomycin
• Duration of tx is 3/52 generally, 4/52 if staph aureus or longer if
metastatic disease, repeat cultures 1/52 after tx.
• Switch to definitive Abxs once m/c/s ready.
• New perm cath should not be placed until cultures are negative for
≥48hrs after Abx cessation. NKF-DOQI working group recommendation
• 6. assess need for catheter removal
• Indications ;
• Severe sepsis/shock despite med tx
• Metastatic infections
• Unstable pt with clear exit site infections- hence need to exam cath site
• CRBSI 2° staph aureus and candida albicans
• Persistent fevers and positive blood cultures while on appropriate Abx
therapy for 36-48hrs
• Failure of s/s resolution 48hrs after lock therapy
• Biofilm- extracellular polysaccharide matrix encasing bacteria on a
biomaterial.
• Importance: Abx penetration barrier/host immune
interference/seeding portal
• Examples of biofilm forming organisms
• E. coli. P. aeruginosa, S. aureus,S. epidermis,E. cloacae, K.
Pneumoniae, actinomyces spp, H. influenza,
TAKE HOME MESSAGE
• CRBSI
• multidisciplinary approach[renal/ID]
• Prevention of infection critical- Asceptic techniques pt/HCWs
• Prompt clinical evaluation and diagnosis
• Evaluation of Abx choice, dosing, frequency, timing, duration and cath
mx
• MANAGEMENT INPUT FROM GROUP???
References
1. Charmaine E. Lok1 and Michele H. Mokrzycki2, 2015 Prevention
and management of catheter-related infection in hemodialysis
patients New York, USA

2. Anil K. Saxena, Bodh R. Panhotra Division of Nephrology, King Faizal

University, King Fahad Hospital, Hofuf, Al-Hasa, Saudi
ArabiaHaemodialysis catheter-related bloodstream infections:
current treatment options and strategies for prevention,SWISS MED WKLY
2005;135:127–138

3. Up toDate@2020