It may also occur without a clearly identifiable mechanism, for example, in some cases of complicated community-acquired S. aureus bacteremia.1,2 The spleen is major immune organ for responding to invasive pathogens reaching the bloodstream. Blood stream infections may result from primary infection within the cardiovascular system (e.g., from an infected vascular catheter) or may be secondary to a local infection in another organ (e.g., E. coli infection of the urinary tract). CDC’s National Healthcare Safety Network Patient Safety Component includes surveillance methods to identify and track device-associated infections, such as central-line associated bloodstream infections. Bacteria account for over 90% of bloodstream infections. Recently, studies have demonstrated that the use of needleless administration systems also contributes to the risk for intravascular device–associated infections. CDC is providing guidelines and tools to the healthcare community to help end CLABSIs. Use of combination therapy should be strongly considered in the severely ill patient for the empirical treatment of P. aeruginosa BSI, especially in those health care institutions with patients with a high rate of multidrug resistance. Over the last 30 years, the epidemiology of single-organism bacteremia in neutropenic patients has changed and may vary from center to center (Figure 79-1). Minocycline-rifampin catheters are coated on both the internal and external surfaces of the catheters, whereas first-generation chlorhexidine–silver sulfadiazine catheters were coated only on their external surfaces. Pablo Yagupsky, in Principles and Practice of Pediatric Infectious Diseases (Fifth Edition), 2018, Bloodstream infection (BSI) without focus is the second most frequent presentation of pediatric K. kingae infections.14,18,32,33 In a large study, only one half of children with this condition had a body temperature of ≥39°C, and one third had a WBC count of <15,000 cells/mm3. Copyright © 2020 Elsevier B.V. or its licensors or contributors. Bloodstream infections are the most common infections acquired by hospitalized children, accounting for 21% to 34% of all nosocomial infections in PICU patients.3-5 Most of these bloodstream infections occur as a consequence of intravascular catheterization.3 The attributable cost of these infections in PICU patients is approximately $39,000 per episode,6 and it is an increasingly common problem. These two types of dressings have been shown to be equivalent with respect to infection rate and local complications. Staff may not disinfect the device properly, or the device may be intrinsically difficult to disinfect. Either cotton gauze dressings covered by tape or semipermeable transparent membrane dressings can be used to protect the insertion site; however, the cutaneous microbial burden increases substantially underneath the semipermeable dressing. Phlebitis and bloodstream infections due to intravenous infusion catheters (Dutch National Institute for Public Health and the Environment, 2015) Flebitis en bloedbaaninfecties door intraveneuze infuuskatheters (Rijksinstituut voor Volksgezondheid en Milieu, revised 2015) Portugal. Future clinical studies, however, are required to further validate this treatment regimen. By contrast, after 10 days of placement, ultrastructural studies demonstrate an increasing relative frequency of intraluminal contamination, and most long-term catheters appear to become colonized and produce blood stream infection by the intraluminal route. Furthermore, health care workers who do not practice appropriate hand hygiene may inadvertently colonize a patient's catheter insertion site with health care–associated pathogens (e.g., MRSA). In people who are hospitalized, bacteria may enter through IV lines, surgical wounds, urinary catheters, and bed sores. The use of maximal barriers to create a large sterile field during catheter insertion has also been shown to decrease the risk for infection. Approximately 80% of health care–associated blood stream infections are primary, and the overwhelming preponderance of them are due to vascular catheter infections. Although most such trials were designed to have statistical power only to be able to detect a reduction in catheter colonization, two of the studies demonstrated significant reductions in catheter-related blood stream infections as well. 2011, Reduction in central line-associated bloodstream infections (CLABSIs) among patients in intensive care units. A number of other factors, such as the type of dressing, the composition of the catheter, the number of lumens, and the type of intravenous administration system used, all influence the risk for catheter-associated primary blood stream infection. Narrowing to a single agent is especially relevant when the combination therapy includes an aminoglycoside, because this regimen is associated with increased nephrotoxicity.67,68 Other adverse events that are more likely to occur with combination therapy, compared with monotherapy, include an increased risk for Clostridium difficile infection, further alterations in the protective effects of the human microbiota against colonization by other multidrug-resistant organisms, and fungal infections. Femoral arterial lines. Top of Page. The great majority of reported crude mortality percentages from large surveillance studies range from 39% to 60%. Central line-associated bloodstream infections (CLABSIs) result in thousands of deaths each year and billions of dollars in added costs to the U.S. healthcare system, yet these infections are preventable. BSI can be transient and asymptomatic in normal hosts but severe in hosts who are immunosuppressed, with mortality of 10% to 15%.43,61–63 Most episodes of BSI occur in patients with diarrhea. The predominant distinguishing feature of P. aeruginosa BSI is the occurrence of ecthyma gangrenosum. Healthcare associated infections (HAI): central line-associated bloodstream infections (CLABSIs) in non-intensive care unit (non-ICU) settings toolkit activity C: ELC Prevention Collaboratives. Infection Control Guidelines. Recently, the Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), has adopted the IHI recommendation and requires implementation of these five strategies as a standard for continued accreditation. Preventing Central Line–Associated Bloodstream Infections. Second-generation chlorhexidine–silver sulfadiazine catheters are coated on both the internal and external surfaces but have not yet been compared with minocycline-rifampin catheters. Central line related infections can be either localised or systemic. Because vascular catheters are usually placed through the patient's skin, most such colonizing microbes come from the patient's resident skin flora. The care and use practices of staff who are unfamiliar with these systems often do not follow the manufacturer's recommendations. The reason that all vascular catheters do not uniformly result in clinical infection relates to the body's innate immune response and its ability to kill microbial invaders and limit their growth and spread. Saving Lives, Protecting People, Central Line-associated Bloodstream Infections: Resources for Patients and Healthcare Providers, Frequently Asked Questions about Catheters, Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update, Checklist for Prevention of Central Line Associated Blood Stream Infections, Guidelines for the prevention of intravascular catheter-related infections. The nationwide Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE), which included data from 49 U.S. hospitals, reported that from 1995 to 2002 the incidence of P. aeruginosa nosocomial BSI was 2.1 per 10,000 hospital admissions. Three clinical manifestations of BSI are described: (1) cryptogenic BSI, which occurs as an isolated event that is self-limited or readily responds to antibiotics; (2) secondary BSI associated with focal infections such as meningitis, pneumonia, endocarditis, and thrombophlebitis; and (3) chronic BSI with relapses that can persist for several months (mostly in immunosuppressed patients). Studies using electron microscopy have shown that microbial contamination of catheters is virtually universal from the first day after insertion. Prompt initiation of the appropriate antimicrobial agents is also key to a successful outcome, as is removal of invasive devices if implicated. Finally, the manner in which catheters are used may influence the risk for infection. A few earlier studies support the use of combination therapy since mortality rates were lower when two antimicrobial agents, instead of a single agent, were used to treat BSI caused by P. aeruginosa.60 The main limitation of these studies is that in many the monotherapy study arm consisted of only an aminoglycoside, which is suboptimal for the treatment of P. aeruginosa BSI.61 In a meta-analysis, which also concluded that combination therapy is superior to monotherapy, four of the five included studies used aminoglycosides in the monotherapy study arm.62 There are numerous other limitations with older studies that support the use of combination therapy, including lack of double blinding and randomization, different sources of BSI, retrospective lack of adjustment for time to start of appropriate antimicrobial therapy, and duration of follow-up. Section 1.4 Vascular - access devices (National Institute for Health and Care Excellence, 2017), Winning Ways: Working together to reduce Healthcare Associated Infection in England - Action Area Two  (UK Department of Health, 2003), Compendium of HAI guidance; page 35 (Health Protection Scotland), Tools: Preventing infections when inserting and maintaining a central vascular catheter (CVC) (Health Protection Scotland, 2014), Prevention of bloodstream infections associated with intravascular catheters (Ministry of Health, 2013), National infection control guidelines – for use of intravascular catheters (Statens Serum Institut, 2016), Recommendations: Prevention of infections associated with implantable venous access port (French society for hospital hygiene, 2012), Recommendations: Good practices and risk management associated with PICC (Société française d'hygiène hospitalière (, Guidelines for drafting internal regulations for the prevention and control of infection in healthcare settings, Annex 6, page 160-63.

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