A 72-year-old man with a history of stroke, hypertension, hyperlipidemia, and metastatic lung cancer with known metastases to the brain and bone presents with status epilepticus. The patient had four generalized tonic clonic seizures lasting less than 1 minute each. He was initially treated with 6 mg of lorazepam en route, but his seizures persisted. Upon arrival in the emergency department he was intubated, loaded with phosphenytoin, and transferred to the neurologic intensive care unit (NeuroICU), and EEG monitoring was initiated. In the NeuroICU he continued to have convulsive and nonconvulsive seizures, eventually requiring high doses of midazolam and propofol to create burst suppression. His tunneled chemotherapy port was accessed for immediate infusion of midazolam. In addition, a radial arterial line was placed for blood pressure monitoring. His seizures stop on hospital day 4, but then he develops a fever of 101.9°F (38.8°C) on hospital day 6.
Would you have concern for central line–associated bloodstream infection in this patient?
Diagnostic evaluation of fever in a patient in the NeuroICU can be challenging. Despite testing for infectious etiology of fever, many NeuroICU patients do not have an infectious source identified. Catheter-related bloodstream infections (CRBSIs) are relatively common hospital-acquired infections causing fever in the critical care setting. CRBSIs are the most common cause of nosocomial bacteremia, accounting for significant morbidity and mortality.1 Many types of catheters are utilized in the management of critically ill patients, including peripheral intravenous lines, arterial catheters, and central venous catheters (CVCs). All catheter types have potential to cause bloodstream infections, albeit with varying frequency depending on the catheter type and anatomic location. Peripheral venous catheters, arterial lines, and midline catheters have been reported as having lower rates of CRBSIs than CVCs.2 CVCs are commonly used in the ICU for administration of medication, fluid resuscitation, transfusing blood products, hemodialysis, parenteral nutrition, intravascular cooling, and hemodynamic monitoring.3
Studies suggest that placement of nontunneled subclavian catheters may pose a reduced risk of a CRBSI when compared with femoral or internal jugular vein insertion.4 Numerous risk factors for CRBSIs have been described (Table 55-1).
Table 55-1.Risk Factors for Catheter-Related Bloodstream Infectionsa ||Download (.pdf) Table 55-1. Risk Factors for Catheter-Related Bloodstream Infectionsa
|Duration of catheterization |
|Conditions of insertion, submaximal barrier precautions during insertion, and emergent procedure |
|Nontunneled compared with tunneled catheters |
|Femoral or internal jugular compared with subclavian insertion |
|Bare compared with antibiotic-impregnated catheters |
|Catheter site care |
|Skill of the catheter inserter |
|Parenteral nutrition |
|Immunocompromised patient |
Laboratory results reveal a leukocytosis of 18,000 B/L with 12% immature band forms. The patient has become hypotensive and is started on norepinephrine to maintain his mean arterial pressure of > 65 mm Hg. Blood, urine, and sputum cultures are collected, and the patient is started on broad spectrum antibiotics ...