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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 15  |  Issue : 1  |  Page : 50-57

Bacteriological study of indwelling central venous catheter among patients in ICU


Department of Microbiology, Krishna Institute of Medical Sciences Deemed to be University, Karad, Maharashtra, India

Date of Submission27-Jan-2020
Date of Decision15-Feb-2020
Date of Acceptance20-Feb-2020
Date of Web Publication13-Oct-2020

Correspondence Address:
Dr. Geeta S Karande
Krishna Institute of Medical Sciences Deemed to be University, Karad - 415 110, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_25_20

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  Abstract 


Aim: The aim is to study the bacteriological profile of indwelling central venous catheter (CVC) among patients in intensive care unit (ICU). Settings and Design: The study was conducted on admitted patients with indwelling CVC in medical ICU, surgical ICU, and critical care unit of Krishna hospital, Karad. The study design was a prospective observational study. Materials and Methods: Two hundreded patients admitted with an indwelling, CVC. These patients were followed daily for the development of catheter related blood stream infections (CRBSIs) 48 h after insertion of CVC, in which case two sets of blood samples were drawn along with catheter tip and skin swab for culture. Statistical Methods: Incidence of CRBSIs was measured per 1000 catheter days. Results: Among 200 suspected cases with indwelling CVC, 1028 catheter days were observed, and CRBSI rate was 61.28/1000 catheter days. The incidence of CRBSIs were detected in 63 (31.5%) patients. Conclusions: This prospective study has highlighted the incidence, aerobic bacteriological profile of CVC infections, and also the changing trends in the susceptibility pattern of the isolates to routinely used antibiotics in our tertiary care centre. Combined efforts of the microbiologist, clinicians, and hospital infection control team are needed to tackle CRBSI. A proper training program of hospital staffs, maintenance of proper hand hygiene, following up of proper guidelines of catheter insertion, and maintaining aseptic precaution, prior to CVC insertion can reduce CRBSI.

Keywords: Bacteriological Study, indwelling central venous catheter, catheter related blood stream infection


How to cite this article:
Karande GS, Gupta D, Patil S R, Shinde R V, Pawar S K, Patil H V, Mane P M. Bacteriological study of indwelling central venous catheter among patients in ICU. J Datta Meghe Inst Med Sci Univ 2020;15:50-7

How to cite this URL:
Karande GS, Gupta D, Patil S R, Shinde R V, Pawar S K, Patil H V, Mane P M. Bacteriological study of indwelling central venous catheter among patients in ICU. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2020 Oct 28];15:50-7. Available from: http://www.journaldmims.com/text.asp?2020/15/1/50/297984




  Introduction Top


Intravenous (IV) therapy is an essential part of clinical care used in a wide variety of healthcare settings.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] Venous access is one of the most basic yet critical components of patient care both in hospital and ambulatory settings. It is estimated that almost 300 million catheters are used each year, and nearly 3 million are central venous catheters (CVCs), otherwise known as central lines. They play an integral role in modern health care allowing for the administration of IV fluids, medications, blood products, parenteral nutrition as well as hemodialysis access and hemodynamic monitoring. CVCs are frequently used in monitoring and management of patients in the intensive care unit (ICU). These catheters provide access for the infusion of fluids and electrolytes, for the infusion of antimicrobial agents, for short-term hyperalimentation and for hemodynamic monitoring in critically ill individuals.[16],[17] Catheter-related bloodstream infections (CRBSIs) are an important contributor for the increasing morbidity and mortality in patients on CVC. The incidence of CRBSI increases with the duration of catheterization. All catheters either entering central or peripheral veins or arteries, are foreign bodies and are prone to get infected. Such infected vascular catheters constitute an important source of varying degrees of sepsis in all critical care units (CCUs).[18],[19],[20],[21],[22] Infection associated with CVC use is thought to be a consequence of catheter colonization. This occurs either during insertion or during the subsequent care of the catheter.[2] It is important to distinguish between colonization, which may affect up to 25% of catheters inserted and which has no serious clinical effects, and CRBSI, otherwise defined as sepsis due to an infected CVC. This is thought to affect 5% of catheterized patients.[4]


  Material and Methods Top


  • The present study “Bacteriological study of indwelling CVC” was carried out in the Department of Microbiology, Krishna Institute of Medical Sciences, Krishna Hospital, and Medical Research Center, Karad, Dist.-Satara
  • A total of 200 samples were collected during the study.


Study design

Prospective, observational study.

Study period

October 2017 to October 2019.

Source of data

The study was conducted on admitted patients with indwelling CVC in medical ICU (MICU), surgical ICU (SICU), and critical care unit of Krishna hospital, Karad.

Statistical analysis

Carried out by percentage and Chi-square test.

  • CRBSI rate was calculated by the following formula.[12]




Expressed as number of CRBI per 1000 catheter days:

  • Catheter samples were collected from cases of CVC inserted patients admitted to the ward of SICU, MICU, and CCU at Krishna Hospital, Karad
  • Samples were collected after removal of the catheter
  • Paired blood samples were collected from the patient from two different sites on the same day along with catheter tip and skin swab
  • Informed consent was taken (Patient/Relative)
  • All the samples were collected, transported, and processed in the department of microbiology according to the standard laboratory procedures.


Inclusion criteria

  • Patients with CVC-associated septicemia after 48 h of insertion of intravascular device
  • Patients of both sexes were included.


Exclusion criteria

  • Patient with septicemia on admission or within 48 h of admission.


Ethical clearance

  • The study was approved by Ethical committee of Krishna Institute of Medical Sciences, Deemed to be University Karad.


Sample collection

  • A detailed medical history was taken of all the patients and proforma filled for each patient documenting age, sex, underlying disease, duration of stay in ward, along with any other procedure done
  • Catheter tip sample obtained by cutting the distal 5 cm segment for semi-quantitative culture
  • Ten millilitre paired blood sample, one from the peripheral vein and other from the central line for culture was collected aseptically
  • Superficial swab from the insertion site was obtained by lifting the dressing and rubbing the area around the insertion site (in a 3 cm radius) with a cotton swab moistened with sterile saline
  • The catheter tip was processed by roll plate technique (semiquantitative method) on agar plates for routine clinical microbiological analysis[1]
  • Growth of >15 CFU/plate of catheter tip was considered positive
  • Blood sample was directly inoculated into automated blood culture bottle “Adult” (green, 20 mL, BacT/Alert FA)
  • The bottle was loaded in the BacT/Alert 3D microbial detection system (BIOMÉRIEUX Durham, North Carolina) and incubated at 37°C for 5 days
  • Superficial skin swab was inoculated on both blood and MacConkey agar plate
  • The inoculated media was incubated at 37°C overnight
  • Bacterial isolates were identified as per standard protocol as described in Practical Microbiology of Mackie McCartney 14th volume
  • After the blood culture bottle flagged positive, the smear was prepared from the broth, for gram staining, and the broth was subcultured onto Blood agar and MacConkey agar plate, then it was processed for microbiological examination
  • Gram staining was done to identify morphology of bacteria
  • Antimicrobial susceptibility testing of isolates was performed on Muller Hinton agar plates using the Kirby-Bauer disc diffusion method as recommended by the Clinical and Laboratory Standard Institute (CLSI Guidelines, 2018) [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
Figure 1: Distribution of Gram-positive bacteria in catheter tip only

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Figure 2: Distribution of gram negative bacteria in catheter tip only

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Figure 3: Distribution of Gram-positive bacteria in blood and catheter tip

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Figure 4: Distribution of Gram-negative bacteria in blood and catheter tip

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Figure 5: Extended-spectrum of beta-lactamase detection in Gram-negative organisms

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Phenotypic test

Detection of extended-spectrum of beta-lactamase production

Gram-negative bacilli isolated was suspected to be an extended spectrum of beta lactamase (ESBL) producer if it was resistant to Aztreonam (30 μg), Cefotaxime (30 μg), Cefpodoxime (10 μg), Ceftazidime (30 μg), and Ceftriaxone (30 μg).

Phenotypic methods

Control strain

  • Positive control-Klebsiella pneumonia ATCC 700603
  • Negative control- Escherichia More Details coli ATCC 25922.


Double disc synergy test

  • Inoculum of test and control organisms was prepared and matched with turbidity 0.5 McFarland standard
  • Test and control organisms were inoculated on Mueller Hinton agar to give a semi-confluent growth
  • A Ceftazidime 30 μg disc and an Amoxicillin + Clavulanic acid (20 μg + 10 μg) disc were placed 20 mm apart, center to center and incubated aerobically at 37°C for 16–18 h
  • ESBL production: Zone of inhibition around the Ceftazidime disc increases towards the Clavulanic acid disc, in an ESBL producer.


Detection of metallo beta-lactamase

  • Control: Pseudomonas aeruginosa ATCC 27853 was used as a control
  • Screening for detection and confirmation was tested by Imipenem-ethylenediaminetetraacetic acid (EDTA) double-disc synergy test
  • Inoculum of test and control organisms was prepared and matched with turbidity 0.5 McFarland standard
  • Test and control organisms were inoculated onto Mueller Hinton agar plates
  • Imipenem 10 μg disc was placed 20 mm apart, center to center from a Imipenem + EDTA disc containing 0.5 μl of 0.5 M EDTA (750 μg)
  • Plates were incubated at 37°C for 16–18 h
  • Metallo Beta Lactamase (MBL) production: Zone of inhibition around the imipenem disc increases towards the EDTA disc in an MBL producer.


Detection of methicillin-resistant Staphylococcus

  • Staphylococcus aureus ATCC 25923 was used as a control strain for the test
  • Inoculum of test and control organisms was prepared and matched with turbidity 0.5 McFarland standard
  • Test and control organisms were inoculated onto Mueller Hinton agar plates
  • Staphylococcus species were tested for Methicillin resistance using 30 μg Cefoxitin discs by Kirby-Bauer disc diffusion method
  • Plates were incubated at 37°C for 24 h.


Data results

  • In this study, among 200 patients with CVC insertion, CRBSI was detected in 63 (31.5%) patients
  • Catheter-associated infection was seen in 24 (12%) patients in which only catheter tip culture was positive
  • In remaining, 113 (56.5%) patients, all three samples were sterile
  • Majority of the patients were over 50 years of age, and maximum number 74 (37%) of them were above 60 years
  • Mean age of the patient was 57 ± 10 years
  • Of the total patients, 122 were males and 78 females
  • The study shows a male predominance, that is 122 (61%) in the study.


Out of 200 samples, 69% of cases were from MICU, 23.5% from SICU, and 7.5% from CCU.

  • Total 200 suspected patients' blood samples were processed out of which 63 were diagnosed as CRBSI, so culture-positive rate was 31.5%
  • In this study, among 200 patients with CVC insertion, CRBSI were detected in 63 (31.5%) patients
  • Catheter-associated infection were seen in 24 (12%) patients in which only catheter tip culture was positive
  • In remaining, 113 (56.5%) patients, all three samples were sterile
  • To confirm CONS as true cause of CRBSI, repeat blood sample was taken from the same patient, and when the same organism was isolated with the same AST pattern, then, it was regarded as an agent of CRBSI
  • Of a total of 200 skin swab samples collected, 62 samples showed culture positivity. Twenty-three isolates correlated with the source of CRBSI, i.e., organisms isolated and their antibiogram were same in paired blood and catheter tip samples.


Among Gram-positive bacteria, S. aureus was the most common isolate 5 (33%), Micrococcus species was the least common isolate 2 (13%).

Among Gram-negative bacteria, Klebsiella species were the most common isolate 4 (45%) and Acinetobacter species were the least common isolate 1 (11%).

Among Gram-positive bacteria, Coagulase-negative Staphylococcus were the most common isolate 18 (62%), beta-hemolytic Streptococci was the least 1 (4%).

Among Gram-negative bacteria, E. coli was the most common isolate 15 (44%) and Enterobacter species was the least 2 (6%).

  • Most of the Gram-positive bacteria isolated from catheter tips were resistant to penicillin, ampicillin, cotrimoxazole drugs.




  • Antibiotic Sensitivity Testing

  • Vancomycin and linezolid were the most effective antimicrobial agents against all the isolated Gram-positive species
  • Most of the Gram-negative bacteria isolated from catheter tips were resistant to ampicillin, cefuroxime, norfloxacin antibiotics
  • Amikacin, gentamycin, and tigecycline were found most effective antimicrobial agents against all the isolated Gram-negative bacterial species
  • Most of the gram-positive bacteria isolated from blood were resistant to Ampicillin, Penicillin, Cefotaxime, Cotrimoxazole drugs
  • Vancomycin, tigecycline, and linezolid were the most effective antimicrobial agents against all the isolated Gram-positive species
  • Most of the Gram-negative bacteria isolated from blood were resistant to ampicillin, cefuroxime, norfloxacin antibiotics
  • Colistin and tigecycline were found the most effective antimicrobial agents against all the isolated Gram-negative bacterial species.


MRSA was seen in 2 (29%) isolates of S. aureus.



Methicillin Resistant

S. aureus



Methicillin Sensitive

S. aureus


Of a total of 34 g negative organisms isolated from the patient of definitive catheter-associated bacteremia, 8 (23.5%) shows ESBL production.

Double disc synergy test positive for ESBL production:



MBL was seen in 1 (11.11%) isolates of Acinetobacter species.

Imipenem-ethylenediaminetetraacetic acid double disc synergy test





Metallobeta lactamase negative Metallobeta lactamase positive [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13].
Table 1: Age and sex distribution of patients studied

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Table 2: Ward-wise distribution

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Table 3: Distribution of organism in three samples

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Table 4: Incidence of catheter-related infection

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Table 5: Pattern of organisms isolated in three samples

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Table 6: Pattern of organisms isolated from both skin swab and blood culture

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Table 7: Antibiotic susceptibility pattern of Gram-positive organism in catheter tip only

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Table 8: Antibiotic sensitivity pattern of Gram-negative organism in catheter tip only

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Table 9: Antibiotic sensitivity pattern of Gram-positive organism in catheter-associated bloodstream infection

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Table 10: Antibiotic sensitivity pattern of Gram-negative organism in catheter-associated bloodstream infection

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Table 11: Detection of methicillin-resistant staphylococcus aureus Scientific Name Search  in catheter-associated bloodstream infection

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Table 12: Detection of extended spectrum beta-lactamase among Gram-negative organisms in catheter-associated bloodstream infection

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Table 13: Metallo-beta lactamase detection in Acinetobacter species in catheter-associated bloodstream infection

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  Conclusions Top


  • The overall incidence of CRBSI in the present study was 31.5%
  • The incidence of CAI was 12%
  • The rate of BSI associated with CVCs placed in the ICU was 61.28 per 1000 catheter-days
  • Coagulase-negative Staphylococcus was the most common organism isolated from the CVC infections
  • All Staphylococci were resistant to Penicillin and Ampicillin
  • Majority of the isolates were susceptible to amikacin, tigecycline, and gentamycin
  • All Staphylococci were susceptible to Vancomycin
  • Gram-negative bacilli showed multi drug-resistant patterns
  • CRIs were high among catheters that were placed for more than 3 days
  • CVC infections were higher in emergency procedures as compared with elective procedures
  • The antimicrobial sensitivity pattern of common isolates provides guidelines for the intensivist in critical care medicine to start appropriate empirical antibiotic therapy depending upon the clinical scenario. This can be cost-effective and can prevent the indiscriminate use of antibiotics
  • The importance of strict asepsis and ideal catheter care has to be reinforced. All intensivists are required to follow standard protocols that uniformly demand the use of sterile gowns, gloves, masks, and large drapes during insertion to reduce CVC associated infection
  • CVCs are increasingly used in the inpatient and outpatient setting to provide long-term venous access
  • The duration of catheterization and catheter colonization has an important role in the development of CRBSI which may lead to septicaemia
  • While inserting CVC, preventive measures should be used such as local antibiotics and catheter lock solution
  • Duration of catheterization increases the morbidity, so regular monitoring of catheterized patient should be done for both insertion site and general condition
  • It is important that the critical care practitioner be proficient in the techniques of CVC ization
  • This prospective study has highlighted the incidence, aerobic bacteriological profile of CVC infections, and also the changing trends in the susceptibility pattern of the isolates to routinely used antibiotics in our tertiary care center
  • Combined efforts of the microbiologist, clinicians, and hospital infection control team are needed to tackle CRBSI
  • Proper training program of hospital staffs, maintenance of proper hand hygiene, following up of proper guidelines of catheter insertion, and maintaining aseptic precaution prior to CVC insertion can reduce CRBSI.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]



 

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