Case 02 - David 4 Years Old (Answers) | PIAC Series

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ANSWERS
Case 02 - David, 4 Years Old - Answers

David is a 4 year old with developmental delay who required abdominal surgery for volvulus.

  • He has not tolerated oral/enteral nutrition and has received TPN. On post-op day 6 he develops T=38.8 and WBC=15K
  • The following day 2 of 2 blood cultures are positive for gm + cocci

Questions

1) How is a central-line associated bloodstream infection (CLA-BSI) diagnosed?

2) What organisms in blood culture are possible contaminants? Which organisms should definitely not be considered contaminants?

Consider:
- Staphylococcus aureus
- Staphylococcus epidermidis (CONS)
- Pseudomonas aeruginosa
- Bacillus species
- Candida albicans
- Diptheroids

Answers

CLA-BSI diagnosed by:

  • + blood culture with recognized pathogen (e.g. S. aureus), central line in place and no other evident source
  • If blood culture + for pathogen of uncertain significance (e.g. CONS), need 2 positive cultures and sign/symptom (fever, chills, hypotension)
  • Organisms likely contaminants = corynebacterium ("diptheroids"), bacillus (non-anthracis), propionibacterium
  • Possible contaminants = coagulase-negative staph
  • NOT contaminants = Staph aureus, Candida, Pseudomonas


Questions

3) What measures are undertaken to prevent CLA-BSI?

Answers

Measures  undertaken to prevent CLA-BSI in all patients:

Line  bundle for placement

  • Site  prep = chlorhexidine/alcohol  (allow it to dry!)
  • Full  site drape on patient
  • Full  barriers on operator (cap, mask, gown, sterile gloves)

Optimal  care of line

  • scrub  the hub" for any access; dry/intact dressing at all times

Daily  review of necessity of line - remove if not needed!

Other  measures to consider

  • Our  standard is silver impregnated catheter; an antibiotic (minocycline/rifampin)  impregnated catheter available - use if prior CLA-BSI or other high risk
  • Some  hospitals have shown decrease in CLA-BSI with daily chlorhexidine  bathing in ICU patients

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