These guidelines from the Infectious Diseases Society of America (IDSA), the American College of Critical Care Medicine (for the Society of Critical Care Medicine), and the Society for Healthcare Epidemiology of America contain recommendations for the management of adults and children with, and diagnosis of infections related to, peripheral and nontunneled central venous catheters (CVCs), pulmonary artery catheters, tunneled central catheters, and implantable devices. The guidelines, written for clinicians, contain IDSA evidence-based recommendations for assessment of the quality and strength of the data. Recommendations are presented according to the type of catheter, the infecting organism, and the associated complications.Intravascular catheter-related infections are a major cause of morbidity and mortality in the United States. Coagulase-negative staphylococci,Staphylococcus aureus, aerobic gram-negative bacilli, andCandida albicansmost commonly cause catheter-related bloodstream infection. Management of catheter-related infection varies according to the type of catheter involved. After appropriate cultures of blood and catheter samples are done, empirical iv antimicrobial therapy should be initiated on the basis of clinical clues, the severity of the patient's acute illness, underlying disease, and the potential pathogen (s) involved. In most cases of nontunneled CVC-related bacteremia and fungemia, the CVC should be removed.
Reports suggest that carriage of methicillin-resistant Staphylococcus aureus (MRSA) among persons without health care-associated risks has increased. A meta-analysis of studies reporting the prevalence of community-acquired MRSA (CA-MRSA) among MRSA isolates from hospitalized patients or the prevalence of MRSA colonization among community members was conducted. The CA-MRSA prevalence among hospital MRSA was 30.2% in 27 retrospective studies and 37.3% in 5 prospective studies; 85% of all patients with CA-MRSA had > or =1 health care-associated risk. The pooled MRSA colonization rate among community members was 1.3% (95% confidence interval [CI], 1.04%-1.53%), but there was significant heterogeneity among study populations. Community members from whom samples were obtained in health care facilities were more likely to be carrying MRSA than were community members from whom samples were obtained outside of the health care setting (relative risk, 2.35; 95% CI, 1.56-3.53). Among studies that excluded persons with health care contacts, the MRSA prevalence was 0.2%. Moreover, most persons with CA-MRSA had > or =1 health care-associated risk, which suggests that the prevalence of MRSA among persons without risks remains low (< or =0.24%). Effective control of dissemination of MRSA throughout the community likely will require effective control of nosocomial MRSA transmission.
Contact isolation has been recommended by the Centers for Disease Control and Prevention for the prevention of nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA), but there are few data which prospectively quantitate the effectiveness of contact isolation for this purpose. During an outbreak of MRSA in a neonatal intensive care unit between July 18, 1991 and January 30, 1992, weekly surveillance cultures were performed on all patients. Sixteen of 331 admissions became colonized with MRSA, and 3 (19%) developed infections: bacteremia, conjunctivitis, and dialysis catheter site infection. The isolates from all 16 patients were submitted to plasmid profile analysis and restriction enzyme analysis of whole cell DNA. All of the patients had identical chromosomal patterns and plasmid profiles, which differed from control isolates from other wards, indicating that the outbreak resulted from spread of a unique strain. None of 144 personnel who were cultured after recent contact with newly colonized patients during the outbreak were found to carry MRSA, which suggests that patients were the reservoir for transmission rather than caregivers. The most probable source for each individual transmission was determined based on proximity in time and space and shared exposure to caregivers. The rate of transmission of MRSA from patients on contact isolation was significantly lower (0.009 transmissions per day on isolation) than the rate for patients not on isolation (0.140 transmissions per day unisolated, relative risk = 15.6, 95% confidence interval 5.3-45.6, p < 0.0001). The authors conclude that the risk of nosocomial transmission of MRSA was reduced 16-fold by contact isolation during the outbreak in this neonatal intensive care unit. These data confirm the results of previous studies which have suggested that contact isolation was effective in controlling the epidemic spread of methicillin-resistant Staphylococcus aureus.
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