Vascular Access Devices
Once antimicrobial susceptibility results are available, deescalation to the appropriate intervention is then recommended. If blood cultures have no growth, the need for further empiric antibiotic treatment must be reassessed to determine need. Catheter salvage may be considered on a case-by-case basis, considering factors such as whether the patient has other available vascular access sites. Organisms common to CRBSI in patients receving HPN include
all species of Candida or yeast, gram-positive bacteria (eg, S. aureus, Staphylococcus epidermidis, or Enterococcus species), and gram-negative bacteria (eg, Pseudomonas species, Serratia marcescens, Klebsiella pneu- moniae, Escherichia coli). Candida species and S. aureus are very difficult to eradicate and, in many cases, will require removal of the catheter.22,23
Care of Vascular Access Devices
Catheter care protocols, also known as central line bundles, are a key component in ensuring successful outcomes, for both patients who are hospitalized and those receiving care at home. Central line bundles pro- vide guidance aimed at avoiding infectious and noninfectious complica- tions. Infectious complications include exit-site infection, tunnel-related infection, and CRBSI. Noninfectious complications include catheter occlusion, breakage, and dislodgement. Two types of central line bundles are now recommended: central line insertion bundles and central line maintenance bundles.5 Central line insertion bundles are composed of the following 5 com-
ponents, explored below.5,24 1. Hand hygiene: Before and after touching or accessing a VAD or palpating the surrounding area, patients, caregivers, and health care workers must practice good hand hygiene. This can be achieved by washing hands frequently with soap and water. Ster- ile gloves should be used for line insertion, while clean or sterile gloves can be used for dressing changes.
2. Maximal barrier precautions: During insertion of VADs or guidewire exchange, clinicians should don a cap, mask, sterile gown, and sterile gloves as well as utilize a sterile full body drape.
3. Chlorhexidine skin antisepsis: The recommended agent of choice for daily cleaning of catheter exit sites is 2% chlorhexidine gluconate solution. Use a 0.5% or greater chlorhexidine prepara- tion with alcohol before catheter insertion and during dressing changes. If chlorhexidine is contraindicated, check the facility policy for the appropriate alternative.
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