You admit a 28-year-old woman to the intensive care unit for hypoxemia requiring noninvasive positive-pressure ventilation. She received an allogeneic bone marrow transplant 13 days ago for relapsed acute leukemia and remains neutropenic.
What are the MOST appropriate infection control measures?
Correct Answer: D
Recent hematopoietic stem cell transplant (HSCT) recipients, especially allogeneic bone marrow transplant recipients, are at high risk of bacterial, viral, fungal, and parasitic infection. Current guidelines recommend that HSCT patients be admitted to rooms with HEPA filters, and the rooms be maintained with positive pressure relative to the corridor. Gown, gloves, and mask are not required for healthcare workers or visitors for routine entry into the room. Standard precautions are recommended for healthcare workers and visitors. HSCT patients should wear N95 respirator masks when leaving the positive pressure environment.
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You are caring for a patient who underwent right internal jugular central venous catheter placement 36 hours ago. She developed fever 12 hours ago, and blood cultures were sent. No other signs or symptoms of infection are present, and chest X-ray and urinalysis are normal. Five hours after they were drawn, blood cultures are now growing Staphylococcus aureus in two of four bottles.
What is the MOST likely diagnosis?
Correct Answer: A
Catheter-related (also called central line-associated) bloodstream infections (CRBSI or CLABSI) can be challenging to diagnose. Diagnosing CRBSI requires the presence of a bloodstream infection and demonstrating no alternative sources of bacteremia. Diagnosis of CRBSI is supported when the same organism is isolated from at least two blood cultures. Blood cultures should be obtained before initiating antibiotic therapy, and at least one blood culture should be obtained by peripheral venipuncture. Resolution of fever, leukocytosis, hypotension, and other infectious signs and symptoms within 24 hours of removing a central venous catheter also supports this diagnosis. S. aureus should not be considered a blood culture contaminant. This scenario presents insufficient information to determine whether the cultured S. aureus is methicillin-resistant, as the bacterial species was just identified, and susceptibility information will follow later. Lastly, this scenario meets criteria for CRBSI, and as such, the source of bacteremia is not unknown.
Which of the following is the MOST common route(s) of contamination for nonemergently placed central venous catheters?
Although all of the answers listed are potential ways in which central venous catheters can become contaminated, the two most common are migration of skin organisms along the catheter from the skin surface to the catheter tip, and direct contamination of the catheter hub itself (Answer D). Hematogenous seeding (Answer C) occurs but is rare, and contaminated infusates (intravenous medications, Answer B) are also uncommon. Lastly, owing to improvements in sterile technique, contamination of the catheter during nonemergent placement is rare (Answer A).
A 27-year-old woman with cystic fibrosis is admitted to the intensive care unit with a cystic fibrosis exacerbation due to Pseudomonas aeruginosa. Peripheral venous access cannot be obtained, and you plan to place a central venous catheter.
What infection control precautions are MOST appropriate for the person performing the procedure?
Maximal sterile barrier precautions should be used when placing central venous catheters to reduce the risk of catheter-related bloodstream infection and other complications. A half-body patient drape is not considered a maximal sterile barrier. N95 respirator masks and disposable shoe covers are not necessary or recommended for central venous catheter placement.
A 82-year-old man presents to the emergency department with fever and shortness of breath and is admitted to the intensive care unit for presumed pneumonia requiring high-flow nasal cannula treatment of hypoxemia. On examination, he is awake, alert, conversant in short sentences, and appropriate. His other medical problems include benign prostatic hypertrophy, for which he underwent a remote transurethral resection of the prostate (TURP). Since the procedure, he has been intermittently incontinent of urine, but has not had urinary retention or obstruction.
What is the MOST appropriate way to manage his urinary incontinence and measure urine output?
Correct Answer: B
Indwelling urethral catheters are overused, and 20% to 50% of catheters placed in hospitalized patients are unwarranted. Because indwelling urethral catheters confer a higher risk of urinary tract infection than other methods of collecting urine, noninvasive or intermittently invasive measures are preferred, where appropriate. External penile sheath catheters are associated with a lower risk of infection when the patient does not have urinary retention, the sheath is placed correctly (not too tight), and the patient does not excessively manipulate the catheter. Patients with normal mental status and no evidence of urinary retention are therefore good candidates for an external penile sheath catheter. Patients with urinary retention are better candidates for intermittent urethral catheterization. Although a portable urinal at bedside combined with weighing sheets, blankets, and pads soiled with urine is logistically possible, this is not the most appropriate way to manage the patient’s urinary incontinence, as sitting or lying in urine-soaked linens could lead to skin breakdown.
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