Catheter Related Blood Stream Infection (CRBSI) PDF

Catheter Related Blood Stream Infection (CRBSI) Edoabasi McGee, PharmD, BCPS Associate Professor of Pharm. Prac. @ASPPharmD Lecture Objectives Lecture Objectives = Exam Objectives Lecture Objectives 1. Describe the pathophys...

Catheter Related Blood Stream Infection (CRBSI) Edoabasi McGee, PharmD, BCPS Associate Professor of Pharm. Prac. @ASPPharmD Lecture Objectives Lecture Objectives = Exam Objectives Lecture Objectives 1. Describe the pathophysiology of CRSBI. 2. Identify medical complications associated with CRSBI. 3. Identify and classify disease severity of CRSBI 4. Describe appropriate criteria needed to diagnose CRSBI. 5. Establish goals of therapy for CRSBI. 6. Interpret evidence which supports goals of therapy for CRSBI. 7. Recommend non-antibiotic alternative therapies for CRSBI. 8. Describe the efficacy of non-antibiotic alternative therapies for CRSBI. Lecture Objectives 9. Compare and contrast clinical characteristics (pharmacology/mechanism of action, benefits, adverse effects, interactions, contraindications, monitoring) of agents for CRSBI. 10. Identify evidence-based pharmacotherapy options for preferred and alternative (non-first line) treatment of patients with CRSBI. 11. List essential components of patient counseling regarding CRSBI, lifestyle modifications, and drug therapy. 12. Identify potential causes for lack of responsiveness to therapy. 13. Describe the rationale, benefits, and appropriate use of combination drug therapy for CRSBI. 14. Devise appropriate therapy plans for patients with CRSBI. 15. Devise appropriate monitoring plans for patients with CRSBI.  Common Device Definitions  Central vascular catheter: A catheter placed within a vein or artery whose distal end is intended to be located within a central vein or artery, usually the vena cava (inferior or superior). This includes peripherally inserted central catheters, tunneled and non-tunneled central venous catheters, central and pulmonary arterial catheters, and subcutaneous ports or reservoirs.  Short-term central vascular catheter: Central catheter placed into a central vein or artery without tunneling or cuffs, including non-tunneled hemodialysis catheters. These are generally intended for short-term use (less than 30 days). These include catheters placed at the subclavian, internal jugular or femoral sites, as well as peripherally inserted central catheters.  Peripherally inserted central catheter: Catheter inserted into a peripheral vein (usually basilic or cephalic), with distal tip ending in a central vein, usually the superior vena cava.  Long-term central catheter: Surgically implanted central catheter with a tunneled portion under the skin and a cuff just inside the exit site. These catheters are intended for use longer than 30 days and include Pro-Line®, Powerline®, Hickman®, Broviac® and Groshong® catheters. Tunneled hemodialysis catheters are long-term catheters but are discussed separately for the purposes of this guideline.  Hemodialysis catheter: A central venous catheter, either non-tunneled or tunneled, temporary or permanent, which is used to dialyze the blood.  Port: Implantable subcutaneous port or reservoir for self-sealing septum tunneled beneath the skin and accessed by a needle through the skin. These are intended for long-term use and managed similarly to long-term catheters. Baang JH, Inagaki K, Nagel J, et al. Inpatient Diagnosis and Treatment of Catheter-Related Bloodstream Infection [Internet]. Ann Arbor (MI): Michigan Medicine University of Michigan; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK589895/ Types of Intravascular Devices port www.cancer.gov  Common Infection Definitions  Exit site infection: Infection, as indicated by exudate, erythema, induration and/or tenderness, at the catheter exit site with negative blood cultures. Hyperemia, induration, and/or tenderness ≤2 cm from catheter exit site. May be associated with drainage from the exit site. It may or may not be associated with bacteremia. If there is exit site drainage, it should be collected and sent for Gram staining, culture, and sensitivities.  Tunnel infection: Infection, as indicated by erythema, induration, and/or tenderness, >2cm proximal to the catheter exit site, or anywhere along the tract of the tunneled catheter with negative blood cultures. Tenderness, hyperemia, and/or induration that extends >2 cm from the exit site and along the subcutaneous tunnel. It may or may not be associated with bacteremia. If there is drainage, it should be collected and sent for Gram staining, culture, and sensitivities.  Pocket infection: Infection in the subcutaneous pocket of an implanted port site; usually associated with tenderness, erythema, and/or swelling over the pocket/port area with negative blood cultures.  Complicated infection: An infection is considered complicated if: clinical symptoms or bacteremia persist despite 72 hours of appropriate antimicrobial therapy, persistence of sepsis syndrome, intravascular hardware is in place (e.g., mechanical valve, pacemaker, or AICD); or sites of metastatic disease are present (such as endocarditis, septic emboli in lungs or/and brain, osteomyelitis, or suppurative thrombophlebitis). Baang JH, Inagaki K, Nagel J, et al. Inpatient Diagnosis and Treatment of Catheter-Related Bloodstream Infection [Internet]. Ann Arbor (MI): Michigan Medicine University of Michigan; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK589895/  Common Infection Definitions  Severe sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection. Suspected or documented infection and an acute increase of ≥ 2 SOFA points; for more pediatric specific criteria please refer to the Pediatric Sepsis Consensus statement.1  Central Vascular Catheter Infection: Primary bloodstream infection in a patient with a central line, without another infectious source. This includes all CRBSIs, plus CVC infections not meeting strict CDC definition of CRBSI.  Central line-associated blood stream infection (CLABSI) vs Catheter Related Blood Stream Infection (CRBSI): The terms used to describe intravascular catheter-related infections can also be confusing because catheter-related bloodstream infection (CRBSI) and central line–associated bloodstream infection (CLABSI) are often used interchangeably even though the meanings differ. CRBSI is a clinical definition, used when diagnosing and treating patients, that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI. It is not typically used for surveillance purposes. It is often problematic to precisely establish if a BSI is a CRBSI due to the clinical needs of the patient (the catheter is not always pulled), limited availability of microbiologic methods (many labs do not use quantitative blood cultures or differential time to positivity), and procedural compliance by direct care personnel (labeling must be accurate). Simpler definitions are often used for surveillance purposes. For example, CLABSI is a term used by CDC’s National Healthcare Safety Network (NHSN) (visit NHSN CLABSI information). A CLABSI is a primary BSI in a patient that had a central line within the 48-hour period before the development of the BSI and is not bloodstream related to an infection at another site. However, since some BSIs are secondary to other sources other than the central line (e.g., pancreatitis, mucositis) that may not be easily recognized, the CLABSI surveillance definition may overestimate the true incidence of CRBSI. For the purposes of this guideline, the committee decided to use the terminology CRBSI which is also adopted by the Infectious Disease Society of America Guidelines Baang JH, Inagaki K, Nagel J, et al. Inpatient Diagnosis and Treatment of Catheter-Related Bloodstream Infection [Internet]. Ann Arbor (MI): Michigan Medicine University of Michigan; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK589895/ Pathophysiology common than organism IotaphetPT  Clinical Manifestation of CRBSI Altered temperature (i.e. fever or hypothermia) Hypotension Tachycardia Altered perfusion Tachypnea Altered mental status. Clinical suspicion should also be raised in the setting of abnormal skin findings erythema, pain, swelling, or discharge around the CVC exit site, the subcutaneous tunnel, or the port pocket, although absence of skin findings does not rule out CRBSI. Compromised CVC device requiring repair (i.e. broken or leaking line, hub, caps) by itself is not an indication for antibiotic therapy/prophylaxis or blood culture, but if it is accompanied by any of the above, it would raise the suspicion for CRBSI. Baang JH, Inagaki K, Nagel J, et al. Inpatient Diagnosis and Treatment of Catheter-Related Bloodstream Infection [Internet]. Ann Arbor (MI): Michigan Medicine University of Michigan; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK589895/  E.EE i i nEE E Diagnosis of CRBSI  A blood culture “set” includes 2 bottles, 1 aerobic and  Catheter Tip Cultures: 1 anaerobic. A blood culture “site” refers to the location from which the culture is drawn.  Assoantibiotic administration significantly decreases  Growth of >15 cfu/plate from a 5 cm segment of the sensitivity of blood cultures, blood cultures should catheter tip using the roll-plate technique is suggestive be obtained prior to the initiation of antibiotics, unless of infection. the patient is unstable or critically ill, in which case antimicrobials should be initiated immediately, drawn from regardless of whether blood cultures have been line  Blood cultures drawn from a catheter have higher risk obtained. peripheral PIC of contamination, but may be more sensitive for catheter infection. Blood cultures from a catheter  Differential Time to Positivity (DTTP): The growth of should be obtained only when there is suspicion of a microbe from a sample drawn from a catheter hub at catheter infection and no other source of infection least 2 hours before growth of the same microbe from identified. a peripheral site is consistent with CRBSI. Baang JH, Inagaki K, Nagel J, et al. Inpatient Diagnosis and Treatment of Catheter-Related Bloodstream Infection [Internet]. Ann Arbor (MI): Michigan Medicine University of Michigan; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK589895/  Diagnosis of CRBSI hare  DEFINITIVE CRBSI: when two blood samples,Aone from the lumen of the CVC and one from a peripheral site, grow the same organism with significant DTTP.  Alternatively, if a peripheral blood culture cannot be obtained, then diagnosis can be made when two or more lumens of a CVC are positive for the same organism.  PRESUMED CRBSI: a CVC is in place and there is at least one positive blood culture growing a pathogen from any site, in the setting of clinical signs of infection with no other apparent source for Jml.athennutumyg that infection.  CULTURE CONTAMINATION: A single blood culture from any site growing a common skin contaminant likely represents a contaminated blood culture ex.wagesstaph.I  If an initial single positive blood culture grows coagulase-negative staphylococci, or other common skin contaminants, in a patient with clinical suspicion for infection, then additional blood cultures from the CVC and peripheral site should be obtained to help rule out contamination. Baang JH, Inagaki K, Nagel J, et al. Inpatient Diagnosis and Treatment of Catheter-Related Bloodstream Infection [Internet]. Ann Arbor (MI): Michigan Medicine University of Michigan; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK589895/  Diagnosis of CRBSI CONTAMINATION VS. INFECTION  Blood cultures positive with skin flora can represent true infection.  In the setting of multiple positive blood cultures from different sites, growing the same organism- consider the likelihood of a true infection even if the organism is otherwise considered a commensal organism (common skin contaminant).  For example, if a blood culture from the catheter and peripheral site both grow coagulase-negative staphylococci, in the setting of clinical symptoms consistent with a potential CRBSI, the treatment for an infection is warranted.  In immunocompromised patients, a single positive blood culture with an organism considered to be skin flora can represent true infection, and determination of contaminated blood culture should be made carefully. Baang JH, Inagaki K, Nagel J, et al. Inpatient Diagnosis and Treatment of Catheter-Related Bloodstream Infection [Internet]. Ann Arbor (MI): Michigan Medicine University of Michigan; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK589895/  Confirming CRBSI Bacteremia Proof that the from peripheral Clinical signs catheter is the cx of infection culprit ┼ ┼ ┼ ┼ Intravascular No other catheter in place apparent source ═ CRBSI ofinvention DEFINITIVE Diagnosis of CRBSI No true guideline to CRBSI Definitive diagnosis of CRBSI – quantitative blood culture drawn through the central line and from a peripheral vein with the single bacterial colony count at least threefold higher in the sample from central line as compared to that obtained from peripheral vein OR – same organism recovered from percutaneous blood culture and from quantitative (>15 colony-forming units) culture of the catheter tip OR – a shorter time to positive culture (>2 hours earlier) in the central line sample than the peripheral sample (differential time to positivity [ DTP ]) Mermel LA, et al. CID 2009:49:1-45  Rapid Diagnostic Test  Traditional methods for identification  Rapid molecular methods for organism ID  Polymerase Chain Reaction  Multiplex PCR  Nanoparticle Probe Technology (Nucleic Acid Extraction and PCR Amplification)  Peptide Nucleic Acid Fluorescent In Situ Hybridization  Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry Bauer KA, Perez KK, et al. review of rapid diagnostics. CID.2014:59(S3) 134-45  Rapid ID Sample Testing: PBP2a EXAM o Bacteria have PBPs in their plasma membranes ○ These proteins are targets for on penicillin o MRSA (Methicillin-resistant Staphylococcus aureus) has acquired a gene (mecA) that codes for a different PBP It has a in different three-dimensional structure https://www.futurelearn.com/info/courses/antimicrobial-resistance/0/steps/92121 o It is less sensitive to penicillins  Treatment for CRBSI est youneed tomake lure it is not a contamination  Treatment Based on Microorganism 2nd whatare myorganum gramc 1grame fungus 3M none  Tailored to the organism identified and the susceptibilities treatment of that organism.  Oral stepdown when appropriate with antimicrobials with high bioavailability ftp.agntiiihmehntytsmens  Antimicrobial treatment and duration will be determined based on catheter type and organisms identified in cultures  Antibiotic Lock Therapy veryspenne aspecializetryingtosavethelinebased oftheorganism 2 it acomboor axarea  Antibiotic lock treatment may be considered for treatment of infected catheters with no signs of exit site or tunnel infection for which catheter salvage is the goal 1  The preferred management of a confirmed CRBSI includes removal of the central vascular catheter in most cases 000  Catheter removal is strongly recommended for CRBSI due to S. aureus, Pseudomonas aeruginosa and Candida spp, instead of treatment with antibiotic lock and catheter retention  Salvage of central vascular catheter Baang JH, Inagaki K, Nagel J, et al. Inpatient Diagnosis and Treatment of Catheter-Related Bloodstream Infection [Internet]. Ann Arbor (MI): Michigan Medicine University of Michigan; 2023 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK589895/  Case 1 Justin Bieber is a 23 year old male admitted to the hospital three days ago after a motor vehicle accident. He underwent successful surgery to repair a broken tibia and is recovering on the surgical floor. Currently he is clinically stable and afebrile, requiring only medications for pain management. He experienced a transient fever in the operating room after his surgery so blood cultures were sent at that time. While on rounds today the intern on your surgery team gets a page from the laboratory saying that a blood culture is positive. Initial blood culture results (at 72 hours) indicate: Culture #1 (drawn from L PICC): no growth to date Culture #2 (drawn from peripheral venipuncture): Staphylococcus epidermidis, sensitivities pending Time to positivity: 1028 minutes Adapted from Conan Macdougall, Pharm.D, MAS, BCPS HOW DO YOU KNOW THE PROBLEM EXIST? Confirming Infection What makes you suspect the problem is present? rever What are the signs and symptoms of CRBSI? culture 2 staphepidermis Pt doesnot have a deanitive diagnolis of CRBJI int inahdbYimartTeent'Integer protein WHAT ARE YOUR NON-PHARMACOLOGIC OPTIONS? Non- Tamm Pharmacologic Options for CRSBI Close monitoring - No antibiotics yes Repeat cultures 140 pic there is nothing definitive sign symptoms that requires it he is clinically stable Remove Catheter NO LOCK therapy NO Case 2 CC: J.M. is a 65 year old woman with history of colon cancer with treatment within the last month, altered GI anatomy and recurrent bacteremia HPI: Recent history of drug resistant E coli bacteremia for of which she just completed a course of antibiotics via PICC line (still in place)Came to clinic for follow up and complained of vague fatigue and headache. Case 2  Blood cultures were drawn from PICC and showed PICC culture #1: 2/3 bottles candida parapsilosis at 13 hours e  Patient was sent to ER. Repeat cultures obtained (prior to antimicrobials): the peripheraltime this is PICC culture #2: Negative Peripheral culture: Negative  PICC culture #1: 2/3 bottles candida parapsilosis @ 13 hrs  PICC culture #2: NegativePeripheralto culture: Negative HOW DO YOU KNOW THE PROBLEM EXIST? Confirming Infection What makes you suspect the This is may be presumed problem is present? There's a problem What are the signs and not definitive symptoms of CRBSI? themotherapy Mmancompromised vaguefatigue whatthey are diagnosis multidrug resistance immunocompromise you needto treateven If we are presuming If WHAT ARE YOUR NON-PHARMACOLOGIC OPTIONS? Non- Pharmacologic mammammm Options for CRSBI Close monitoring - No antibiotics NO Repeat cultures NO Remove t s aureus candialis P orPseudomonas Catheter hkmkhonmattnthtty.MN Hymmeth LOCK therapy WHAT ARE YOUR OPTIONS HOW DO YOU PICK AN OPTION? TO TREAT THE PROBLEM? Start with Q1 and end with Q2 and Q3. You may or may not have additional considerations (i.e., other patient, List all options here disease and drug-related factors) to filter out all available options before asking Q2 and Q3. Students responsible for knowing Q1. Based on how the patient is presenting (e.g., class, MOA, route, major AE’s severity/type/dx classification), what drugs would be effective and/or indicated? Q2. If currently being treated, is the current treatment WHAT IS/ARE THE appropriate? GOAL(S) OF THERAPY? Q3. Of the available options, which are safe for the patient (e.g., warnings, contraindications, BBW)? What are you trying to Q4. Of the available options, are there any patient preference considerations to take into account (e.g., accomplish? oral vs injectable) 26 Give students the factor and have the them work though each factor for the options you listed on the left side of this slide.  WHAT ARE YOUR OPTIONS? Goal of Treatment for CRBSI eradicate infx 51J mim  really know your SE WHAT IS THE PLAN? Please provide an antimicrobial regimen for the patient to include the name of antibiotics, duration, at least 1 major side effect of the selected antimicrobial(s) that the patient may experience, when the patient should start feeling better. Be sure to provide the rationale for your antimicrobial regimen selection. microtungin 14 SE Mushing phlebitisduring remove catheter mitiate a intuition nyqYproFIann iEEiEi ii.IE ei n no toxin ITiini.it ai mm Yarm antismuder microrungin tianya.ttiit.mn Casporungin empirttremor ammannan 28  Case 3 Fergie is a 42 year old female status post gallbladder surgery three days ago. Her hospital course has been complicated by post-operative hemorrhaging, and she was only transferred out of the ICU on 2/12/18. She has a right-sided subclavian catheter and a left-sided peripheral IV catheter. Yesterday morning she began experiencing chills and was febrile to 39.2 C. Blood cultures were drawn from her subclavian catheter and from a new peripheral venipuncture, and vancomycin was initiated. Initial blood culture results indicate: Culture #1 (drawn from R subclavian): S. aureus, sensitivities pending. Time to positivity: 4 hours Culture #2 (drawn from peripheral venipuncture): S. aureus, sensitivities pending. Time to positivity: 9 hours Adapted from Conan Macdougall, Pharm.D, MAS, BCPS  2 e culture are greater than 2hr Definitive pared off of Porting HOW DO YOU KNOW THE PROBLEM EXIST? Confirming Infection What makes you suspect the problem is present? fever Chill postop gallblackler complitation What are the signs and Blood lulture e for staph aureus time to Positive 4hr symptoms of CRBSI? WHAT ARE YOUR NON-PHARMACOLOGIC OPTIONS? Non- Pharmacologic memo Options for CRSBI Close monitoring - No antibiotics Repeat cultures Remove 0 then at somelater point repeat auture Catheter 1 LOCK therapy NO WHAT ARE YOUR OPTIONS HOW DO YOU PICK AN OPTION? TO TREAT THE PROBLEM? Start with Q1 and end with Q2 and Q3. You may or may not have additional considerations (i.e., other patient, List all options here disease and drug-related factors) to filter out all available options before asking Q2 and Q3. Students responsible for knowing Q1. Based on how the patient is presenting (e.g., class, MOA, route, major AE’s severity/type/dx classification), what drugs would be effective and/or indicated? Q2. If currently being treated, is the current treatment WHAT IS/ARE THE appropriate? GOAL(S) OF THERAPY? Q3. Of the available options, which are safe for the patient (e.g., warnings, contraindications, BBW)? What are you trying to Q4. Of the available options, are there any patient preference considerations to take into account (e.g., accomplish? oral vs injectable) 32 Give students the factor and have the them work though each factor for the options you listed on the left side of this slide.  WHAT ARE YOUR OPTIONS? Based on how the patient is presenting (e.g. bug factors, drug factors), what drugs would be effective and/or indicated? pug autlet continue raniomycin bit grew out staph 3day Purhaving surgery man tonalculturethat than not and until we have morta tent likeliball they may MRSA Is not a concern empirically we couldcrant broadcoverage toinclude MRSA  WHAT ARE YOUR OPTIONS? ALL Treatment Options for vancomycin CRBSI Class grylopeptive MOA Review on your own iii iiiiniai.ieiniiaineiiiimii iii iammiiise.no EXAM It Thiefchair.aetoruruniomucin in Route Which are available orally? to NO major AE’s Which require renal dosing? Major SE/ BBW? hepatotoxicity nephrotoxic ototoxin  WHAT ARE YOUR OPTIONS? Of the available options, (patient factors) which are safe for the patient (e.g., warnings, contraindications, BBW)? What of if the patient had a beta lactam (i.e. penicillin) allergy? Generally, When can we change a patient from IV to PO antibiotics? PCN Allergy: Rash PCN Allergy: Difficulty breathing  WHAT ARE YOUR OPTIONS? Goal of Treatment for CRBSI  MRSA Treatment Options Antibiotic (Brand) or Available Route Renal dosage adjustments Unique benefit/ MAJOR SEs Vancomycin IV Yet Nophrotoxic Linezolid (Zyvox) IV PO NO 1h EETPnEEtampeYyCBUCExAg Benents dosing aunt www.tunoansonomewi Daptomycin (Cubicin) IVYer ii i iiimeam arans Ceftaroline (Teflaro) IV yes senemronxi.ca renaranure Telvancin (Vibativ) IV yes Linezolid (Zyvox) Bements cnet.eareaoneamea.mg Oritavancin IV answer iuaaurmeaning Dalbavancin IV ddP hit.nameakren ummm Tigecycline batterate any aokupip.ggeaigyga.aaea Omadacycline Eravacycline Delafloxacin  WHAT SHOULD I TELL MY WHAT IS THE PLAN? PATIENT ABOUT THE PLAN? Provide name, dose, route, How to take it (if applicable)? frequency and duration (if applicable). What to expect in terms of side effects? When should the patient feel better? 38  WHAT IS THE PLAN? Please provide an antimicrobial regimen for the patient to include the name of antibiotics, duration, at least 1 major side effect of the selected antimicrobial(s) that the patient may experience, when the patient should start feeling better. Be sure to provide the rationale for your antimicrobial regimen selection. 39  WHAT WILL TELL WHAT WILL TELL WHEN WHEN YOU IF THE YOU IF THE MEDS WOULD YOU WOULD YOU MEDS ARE ARE WORKING? CHECK? CHECK? SAFE? Signs/symptoms Signs/symptoms Be specific Be specific Labs Labs: Imaging Imaging 40 Students should understand the rationale behind each monitoring parameter. Determining Duration of Therapy mtfn am tnain t 1odtoitaantt Mermel LA, et al. CID 2009:49:1-45 Practice Questions 1. Bacterial pathogens that typically cause intravascular-related catheter infections are _______________, staph _______________, staph and Aerpic _______________. Gram e bacilli coag 2. In settings where methicillin-resistant staphylococci are uncommon, Natalinin oxacillin _______________ or _______________ are the empiric antibiotics of choice for these infections. 3. In settings where methicillin-resistant staphylococci are common, _______________ vancomycin is the empiric antibiotic of choice for these infections. 4. In immunocompromised or severely ill patients, an agent with activity against aerobic _______________ gram _______________ negative should be added.  Sample Exam MCQ A 60-year-old male is admitted with severe cardiogenic shock. A pulmonary artery catheter is placed to gauge the volume status of the patient. After 48 hours, the patient develops a fever of 38.3 C (101°F). Blood tests show a white blood cell count of 16000 per microliter with 80% neutrophils and a platelet count of 152,000 cells per microliter. An infection of the pulmonary artery catheter is suspected. What is the most appropriate next step in the management of this patient A. Remove the catheter B. Instill the antibiotic through the catheter and repeat the blood culture in three days C. Remove the catheter and introducer, perform a three-time blood culture D. Remove the catheter and introducer, and culture the introducer tip Catheter Related Blood Stream Infection (CRBSI) Edoabasi McGee, PharmD, BCPS Associate Professor of Pharm. Prac. @ASPPharmD