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In situ endoluminal brushing: a safe technique for the diagnosis of catheter-related bloodstream infection

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Summary

We assessed the safety of the endoluminal brush technique for the in situ diagnosis of central-venous-catheter (CVC)-related bloodstream infection (CRBSI). The endoluminal brush was used to investigate patients with suspected CRBSI by sampling the CVC lumen to within 3–5 cm of the catheter tip (the brush was kinked to mark the length required). Quantitative peripheral blood cultures were taken 1 min pre-brushing and 1 min and 1 h post-brushing. In addition, a 1 mL sample of through-catheter blood was aspirated immediately pre- and post-brushing, and aliquots were directly plated on to blood agar to determine the load of CVC-associated bacteria. After CVC removal, catheter tips were sent for culture using the Maki roll and modified Cleri flush techniques. Of 139 suspected cases, 61 (45%) had confirmed episodes of CRBSI. No patients experienced fever or rigors, or had evidence of embolic phenomena after CVC endoluminal brushing. There was no difference overall in pre-brushing and 1-min post-brushing peripheral blood bacterial counts (P<0.702). Peripheral and CVC blood bacterial counts were significantly reduced 1 h post-brushing (P<0.03 and P<0.001, respectively), possibly due to removal of endoluminal biomass. The endoluminal brush technique can be safely used to diagnose CRBSI without the need for CVC removal, provided that the brush is not allowed to protrude beyond the tip of the catheter.

Introduction

Catheter-related bloodstream infection (CRBSI) is the major complication of central venous catheter (CVC) use, affecting 4–14% of catheters.1, 2, 3, 4 Traditional methods often rely on CVC removal and subsequent tip culture,5, 6 but as few as 15% of suspected cases of CRBSI are subsequently confirmed.7 Indeed, only 4% of Maki-positive tip cultures have been reported to influence clinical management, and of those catheters removed on suspicion of CRBSI, 86% subsequently had to be replaced.8 Hub culture and skin-entry-site cultures have been advocated as in situ methods of predicting catheter infection, but are non-specific and hence can seldom be relied upon.9, 10 Techniques that rely on blood collected through the CVC have been shown to be accurate for in situ diagnosis of CRBSI,11, 12 although blood can only be aspirated in 50–75% of cases.13, 14 The endoluminal brush is a novel method for sampling CVCs in situ, originally developed by Marcus and Buday,15 and does not rely on the ability to aspirate blood from the catheter. The technique has been shown to be both sensitive and specific for the diagnosis of CRBSI,16, 17 and has recently received approval from the US Food and Drug Administration (Ref. No. FDA 510K. 993514).

The possibilities of inducing an embolic shower of micro-organisms during or soon after brushing, and the potential of producing endothelial or atrial trauma when the endoluminal brush is advanced through the catheter tip have been suggested.17 Early descriptions of the technique involved advancing the brush through the catheter tip to sample the distal external surface.15 However, increasing evidence suggests that the pathogenesis of CRBSI and the accuracy of culture techniques in diagnosing CRBSI are centred on the CVC lumen, thus obviating a need to brush beyond the catheter tip.13 The present study aimed to evaluate the safety of the endoluminal brush method when used to sample the CVC lumen alone, and specifically to determine whether the technique induces bacteraemia.

Section snippets

Patients and methods

A total of 139 cases in 108 patients with suspected CRBSI (temperature >37 °C, leucocytosis >11×109/L or evidence of catheter-entry-site infection) were evaluated over two years. CVCs were assessed using the modified brushing technique, which involved advancing the brush to within 3–5 cm of the tip but not through it. Prior to brushing, the length of the lumen to be brushed was determined and the wire of the brush was kinked at an appropriate length (3 cm shorter than the luminal length) to

Results

No patients were observed to have episodes of fever or rigors post-brushing, and no embolic phenomena were seen. The process of endoluminal brushing was generally painless, with patients only describing mild discomfort if the sutures securing the catheter to the skin were unduly placed under tension.

CRBSI was confirmed in 63 cases (45%). The micro-organisms recovered were coagulase-negative staphylococci (37%), Staphylococcus aureus (18.5%), yeasts (18.5%), Gram-negative bacilli (15%) and

Discussion

Since its first description in 1989,15 the endoluminal brush technique has been slow to gain acceptance for the in situ diagnosis of CRBSI, despite published evidence of its effectiveness.12, 16, 17, 18 Initial studies described the need to advance the brush through the CVC tip in order to sample the external surface of the catheter tip. However, increasing evidence has highlighted the lumen as the primary site in CRBSI.13, 18 Furthermore, the sensitivity of the modified brush technique used in

References (19)

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    It is theoretically possible to induce a peripheral bacteremia by endoluminal brushing of colonized CVCs. Dobbins et al. [61] found no peripheral bacteremia either 1 min or 1 h post-brushing in any of eight cases with significant endoluminal colonization. Few studies have assessed the endoluminal brush and most of the studies identified were performed by the same group of investigators.

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