What is the best practice for accessing a port (peripherally inserted central catheter) in a patient with sepsis of unknown source?

From the Guidelines

The best practice for accessing a port in a patient with sepsis of unknown source involves strict aseptic technique, including hand hygiene, use of sterile gloves, mask, and gown, and cleaning the port access site with 2% chlorhexidine gluconate in 70% alcohol. When accessing a port in a patient with sepsis of unknown source, it is crucial to follow proper protocols to minimize the risk of infection and ensure patient safety.

• Perform hand hygiene before accessing the port, as emphasized in the guidelines 1.
• Don sterile gloves, mask, and gown to maintain asepsis.
• Clean the port access site with 2% chlorhexidine gluconate in 70% alcohol using a back-and-forth scrubbing motion for at least 30 seconds, allowing it to completely dry, as recommended by 1.
• Access the port using a sterile non-coring (Huber) needle of appropriate length.
• Draw blood cultures from the port, obtaining both aerobic and anaerobic samples, and label them as catheter-drawn.
• Additionally, collect peripheral blood cultures from a separate venipuncture site for comparison.
• After obtaining cultures, flush the port with 10-20 mL of normal saline followed by heparin flush (typically 5 mL of 100 units/mL) unless contraindicated.
• Empiric broad-spectrum antibiotics should then be administered through the port, commonly including vancomycin (15-20 mg/kg IV loading dose) plus an antipseudomonal beta-lactam such as piperacillin-tazobactam (4.5g IV every 6 hours) or meropenem (1g IV every 8 hours), adjusted for renal function, as suggested by 1. This approach allows for both diagnosis and treatment while maintaining catheter sterility, as the port itself could be the source of infection in up to 20-30% of cases of sepsis of unknown origin in patients with central venous access devices. It is also important to consider the potential need for prompt removal of the port if it is suspected to be the source of sepsis, as recommended by 1.

From the Research

Accessing a Port in Sepsis of Unknown Source

• When accessing a port in a patient with sepsis of unknown source, it is essential to follow best practices to minimize the risk of complications.
• The use of a peripherally inserted central catheter (PICC) or a totally implantable venous access port (TIVAP) can be beneficial for patients requiring long-term antibiotic therapy or fluid administration 2, 3.
• However, these devices can also increase the risk of infection, thrombosis, and other complications, particularly in patients with sepsis 2, 3.

Infection Control and Prevention

• To minimize the risk of infection, it is crucial to follow proper infection control and prevention protocols when accessing a port, including the use of sterile technique, appropriate dressing, and flushing of the catheter 2, 3.
• The risk of infection can be higher in patients with certain underlying conditions, such as neutropenia or immunosuppression, and in those with a history of previous infections 3.
• Regular monitoring of the patient's condition, including vital signs, laboratory results, and clinical symptoms, can help identify potential complications early on 4.

Antibiotic Therapy and Sepsis Management

• In patients with sepsis of unknown source, broad-spectrum antibiotic therapy is often initiated empirically, and the use of a combination antibiotic bag can increase the likelihood of meeting Surviving Sepsis Campaign (SSC) recommendations for antibiotic and fluid goals within 3 hours of ED arrival 5.
• The choice of antibiotic therapy should be guided by the patient's clinical condition, laboratory results, and local antimicrobial resistance patterns 6.
• Early recognition and treatment of sepsis, including the administration of antibiotics and fluids, can improve patient outcomes and reduce mortality 4.

Port Management and Maintenance

• Regular maintenance and flushing of the port can help prevent complications, such as thrombosis and infection 2.
• The use of antimicrobial locks or flush solutions can also help reduce the risk of infection 2.
• Patients and caregivers should be educated on proper port care and maintenance to minimize the risk of complications and ensure optimal outcomes 2, 3.