Case of Viral Hepatitis with Central Venous Catheter lands in Hospital Acquired Infection with Multi Drug Resistant Acinetobactor baumannii

Introduction

Central venous catheter (CVC) placement is a routine practice in critically ill patients in intensive care units (ICU) and in perioperative period, and use of CVC also is increasing in general ward patients.(1) Under the image-guidance (ultrasonography, USG) or color Doppler or fluoroscopy) accuracy of CVC insertion is more precise with minimal complications. But unavailability of resources and lack of experience with guided procedure is the reason behind routine practice of blind insertion of CVC leading to complications such as hematoma at insertion site, pneumothorax, inadvertant arterial puncture, nerve injury, infection, malposition and many more.^2,3

Case Report

A 39-year old male was admitted in intensive care unit with complaints of fever with chills, abdominal distension, headache and swelling over feet since 3-4 days with central venous catheter in situ. CVC catheter insertion had been done before 10 days at other center. Later he was diagnosed as pyrexia of unknown origin (PUO).

On the day of admission his blood pressure was 100/50 mm Hg, pulse 130 beats/min, respiratory rate 36/min SpO2 86% on room air, febrile, and icterus was present. After initial fluid replacement and antibiotic and antiviral coverage and other supportive care urgent CT scan of abdomen, chest and CT pulmonary angiogram, chest X-ray and USG abdomen and pelvis was done.

These investigations revealed mild hepatomegaly with fatty changes, mild ascites with gall bladder wall edema, mild-to-moderate pleural effusion with collapse consolidation complex in lower lobe of the lung. Blood investigation was suggestive of leucocytosis (47000 cells/cmm).

Diagnostic pleural tapping was suggestive of acute inflammatory lesion with suspected positive for ADA MTB. As the patient did not respond to antibiotic and antiviral coverage in initial 24 hours, vancomycin was added on next day. Still patient was febrile (102 degree F) and even with antipyretics and antibiotics temperature was not touching to baseline, and hypotension did not recover with intravenous fluid replacement.

Then it was decided to remove CVC presuming it to be the source of infection. On 3rd day CV catheter was removed. There was presence of pus at tip of CVC. Tip of CVC was sent for culture and sensitivity. Till culture and sensitivity reports available trial of antituberculosis drugs was given but that does not abate the fever spike. On day 5th, culture and sensitivity reports arrived which was suggestive of growth of Acinetobactor baumannii at the tip of CVC which was sensitive only to imipenem, colistin and polymyxin B.

We decided to put him on imipenem and colistin by intravenous and nasal route. This antibiotic regimen took almost next 13 days to make him free from fever spike. The patient was discharged on day 18th of hospitalization. Two days following discharge this patient came to hospital OPD with high grade fever (104 degree F). We decided to admit him again and added polymyxin B to imipenem and colistin regimen for next four days that subside fever of patient.

Discussion

CVCs are an important tool in operation room and ICU. The use of CVCs are associated with both mechanical and infectious complications.⁴ Micro-organism may travel from the skin puncture wound along the external surface of the catheter or from the hub through the lumen of catheter, colonizing the distal intravascular tip of the catheter ultimately cause blood stream infection leading bacteraemia and sepsis.⁵ Fever and signs of sepsis  such as chills, rigors, hypotension and hyperventilation should always be considered as a catheter-related infection in a patients with CVCs in situ when there is no other identifiable source of infection.⁶

Conclusion

CVC should be placed under strict aseptic precautions or it might land into deadly hospital acquired infection necessitating prolonged use of antibiotics and hospital stay. Central venous catheter insertion should be performed under image guidance. Over enthusiastic use of CVC should be avoided.