Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Suspected central venous catheter (CVC) infection (CLABSI).
SOAP
Subjective (S):
Symptoms:
Inquire about any recent symptoms suggestive of CLABSI, including:
Fever or chills
Localized redness, swelling, or tenderness at the insertion site
Purulent drainage from the insertion site
Malaise (general feeling of unwellness)
Explore for new or worsening:
Respiratory symptoms (cough, shortness of breath) – if catheter terminates in the superior vena cava
Abdominal pain or diarrhea – if catheter terminates in the inferior vena cava
Catheter History:
Document the date of CVC insertion, type of catheter, and insertion site.
Inquire about any recent catheter manipulations or interventions (e.g., dressing changes, line access).
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Assess for fever (elevated temperature) which is a major criterion for CLABSI diagnosis.
Physical Exam:
Focus on the CVC insertion site and document:
Erythema (redness)
Induration (hardness)
Swelling
Purulence (pus)
Signs of local tenderness
Briefly examine the chest (if catheter terminates in the superior vena cava) and abdomen (if catheter terminates in the inferior vena cava) for signs of infection.
Assessment (A):
CLABSI Criteria:
Based on the Centers for Disease Control and Prevention (CDC) criteria, assess the probability of CLABSI considering:
Two or more of the following: fever, localized signs of infection at the insertion site, positive blood cultures from a peripheral site and a CVC culture obtained with proper technique at least one hour apart without another apparent source of infection.
Other factors like positive catheter tip cultures or positive blood cultures drawn through the CVC lumen may also be considered in specific scenarios.
Differential Diagnosis:
Briefly consider other diagnoses that might mimic CLABSI symptoms, such as:
Local skin infection at the insertion site (not involving the catheter)
Systemic infection from another source (e.g., pneumonia, urinary tract infection)
Plan (P):
Laboratory Tests:
Order blood cultures from peripheral sites (at least two drawn at separate sites) and blood cultures from a CVC culture obtained with proper technique if clinically indicated based on CDC criteria.
Consider additional tests depending on clinical suspicion:
Complete blood count (CBC) to assess for white blood cell count elevation.
Chest X-ray (if catheter terminates in the superior vena cava) or abdominal imaging (if catheter terminates in the inferior vena cava) to rule out other sources of infection.
Imaging Studies (if indicated):
Depending on clinical suspicion, consider imaging studies like ultrasound of the insertion site to assess for abscess formation.
Antibiotic Treatment (if indicated):
Initiate broad-spectrum antibiotic therapy empirically while awaiting culture results, considering local resistance patterns.
Narrow antibiotic therapy based on culture results and organism susceptibility.
CVC Management:
Depending on the severity of infection and response to treatment, consider:
Removal of the CVC if possible.
Salvage therapy with catheter lock solutions containing antibiotics if catheter removal is not feasible.
Infection Control Measures:
Implement strict aseptic technique for all CVC manipulations.
Ensure proper catheter site dressing changes according to institutional protocols.
Follow-up:
Closely monitor vital signs and response to treatment.
Repeat blood cultures as needed based on initial results and clinical course.
Schedule follow-up visits to monitor for complications and assess the need for continued CVC access.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., infectious disease specialist)
Reporting suspected CLABSI to the institution’s infection control department
Patient education regarding signs and symptoms of CLABSI and the importance of maintaining catheter hygiene
Discussing the potential risks and benefits of CVC removal versus salvage therapy