Indian Journal of Anaesthesia 2007; 51 (6) : 496-500 Clinical

Indian Journal of Anaesthesia, Investigation

December 2007

Bacterial Colonization and Infection of Epidural Catheters: A

Prospective Study of Incidence and Risk Factors in Surgical
Patients
Uma Srivastava1 , Parul Chandra2 , Surekha Saxena3, Aditya Kumar 4,
Ashish Kannaujia 5 , Shiv Pratap Singh Rana6 , Hompriya Issar 7
Summary
Infection of the epidural space is a rare but serious complication of catheter placement. The purpose of the present study
was to determine the incidence of bacterial colonization of epidural catheters, the co-relation between colonization and infection
and to identify the risk factors associated with colonization. A prospective observational trial was carried out on 272 adult patients
receiving epidural catheterization for anaesthesia and post-operative analgesia. Patients undergoing a variety of surgical proce-
dures (abdominal, thoracic, urological, orthopaedic, gynaecological and obstetric) both elective and emergency were recruited.
The tips of epidural catheters after removal were sent aseptically for culture. Of 261 tips sent for culture 11 (4.2%) showed positive
culture, the most prevalent microorganism being Staphylococcus epidermidis. None of the patients had signs and symptoms of
local or epidural space infection. Twelve potential risk factors were entered in the step-wise logistic regression analysis to identify
factors associated with catheter colonization. Out of these only the duration of catheterization (P<0.01, odd ratio 3.39, 95%
confidence interval 0.12-1.5) was found to be significant. Summarizing the results, the incidence of bacterial colonization was 4.2%
with no case of epidural space infection. The chances of colonization increased with duration of placement beyond 96 hours and
this was found to be a potential risk factor for colonization but not infection. The positive cultures did not equate with infection.
Key words: Epidural catheterization, Epidural space infection, Risk factors, Colonization, Contamination.
Introduction tor was not clear [Link] aim of this study was to pro-
spectively determine the incidence of epidural catheter
Although many retrospective & prospective stud-
tip colonization and infections as well as to identify risk
ies found epidural anaesthesia to be safe with regard to
infectious complications1-3, serious infections have been factors associated with bacterial colonization in adult sur-
reported after central neuraxial blockade 4-6 . A recent gical patients who received epidural anaesthesia & post-
operative epidural analgesia for longer than 48 hours.
study reported the incidence of epidural abscess of 0.2-
2 cases per 10,000 hospital admissions7. The precise Methods
mechanism of epidural space infection associated with
This prospective observational study was conducted
epidural block is not yet clear; several possible routes
between January ‘04 and November ‘06 after approval
have been proposed8. The micro-organism may reach
from the Institution’s Ethical Committee and informed
the epidural space during needle or catheter insertion,
written consent from the patients. All the adult patients
along the catheter tract, by contaminated syringes or medi-
in whom epidural catheter was placed for surgery and
cation or by local or haematogenous spread from else-
post-operative analgesia for more than 48 hours were
where in the body 8 . While the bacterial colonization of
eligible for the study. Exclusion criteria included patient’s
catheter tips after removal is frequently obtained, the
refusal, coagulation abnormality and local or systemic
incidence of epidural space infection is very low 3,9,10.
infection. Types of surgical procedures performed in-
The predisposing factors, which play a key role in colo-
cluded abdominal, urological, orthopaedic, and obstetri-
nization and infection, are not well defined. In a meta-
cal (both elective & emergency). The epidural catheter
analysis, Reihsaus & colleagues (2000)7 found certain
was inserted at lumbar or thoracic epidural site. Hospital’s
risk factors to be associated with higher chances of in-
prepared trays containing autoclaved epidural needles
fection but the degree of risk associated with each fac-
1. MD,Professor, 2. MD, Ex-Resident, 3. MD, Professor, 4. MD, Professor, 5. MD, Lecturer, 6. MD, Ex-Resident, Department of
Anaesthesia & Critical Care, S. N. Medical College, Agra, 7. DNB (Surgery) Resident, Agra.
Correspondence to: Uma Srivastava, Dept. of Anaesthesia & Critical Care, 15, Master Plan Road, New Lajpat Kunj, Agra-282002.
E mail: drumasrivastava@[Link] Accepted for publication on:16.9.07
496
Uma Srivastava et al. Bacterial colonization and infection of epidural catheter

(16-18 G) were used. A sterile disposable catheter with as > 15 colony forming units. The patients were visited
filter was included in the tray after it was opened. daily till discharge from the hospital, checked regarding
All catheter insertions were done in the operation symptoms and signs of epidural space infection & instructed
theatre with full aseptic precautions. The operator’s to report to the PAC clinic if any of above mentioned symp-
hands were washed and a cap and mask, sterile gown toms appeared after the discharge from the hospital.
and sterile gloves were worn. The patient’s skin was The characteristics of the patients are expressed as
prepared with cetavlon, 10% povidone-iodine solution and median, range or as the number of patients. Twelve po-
rectified spirit and then covered with sterile drapes. The tentially relevant variables studied as the risk factor were
area was allowed to dry between each anti-septic appli- entered into a step-wise backward logistic regression
cation. The epidural space was identified using the “loss analysis using the maximum likelihood method. The fac-
of resistance” technique with air & epidural catheter tors included: age, sex, ASA grade, type of surgery (elec-
was advanced about 4-5 cm into the epidural space. A tive/emergency), site of insertion (thoracic/lumbar), num-
dry sterile gauze pad was applied at the insertion site ber of attempts for epidural puncture, duration of catheter
with the adhesive tape. The exposed length of the cath- in situ, diabetes mellitus, chronic drug abuse, malignancy,
eter was directed cephalad over the patient’s back and corticosteroid therapy and alcoholism. All analyses were
fixed with adhesive tape over the shoulder after attach- performed using Lotus software for Windows.
ing bacterial filter. The filter was enclosed in a sterile
bag. The operations were performed under epidural ana- Results
esthesia alone or combined with general anaesthesia as A total of 272 epidural catheters were inserted in
required. All patients received peri-operative antibiotics 272 patients, the majority (70%) were placed for elective
viz. ceftriaxone, gentamicin/ amikacin, metronidazole, surgery. The main non-elective indications were caesar-
ciprofloxacin, ceftazidime in various combinations. The ean section & exploratory laparotomy. About half the pa-
first dose of antibiotic was administered before place- tients had undergone abdominal surgery followed by or-
ment of epidural catheter. The resident anaesthesiologist, thopaedic, caesarean section, urological & thoracic sur-
observing complete asepsis provided post-operative an- gery. Out of 272 catheters only 36 were placed in the
algesia. The anaesthetist visited each patient twice a day thoracic region (Table 1). About 1/3rd of patients had one
and inspected and palpated the catheter dressing for any or more risk factors or conditions known or suspected to
discharge, staining or tenderness. The dressing was not predispose to infective complications of epidural catheter
changed routinely unless required. The patients were such as diabetes, malignancy, alcoholism or had received
screened daily for symptoms/signs that would suggest steroids.
the presence of epidural space infection which included Table 1 Patients characteristics
pain in back, tenderness, root pain, sensory or motor 1. Age (years)
deficit, fever etc. Catheter related infection was sus- Median 45
pected if the patient became febrile without any other Range 24-82
obvious cause. Epidural catheter was left in place for a 2. Sex (M/F) 147/125
minimum of 48 hours but was removed earlier if analge- 3. ASA Status (I&II/III&IV) 184/88
sia was no longer required, was malfunctioning, acci- 4. Level of catheterization
dentally removed or if local or epidural space infection Thoracic 36
Lumbar 236
was suspected. The catheter was removed in the gen-
5. No. of attempts
eral ward without prior antiseptic skin preparation. The 1,2,3, >3 150, 42,76,4
distal 2 cm of the catheter was aseptically cut with ster- 6. Type of surgery
ile scissors keeping the tip of the catheter upward and Elective/Emergency 193/79
away from the skin surface. The cut portion was trans- 7. Duration of catheterization (h).
ported in a sterile tube for immediate culture onto the Median 52
culture medium in the microbiology laboratory. In the Range 24-120
lab, each catheter segment was cultured at 370 C under 8. Days of antibiotic therapy
Median 5
aerobic conditions for 48 hours and identified by stan-
dard methods and criteria. Positive culture was defined Range 5–7

497
 Indian Journal of Anaesthesia, December 2007

Majority of the catheters were removed after 52 Table 3 Results of stepwise logistic regresion
hours after insertion. Two hundred sixty one catheter analysis (all potential risk factors were included in
tips were sent for microbial culture, as rest were re- the first step and subsequently removed if not sig-
moved accidentally or earlier than 48 hours. The cath- nificant i.e. P>0.05)
eters removed earlier than 48 hours were not sent for Risk factor Removed Removed Removed with a
culture, as they were not eligible for the study. Out of at step with an Odds P-value of
these, 250 were sterile while 11 showed positive culture. -ratio of
The commonest microorganism grown was coagulase- Age (per decade) 2 0.89 0.88
negative Staphylococcus epidermidis present in 64% of Sex (F vs M) 1 0.117 0.57
positive cultures. The clinical & bacteriological data of Emergency vs 11 0.128 0.87
elective surgery
the patients with positive epidural catheter tip culture
No. of attempts taken 10 3.408 0.32
are presented in Table 2. Most of the patients had their
Diabetes mellitus 7 3.7 0.99
catheters in epidural space for equal or more than 90
Chronic drug abuse 4 1.4 0.62
hours. No patient had signs of local infection such as
Steroid therapy 9 0.97 0.97
erythema, tenderness or discharge etc. Also, none of
Alcoholism 5 0.41 0.64
the patients showed clinical signs & symptoms of epidu-
ASA grade 6 2.34 0.47
ral space infection including those with positive cultures. (I & II vs III & IV)
Table 2 Clinical and bacteriological data of patients Duration of Not removed 3.39 0.01
with positive bacterial culture. catheterization
(per 24 h)
[Link]. Age Sex ASA Surgery Site of Atte- Dura- Organism
status Catheter mpts tion(h) cultured Insertion site 8 3.41 0.37
(thoracic vs lumbar)
1 40 M II El Lumbar 1 98 [Link]
Malignancy 3 0.74 0.87
2 24 F I Em Lumbar 2 92 [Link]
thors have reported lower rates of colonization10,12,13
3 30 F I El Lumbar 1 74 [Link]
while others have evidenced higher rates 3,9,14,15,16. Wide
4 42 M II Em Thoracic 1 100 Klebsiella variation in results could be due to methodological dif-
5 32 F I El Lumbar 1 97 [Link] ferences among the studies, making inter-study compari-
6 75 M III El Lumbar 2 90 [Link]
son difficult 17. Low incidence of colonization in our study
could be due to the use of peri-operative antibiotics which
7 32 F IV Em Lumbar 2 72 [Link]
have been shown to lower the risk of catheter related
8 81 F II El Lumbar 2 54 [Link] infectious complications 13,18,19 .
9 50 M I El Lumbar 1 52 S. aureus The commonest microorganism identified in this
10 24 M II Em Lumbar 3 96 Enterobacter study was coagulase negative Staphylococcus
epidermidis, a prominent human skin commensal gener-
11 30 M II El Lumbar 1 90 Enterobacter
El-elective, Em-emergency.
ally regarded as a pathogen of little clinical significance.
It represented about 64 % of cultured pathogens. These
The stepwise regression analysis revealed that out results concur with other studies showing it to be the
of 12 potential risk factors, only one remained in the fi- most common agent of epidural catheter tip culture
nal model as statistically significant. Duration of cath- 5,9,10,12,17,20. However, the findings of culture of Kleb-
eterization was associated with increased incidence of siella, Enterobacter and Staphylococcus aureus in our
bacterial colonization (P< 0.01, odd ratio 3.39, 95% con- study and Pseudomonas and Eschericia coli in other stud-
fidence interval 0.12-1.5). All other factors were re- ies 9,13,16 emphasize the possibility that more virulent mi-
moved as insignificant at some step. (Table 3) croorganism could colonize easily leading to epidural
Discussion space infection. Raedler et al (1999) 21 found that 17.9%
of spinal and epidural needles were colonized when sent
The incidence of catheter tip colonization in the
for culture immediately after use in spite of full aseptic
present study was 4.2% but none of the patients devel-
precautions. In the present study the catheters were re-
oped symptoms of epidural space infection. Some au-
498
Uma Srivastava et al. Bacterial colonization and infection of epidural catheter

moved in the general ward without applying any anti- could be due to the small number of patients with such
septic. Thus catheter tips probably got contaminated by co-morbid conditions.
skin flora during withdrawal 15. As such, it is impossible There were certain methodological limitations to
to exclude catheter contamination that could have oc- this study. Many potential risk factors that were entered
curred during withdrawal 9,20 . in the stepwise logistic regression correlated with each
Despite colonization of the catheter tip with vari- other such as ASA status on one hand and steroid therapy
ous microorganisms, we did not encounter any patient or malignancy on the other hand. Thus, if one of such
with clinical findings of epidural space infection, a find- factors is removed during stepwise exclusion process a
ing in agreement with many studies 1,2,10,13,15. Thus posi- certain part of information of the removed factor is trans-
tive culture is not a reliable predictor of epidural space ferred to the correlated factors still in model. Therefore
infection 3,9,10,15,16 suggesting routine culture of catheter the risk factor remaining as significant in the final model
tips unnecessary. The infection can occur even in the might not be truly significant 19 .The other limitation was
absence of a positive culture. a relatively small sample size which might be insuffi-
Although direct relation between colonization and cient to detect a rare complication like epidural abscess.
infection of epidural space is uncertain some risk fac- Insufficient follow-up data was another limitation as the
tors have been suspected to abet this 11,19. These include symptoms of catheter related infection may present so
age, I/V drug abuse, steroid administration, diabetes, late that the condition might escape detection 25. Though
chronic renal failure, alcoholism, immuno compromise all patients and surgical teams were instructed to report
due to malignancy, sepsis, type of surgery, site and dura- any complication, no patient turned up.
tion of catheterization and number of attempts during To summarize, the incidence of bacterial coloniza-
catheter insertion etc. Out of these we selected 12 po- tion was 4.2% with Staphylococcus epidermidis being
tential risk factors for logistic regression model to deter- the most prevalent microorganism. No clinical infection
mine the effects of these factors on incidence of cath- of epidural space was observed in any patient. Among
eter colonization. The analysis showed that of these 12 the risk factors studied, only the duration of catheter place-
factors, only one i.e. “the duration of catheterization” ment upto or beyond 90 hours was found to increase the
remained in the final model as statistically significant. likelihood of bacterial colonization of epidural catheter
Longer the catheter remained in epidural space, more tips. Therefore we suggest that the epidural catheter
were the chances of colonization 5,22,23 .Out of 11 pa- should be removed by the 4 th day unless deemed neces-
tients who had positive culture, 7 had their catheters in sary. Although we did not find any case of epidural space
the epidural space for equal or more than 90 hours. infection or abscess, sporadic cases are being published.
Currently there is not adequate data to suggest a Therefore, all the anesthesiologists practicing epidural
duration beyond which the risk of infection increases 4 . anaesthesia & analgesia should maintain a high index of
But the data on I/V devices suggests that majority of the suspicion 25 regarding this potential complication.
infections occur after 5 days, lending some support to References
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 Indian Journal of Anaesthesia, December 2007

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