Should a Permcath be removed in a patient with MSSA bacteremia?

From the Guidelines

Yes, a Permcath should be removed in a patient with Methicillin-Sensitive Staphylococcus aureus (MSSA) bacteremia. The presence of MSSA bacteremia is a significant risk factor for morbidity and mortality, and prompt removal of the catheter is recommended to prevent further complications 1. MSSA can form biofilms on catheter surfaces, making antibiotic eradication difficult without device removal.

Key Considerations

• After catheter removal, patients should receive appropriate antibiotic therapy, typically with an anti-staphylococcal beta-lactam such as nafcillin or oxacillin (2 grams IV every 4 hours) or cefazolin (2 grams IV every 8 hours) for a total duration of 14 days from the first negative blood culture 1.
• In cases where catheter removal is absolutely not possible due to limited vascular access, salvage therapy may be attempted with antibiotics for 4-6 weeks plus antibiotic lock therapy, but this approach has lower success rates and higher relapse rates 1.
• Transesophageal echocardiography should be considered to rule out endocarditis, especially if fever or bacteremia persists beyond 72 hours of appropriate therapy 1.
• The decision to replace the catheter should only be made after blood cultures have been negative for at least 48-72 hours and the patient has been on appropriate antibiotic therapy.

Rationale

The strongest predictors for mortality in patients with S. aureus bacteremia are pneumonia and the absence of an identified infective focus, and the presence of malignancy, diabetes, high serum glucose level, methicillin resistance, serum albumin level, interleukin-10, and C-reactive protein are also considered risk factors 1. Removing the catheter and implementing antibiotic systemic therapy is recommended to reduce the risk of morbidity and mortality 1.

Treatment Approach

• Antibiotic therapy should be tailored to the individual patient's needs and should be based on the results of blood cultures and antibiotic susceptibility testing 1.
• The use of antibiotic lock therapy in combination with systemic therapy may be considered in cases where catheter removal is not possible, but this approach should be used with caution and closely monitored for signs of treatment failure or relapse 1.

From the Research

Management of Permcath with MSSA Bacteremia

• The management of a Permcath in a patient with Methicillin-Susceptible Staphylococcus aureus (MSSA) bacteremia involves several considerations, including the removal of the catheter as part of source control 2.
• Source control is a critical component of treating S aureus bacteremia and may include removal of infected intravascular or implanted devices, drainage of abscesses, and surgical debridement 2.
• Failure to remove infected intravascular devices/catheters is a common factor in patients experiencing multiple relapses of S aureus bacteremia 3.
• The decision to remove a Permcath should be based on individual patient factors, including the presence of metastatic infection, the patient's overall clinical condition, and the likelihood of the catheter being the source of the infection.

Antibiotic Treatment

• Initial treatment for S aureus bacteremia typically includes antibiotics active against MRSA, such as vancomycin or daptomycin, until antibiotic susceptibility results are available 2.
• For MSSA, cefazolin or antistaphylococcal penicillins are recommended once antibiotic susceptibility results are available 2, 4.
• The choice of antibiotic therapy may impact the risk of recurrence and mortality, with some studies suggesting that cefazolin may be superior to nafcillin or oxacillin for MSSA infections complicated by bacteremia 4.

Considerations for Permcath Removal

• The removal of a Permcath may be necessary to prevent further complications, such as metastatic infection or relapse of bacteremia 2, 3.
• The decision to remove a Permcath should be made on a case-by-case basis, taking into account the individual patient's condition and the potential risks and benefits of removal.
• In some cases, the use of antibiotic therapy in combination with catheter removal may be effective in clearing the infection and preventing recurrence 5.