What is the protocol for managing line-associated bacteremia, including timing for changing a central line?

Management Protocol for Line-Associated Bacteremia and Central Line Replacement

In cases of suspected line-associated bacteremia, the central line should not be removed immediately unless there are signs of tunnel infection, pocket infection, septic shock, persistent bacteremia despite appropriate antibiotics, or fungemia.

Diagnosis of Central Line-Associated Bloodstream Infection (CLABSI)

• Obtain paired blood cultures from:
  • The central line
  • A peripheral vein
• A differential time to positivity (DTTP) ≥2 hours (central line culture becoming positive at least 2 hours before peripheral culture) is highly sensitive and specific for catheter-related bacteremia 1
• If the catheter must be removed, send the catheter tip for culture 1

Decision Algorithm for Central Line Management

Immediate Line Removal Required For:

• Tunnel infections or port pocket site infections 1
• Septic shock or hemodynamic instability 1
• Persistent bacteremia despite >72 hours of appropriate antibiotic therapy 1
• Bloodstream infections caused by:
  • Fungi (including Candida species) 1
  • Mycobacteria 1
  • Staphylococcus aureus 1
  • Pseudomonas aeruginosa 1
• Evidence of septic thrombosis 1
• Endocarditis 1

Line Retention Possible For:

• Coagulase-negative Staphylococcus (CNS) infections in stable patients 1
  • Success rates of 46-93% reported for line retention with appropriate antibiotics 1
  • Consider antibiotic lock therapy in addition to systemic antibiotics 1

Antibiotic Management

• For suspected central line infection when preserving the line:
  • Administer a glycopeptide (vancomycin) through the line to cover Gram-positive organisms 1
  • Teicoplanin is an alternative that can be administered once daily as a line lock 1
• Duration of therapy:
  • Standard CLABSI: minimum 14 days of appropriate antibiotics 1
  • Complicated CLABSI (deep tissue infection, endocarditis, septic thrombosis): 4-6 weeks 1

Special Considerations

Gram-negative Bacteremia

• Higher mortality rates observed when catheters are retained in Gram-negative bacteremia (43% vs 7% when removed) 2
• More aggressive approach to line removal is warranted

Fungal Infections

• Always remove the line in fungal infections 1
• Start appropriate antifungal therapy (fluconazole initially unless contraindicated) 1

Monitoring After Decision to Retain Line

• Daily assessment of fever trends and clinical status 1
• Follow-up blood cultures to document clearance of bacteremia
• If bacteremia persists >72 hours despite appropriate antibiotics, remove the line 1

Prevention Strategies

• Hand hygiene (most important preventive measure) 1, 3
• Maximal sterile barrier precautions during insertion 1
• Chlorhexidine skin antisepsis 1
• Optimal catheter site selection 1
• Daily evaluation of the need for the central line 3
• Regular assessment of insertion site for signs of infection 4

Common Pitfalls to Avoid

1. Removing the line prematurely without microbiological evidence of infection 1
2. Failing to obtain paired blood cultures before starting antibiotics 1
3. Attempting to salvage lines infected with fungi, S. aureus, or P. aeruginosa 1
4. Inadequate duration of antibiotic therapy, especially for complicated infections 1
5. Not removing the line despite persistent bacteremia after 72 hours of appropriate therapy 1

By following this protocol, healthcare providers can make evidence-based decisions regarding central line management in bacteremia, optimizing patient outcomes while preserving vascular access when appropriate.