What is the recommended empirical treatment for salvage central line infections?

Empirical Treatment for Salvage Central Line Infections

For empirical treatment of salvage central line infections, vancomycin is recommended as first-line therapy, with the addition of anti-Gram-negative coverage (fourth-generation cephalosporins, carbapenems, or β-lactam/β-lactamase combinations) in patients with severe symptoms. 1

Initial Empirical Antibiotic Selection

• Vancomycin is the recommended first-line empirical treatment for suspected central line-related bloodstream infections (CRBSI) before blood culture results are available 1
• Daptomycin can be used as an alternative in patients with higher risk for nephrotoxicity or in settings with high prevalence of MRSA strains with vancomycin MIC ≥2 μg/ml 1
• Linezolid is not recommended for empirical use 1
• For patients with severe symptoms (sepsis, neutropenia), add empirical anti-Gram-negative coverage with one of the following 1:
  • Fourth-generation cephalosporins
  • Carbapenems
  • β-lactam/β-lactamase combinations with or without an aminoglycoside

Empirical Antifungal Therapy

• For suspected fungal infections in critically ill patients, an echinocandin (caspofungin, micafungin, or anidulafungin) is recommended if any of these risk factors are present 1:
  • Hematological malignancy
  • Recent bone marrow or solid organ transplant
  • Presence of femoral catheters
  • Colonization with Candida species at multiple sites
  • Prolonged use of broad-spectrum antibiotics
• Fluconazole can be used if the patient is clinically stable, has had no exposure to azoles in the previous 3 months, and has low risk of C. krusei or C. glabrata colonization 1

Antibiotic Lock Therapy (ALT) for Catheter Salvage

• When attempting catheter salvage, ALT should be used in addition to systemic therapy 1
• ALT is indicated when there are no signs of exit site or tunnel infection 1
• ALT treatment duration should be 7-14 days 1
• Dwell time should ideally be ≥12 hours (minimum 8 hours per day) and should not exceed 48 hours before reinstallation 1

Pathogen-Specific Considerations for Salvage

Coagulase-negative Staphylococci

• Diagnosis should be based on more than one set of positive blood cultures, preferably from both the catheter and peripheral vein 1
• If there are no complications, attempt catheter salvage with systemic antibiotic therapy for 10-14 days plus ALT 1

Staphylococcus aureus

• S. aureus infections typically require catheter removal and systemic antibiotic therapy 1
• If salvage is attempted, ALT should be combined with systemic therapy for at least 4 weeks 1

Enterococcus

• For Enterococcus infections, the catheter can often be retained with systemic antibiotic therapy 1
• Ampicillin is the preferred antibiotic, with vancomycin used in cases of resistance 1

When to Remove the Central Line

Catheter removal is indicated in the following situations 1:

• Severe sepsis
• Suppurative (septic) thrombophlebitis
• Endocarditis
• Tunnel infection
• Port abscess
• Bloodstream infection that continues despite 48-72 hours of adequate coverage
• Infections with S. aureus, fungi, or mycobacteria

Treatment Duration

• For most salvaged catheter infections, 10-14 days of treatment is recommended after resolution of signs of infection 1
• If positive cultures persist 72 hours after catheter removal or when complications are present, 4-6 weeks of treatment is recommended 1
• For osteomyelitis complications, treatment should be 6-8 weeks in duration 1

Important Considerations

• Blood cultures should be obtained before starting antibiotic therapy 1
• The selection of antibiotics should be guided by the antimicrobial susceptibility testing data of each institution 1
• Empiric antibiotic treatment should take into account the risk for drug-resistant strains 1
• Adjust antibiotic treatment based on blood culture results 1