Treatment of Port-a-Cath Infections
Port-a-cath infections require prompt parenteral antibiotic therapy appropriate for the suspected organism(s), with device removal within 72 hours of initiating antibiotics in most cases. 1
Diagnosis of Port-a-Cath Infection
- Blood cultures should be collected before starting antibiotic treatment, with paired samples from the catheter and a peripheral vein 1
- If peripheral vein cultures aren't possible, draw two blood samples at different times from different catheter lumens 1
- Use alcohol, iodine tincture, or alcoholic chlorhexidine (10.5%) for skin preparation before collection 1
- If there is exudate at the exit site, obtain a swab for culture and Gram staining 1
- Differential time to positivity (DTP) can help confirm catheter-related infection (growth from catheter hub at least 2 hours before peripheral sample) 1
Initial Empirical Treatment
- Start parenteral antibiotic therapy immediately when infection is suspected, without waiting for culture results 1
- Vancomycin is the recommended first-line empirical treatment due to the high prevalence of coagulase-negative staphylococci and MRSA 2
- Daptomycin can be used as an alternative in cases with higher risk for nephrotoxicity or in settings with high prevalence of MRSA strains with vancomycin MIC ≥2 μg/ml 1, 2
- For patients with severe symptoms (sepsis, neutropenia), add empirical anti-Gram-negative coverage with fourth-generation cephalosporins, carbapenems, or β-lactam/β-lactamase combinations with or without an aminoglycoside 1, 2
- Adjust antibiotic therapy based on blood culture results and antimicrobial susceptibility testing 1
Port-a-Cath Removal vs. Salvage
Port-a-cath removal is indicated in the following situations: 1, 2
- Severe sepsis
- Suppurative thrombophlebitis
- Endocarditis
- Tunnel infection or port pocket infection/abscess
- Bloodstream infection that persists despite 48-72 hours of adequate antibiotic coverage
- Infections with S. aureus, fungi, or mycobacteria
For port pocket infections specifically, treatment includes systemic antibiotics and irrigation in conjunction with manufacturer recommendations 1
Catheter salvage may be attempted in limited circumstances: 1, 2
- Uncomplicated infections with coagulase-negative staphylococci
- When catheter removal poses significant risks
- When using antibiotic lock therapy in addition to systemic antibiotics
Antibiotic Lock Therapy for Salvage Attempts
- When attempting catheter salvage, antibiotic lock therapy should be used in addition to systemic therapy 2
- Dwell time should ideally be ≥12 hours and not exceed 48 hours before reinstallation 2
- For coagulase-negative staphylococci, systemic antibiotic therapy for 10-14 days plus antibiotic lock therapy may be attempted 1, 2
Treatment Duration
- For uncomplicated infections with device removal: 10-14 days of antibiotic therapy 1
- For complicated infections requiring device removal: 1
- Tunnel infection or port abscess: 7-10 days of antibiotic therapy
- Septic thrombosis or endocarditis: 4-6 weeks of antibiotic therapy
- Osteomyelitis: 6-8 weeks of antibiotic therapy
- For fungal infections: antifungal therapy for 14 days after the last positive blood culture 1
Antifungal Therapy
- For suspected fungal infections in critically ill patients, an echinocandin (caspofungin, micafungin, anidulafungin) is recommended if risk factors are present 1, 2
- 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, 2
Follow-up
- Follow-up blood cultures should be obtained 1 week after cessation of antibiotic therapy 1
- Monitor patients closely for signs of persistent or recurrent infection, particularly with high-risk pathogens like S. aureus or Candida species 1
Special Considerations
- Port-a-cath infections appear to have varying rates in different patient populations, with higher rates reported in sickle cell disease patients (0.4 per 100 patient days) compared to cancer patients (0.11 per 1000 port days) 3, 4
- Coagulase-negative staphylococci are commonly involved in treatment-resistant infections requiring device removal 4
- In rare cases where standard extraction techniques fail, specialized extraction methods may be required 5