What is the treatment for Enterobacter cloacae infection in a tunneled dialysis catheter?

Treatment of Enterobacter cloacae Infection in a Tunneled Dialysis Catheter

For Enterobacter cloacae infection in a tunneled dialysis catheter, treatment should include systemic antibiotics with appropriate gram-negative coverage and catheter management based on clinical presentation, with catheter removal indicated if the patient remains symptomatic after 36 hours of antibiotic therapy. 1

Initial Assessment and Management

• Begin parenteral antibiotic therapy immediately with coverage for both gram-negative bacilli (targeting Enterobacter cloacae) and gram-positive organisms 1
• Initial empiric antibiotic therapy should include:
  • Coverage for Enterobacter species: Cefepime 1-2g IV every 8-12 hours (adjust for renal function in dialysis patients) 2
  • Consider adding gram-positive coverage until culture sensitivities are available 1
• Definitive therapy should be based on culture results and antimicrobial susceptibility testing 1

Catheter Management Algorithm

For clinically stable patients:

• If the patient becomes afebrile within 48 hours of starting antibiotics and has no tunnel tract involvement:
  • Consider catheter exchange over a guidewire plus 3 weeks of systemic antibiotic therapy 1, 3
  • This approach has shown success rates of approximately 80% compared to 37% with antibiotics alone 4

For unstable or non-responding patients:

• Remove the catheter if:
  • Patient remains symptomatic after 36 hours of appropriate antibiotic therapy 1
  • Patient is clinically unstable 1
  • There is evidence of tunnel infection or exit site infection that fails to respond to therapy 1
  • There are complications such as septic thrombosis, endocarditis, or metastatic infection 1

Antibiotic Lock Therapy

• For stable patients without tunnel infection, consider adding antibiotic lock therapy as an adjunct to systemic antibiotics 1
• Antibiotic lock should be instilled into both catheter lumens after each dialysis session 5
• Continue antibiotic lock therapy for 10-14 days in conjunction with systemic antibiotics 1
• Note that antibiotic lock therapy alone has limited success (approximately 51%) for catheter salvage 6

Duration of Therapy and Follow-up

• Continue systemic antibiotics for a minimum of 3 weeks 1
• Obtain surveillance blood cultures periodically during and immediately after treatment to monitor effectiveness 1
• Do not place a new permanent access until blood cultures, performed after cessation of antibiotic treatment, have been negative for at least 48 hours 1

Important Considerations and Pitfalls

• Hypoalbuminemia (serum albumin <3.5 g/dL) is a major risk factor for recurrent bacteremia in replacement catheters 7
• Secondary infections, particularly with Candida species, may develop during treatment and require catheter removal if identified 6
• The infection-free survival time of replacement catheters is similar whether exchanged over a guidewire or removed with delayed replacement, but guidewire exchange minimizes the number of procedures 7
• Serious complications such as endocarditis or osteomyelitis occur in approximately 6% of catheter-related bacteremia cases and are more common in those with treatment failure 5

Remember that catheter-related bacteremia is a life-threatening condition requiring prompt intervention, and the decision to attempt catheter salvage versus removal should be based on the patient's clinical status and response to initial therapy 1.