What is the management for a patient with fever whenever a central line is flushed?

Management of Fever When Central Line is Flushed

For patients who develop fever whenever a central line is flushed, the central venous catheter should be removed as this strongly indicates catheter-related bloodstream infection (CRBSI), and appropriate systemic antimicrobial therapy should be initiated based on blood cultures. 1

Initial Diagnostic Approach

• Obtain two sets of blood cultures: one from the central line and one from a peripheral vein to allow calculation of differential time to positivity (DTTP) 1
• A DTTP of ≥2 hours (central line culture becoming positive at least 2 hours before peripheral culture) is highly sensitive and specific for catheter-related infection 1
• For multi-lumen catheters, collect samples from all lumens as colonization can occur in a single lumen 2
• Collect cultures before initiating antimicrobial therapy to maximize diagnostic yield 2
• Examine the catheter insertion site for signs of infection including erythema, tenderness, or drainage 1

Management Algorithm

For Short-Term Central Venous Catheters:

• Remove the catheter if any of the following are present:

  • Fever when flushing the line (indicating intraluminal infection) 1
  • Signs of local infection at the exit site 1
  • Clinical signs of sepsis 1
  • Positive paired blood cultures 1

• After catheter removal:

  • Culture the catheter tip using the roll plate technique (semiquantitative) 1
  • Growth of >15 CFU from a 5-cm segment of the catheter tip indicates catheter colonization 1
  • Continue appropriate antimicrobial therapy based on culture results 1

For Long-Term Central Venous Access Devices:

• Remove the catheter if any of the following are present:

  • Tunnel infection or port abscess 1
  • Clinical signs of septic shock 1
  • Positive blood cultures for fungi or highly virulent bacteria 1
  • Complicated infection (endocarditis, septic thrombosis, or other metastatic infections) 1

• In other cases without the above criteria, an attempt to save the device may be considered using antibiotic lock technique, but this approach should be used cautiously when fever occurs with line flushing 1

Pathogen-Specific Considerations and Treatment Duration

• Treat according to the identified organism:
  • Coagulase-negative staphylococci: Remove catheter, treat with systemic antibiotics for 5-7 days 1
  • Staphylococcus aureus: Remove catheter, treat with systemic antibiotics for 4-6 weeks (longer for complications) 1
  • Enterococcus: Remove catheter, treat with systemic antibiotics for 7-14 days 1
  • Gram-negative bacilli: Remove catheter, treat with systemic antibiotics for 7-14 days 1
  • Candida species: Remove catheter, treat with antifungal therapy for 14 days after the first negative blood culture 1

Important Caveats and Pitfalls

• Fever occurring specifically during line flushing strongly suggests intraluminal colonization and biofilm formation, which typically requires catheter removal 3
• Simply changing the line over a guidewire is insufficient when fever occurs during flushing, as 68% of cases still develop CRBSI despite this intervention 4
• Delays in antibiotic administration increase morbidity - aim to administer antibiotics within 60 minutes of presentation 5
• Patients with intestinal failure and central lines have particularly high rates of CRBSI (47.5%) and should receive prompt antimicrobial therapy 6
• For patients with long-term dependence on central venous access, consider infectious disease consultation to guide management 2
• Transesophageal echocardiography should be considered in patients with S. aureus bacteremia to rule out endocarditis 1