What is the management of Central Line-Associated Bloodstream Infections (CLABSIs) or Catheter-Related Bloodstream Infections (CRBSI)?

Management of Catheter-Related Bloodstream Infections (CRBSI)

The management of CRBSI requires prompt catheter removal for infections caused by Staphylococcus aureus, Pseudomonas species, or Candida species, along with appropriate antimicrobial therapy based on the causative organism. 1

Diagnosis

Blood Culture Collection

• Obtain paired blood samples for culture from the catheter and a peripheral vein before starting antibiotic therapy 1, 2
• A differential time to positivity (DTTP) of ≥2 hours (catheter culture becoming positive at least 2 hours before peripheral culture) is highly sensitive and specific for CRBSI 1, 2
• When peripheral blood samples cannot be obtained, collect two blood samples from different catheter lumens at different times 1
• Use alcohol, iodine tincture, or alcoholic chlorhexidine (10.5%) for skin preparation before collecting cultures 1

Diagnostic Criteria

• Quantitative or semi-quantitative culture of the catheter (if removed) 1
• Paired quantitative blood cultures or paired qualitative blood cultures with differential time to positivity 1
• Culture of exudate from the catheter exit site if present 1

Management Algorithm

Immediate Actions

1. Assess severity of infection:

   • If patient has sepsis, hypotension, or organ failure, remove the catheter immediately 1, 2
   • If patient has mild to moderate symptoms, blood cultures can be obtained before deciding on catheter removal 1

2. Initiate empirical antimicrobial therapy:

   • Coverage should include vancomycin for gram-positive organisms and a gram-negative agent (third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination) based on local antibiogram 1, 2

Catheter Management Based on Pathogen

Catheter Removal Required:

• Staphylococcus aureus: Remove catheter and treat with systemic antibiotics 1
• Pseudomonas species: Remove catheter and treat with appropriate antibiotics 1
• Candida species: Remove catheter in all cases and provide antifungal therapy 1
• Evidence of tunnel or pocket infection 1
• Septic thrombosis, endocarditis, or osteomyelitis 1
• Persistent bacteremia >72 hours despite appropriate antimicrobial therapy 1

Catheter Retention May Be Considered:

• Coagulase-negative staphylococci: In clinically stable patients, catheter retention with systemic antibiotics and antibiotic lock therapy may be attempted 1
• Corynebacterium jeikeium: Catheter retention may be attempted in clinically stable patients 1
• Limited venous access: For patients with limited access options, salvage therapy with systemic antibiotics and antibiotic lock therapy can be considered for uncomplicated CRBSI, except for S. aureus, Pseudomonas, or Candida infections 1, 3

Antimicrobial Treatment

Duration of Therapy Based on Pathogen:

• Coagulase-negative staphylococci: 5-7 days if catheter removed; 10-14 days if catheter retained 1, 2
• Staphylococcus aureus: 4-6 weeks for complicated infections (endocarditis, thrombophlebitis, osteomyelitis); 2 weeks for uncomplicated infections with prompt resolution of symptoms 1, 2
• Enterococcus: 7-14 days 1, 2
• Gram-negative bacilli: 7-14 days 1, 2
• Candida species: 14 days after the first negative blood culture 1, 2

Antibiotic Lock Therapy (ALT)

• Can be used as adjunctive therapy for catheter salvage in select cases 1, 3, 4
• Not recommended for S. aureus, Pseudomonas, or Candida infections 1
• Should be used in conjunction with systemic antibiotics 3, 4

Special Considerations

Hemodialysis Catheters

• For hemodialysis CRBSI due to S. aureus, Pseudomonas, or Candida, always remove the catheter 1
• For other pathogens, empirical antibiotics can be initiated without immediate catheter removal 1
• If symptoms persist or there is evidence of metastatic infection, remove the catheter 1
• If symptoms resolve within 2-3 days, the catheter can be exchanged over a guidewire 1

Evaluation for Complications

• Perform transesophageal echocardiography (TEE) to rule out endocarditis in patients with S. aureus bacteremia 1, 2
• Evaluate for septic thrombosis, endocarditis, and other metastatic infections if bacteremia persists despite appropriate therapy 1

Prevention Strategies

• Use strict aseptic technique during catheter insertion 5
• Consider chlorhexidine-impregnated sponge dressings at the insertion site 5
• Avoid routine replacement of CVCs to prevent infection 1
• Avoid routine guidewire exchanges of non-tunneled CVCs 1

Common Pitfalls

• Failing to obtain appropriate cultures before initiating antimicrobial therapy 1, 2
• Delaying catheter removal for infections caused by S. aureus, Pseudomonas, or Candida 1
• Using narrow-spectrum antibiotics that don't adequately cover the likely pathogens 1
• Continuing antibiotics when both sets of blood cultures are negative and no other source of infection is identified 1