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

Management and Prevention of Catheter-Related Bloodstream Infections (CRBSI)

The management of CRBSI requires catheter removal for infections caused by Staphylococcus aureus, Pseudomonas, or Candida species, combined with appropriate antimicrobial therapy based on culture results and pathogen susceptibility. 1, 2

Diagnosis

• Obtain paired blood cultures from the catheter and a peripheral vein before initiating antimicrobial therapy 2
• A differential time to positivity (DTTP) ≥2 hours between catheter and peripheral blood cultures is highly sensitive and specific for CRBSI 2
• When peripheral blood samples cannot be obtained, collect two blood samples from different catheter lumens at different times 2
• Use alcohol, iodine tincture, or alcoholic chlorhexidine (10.5%) for skin preparation before collecting cultures 2
• Growth of >15 CFU from a 5-cm segment of the catheter tip by semiquantitative (roll-plate) culture or growth of >10² CFU by quantitative (sonication) broth culture reflects catheter colonization 1

Management Algorithm

Initial Assessment

• Assess the severity of infection (presence of sepsis, hypotension, or organ failure) 2
• Examine the catheter insertion site for signs of infection (erythema, tenderness, drainage) 3
• Remove the catheter immediately if the patient has sepsis, hypotension, or organ failure 2

Empirical Antimicrobial Therapy

• Initiate empirical therapy with coverage for gram-positive organisms 2
• In countries with low MRSA rates, an anti-staphylococcal beta-lactam antimicrobial could be the first option 1
• For severe illness, neutropenic or immunocompromised patients, and those with femoral catheters, add gram-negative coverage (extended-spectrum penicillin, cephalosporin, or carbapenem) based on local antibiogram 1
• The widespread emergence of multi-resistant bacterial strains should discourage adding vancomycin without proof of antibiotic-resistant gram-positive bacteria 1

Catheter Management Based on Pathogen

Catheter Removal Required

• S. aureus infections 1, 2
• Candida species infections 1, 2
• Tunnel or pocket infections 1
• Patients with sepsis or shock 1
• Short-term non-tunneled central venous catheters with documented infection 1

Catheter Retention May Be Considered

• Coagulase-negative staphylococci in clinically stable patients 1, 2
• Corynebacterium jeikeium infections in clinically stable patients 1, 2
• When using antibiotic-lock technique (ALT) for 10-14 days as a treatment option for "highly needed" infected catheters 1

Antimicrobial Treatment Duration

• Coagulase-negative staphylococci: 5-7 days if catheter is removed, 10-14 days if retained 2
• S. aureus: 2 weeks for uncomplicated infections with prompt resolution, 4-6 weeks for complicated infections (endocarditis, thrombophlebitis) 2
• Enterococci: 7-14 days after defervescence in patients with persistent neutropenia 1
• Gram-negative bacilli: 7-14 days, with shorter courses (≤7 days) potentially sufficient once the catheter has been removed 4
• Candida species: At least 14 days after the first negative blood culture 1

Special Considerations

• Perform transesophageal echocardiography (TEE) to rule out endocarditis in patients with S. aureus bacteremia 2, 3
• For persistent bacteremia or fever after 3 days despite adequate antimicrobial therapy and catheter removal, investigate for catheter-related complications (endocarditis, thrombophlebitis, septic metastasis) 5
• Consider infectious disease consultation for patients with long-term dependence on central venous access 3

Prevention Strategies

• Implement education and ongoing training of healthcare personnel who insert and maintain catheters 1
• Use maximal sterile barrier precautions during CVC insertion 1
• Apply >0.5% chlorhexidine skin preparation with alcohol for antisepsis 1
• Avoid routine replacement of CVCs as a strategy to prevent infection 1
• Consider using antiseptic/antibiotic-impregnated short-term CVCs and chlorhexidine-impregnated sponge dressings if infection rates remain high despite adherence to other strategies 1
• Establish surveillance and education programs for nurses and physicians 1
• Use closed infusion systems rather than open systems (three-way stopcocks) 1

Common Pitfalls

• Failing to obtain appropriate cultures before initiating antimicrobial therapy 2
• Delaying catheter removal for infections caused by S. aureus, Pseudomonas, or Candida 2
• Adding vancomycin empirically without evidence of resistant gram-positive bacteria 1
• Overlooking the possibility of endocarditis or other metastatic infections in S. aureus bacteremia 2
• Neglecting to tailor prevention strategies according to the type of ward and type of catheter (tunneled CVCs and PICCs are more common causes of CRBSI in general wards) 6