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 diagnosis, appropriate antimicrobial therapy, and decisions about catheter removal based on pathogen type and clinical status, with removal being mandatory for S. aureus, Candida species, and tunnel infections. 1, 2

Diagnosis of CRBSI

• CRBSI is defined as a primary bloodstream infection in a patient with a central venous catheter (CVC) within 48 hours before infection development, not related to infection at another site 1

• Definitive diagnosis requires one of the following:

  • Growth of the same organism from both peripheral blood culture and catheter tip culture 1
  • Growth of the same organism from catheter-drawn and peripheral blood samples with colony count from catheter hub at least 3-fold greater than from peripheral vein 1
  • Differential time to positivity (DTP): Growth of the same organism from catheter-drawn blood at least 2 hours before detection in peripheral blood sample 1, 2

• Obtain paired blood cultures from the catheter and a peripheral vein before initiating antimicrobial therapy 1, 3

• Properly disinfect catheter hub with alcohol, alcoholic chlorhexidine (>0.5%), or tincture of iodine 1, 3

Common Pathogens

• Most commonly identified organisms in catheter-related infections are:
  • Coagulase-negative staphylococci
  • Staphylococcus aureus
  • Candida species
  • Enteric gram-negative bacilli
  • Pseudomonas aeruginosa 4, 5

Catheter Management Algorithm

1. Assess severity of infection:

   • If patient has sepsis, hypotension, or organ failure, remove catheter immediately 2

2. Decision based on pathogen:

   • Mandatory catheter removal for:
     • Staphylococcus aureus infections 2, 4
     • Pseudomonas species infections 2
     • Candida species infections 2, 4
     • Tunnel or pocket infections 4
   • Consider catheter retention for:
     • Coagulase-negative staphylococci in clinically stable patients 4, 2
     • Corynebacterium jeikeium in clinically stable patients 4

Antimicrobial Treatment

• Start empiric therapy after obtaining blood cultures when CRBSI is suspected 1

• Empiric coverage should include:

  • Vancomycin for gram-positive organisms in settings with elevated MRSA prevalence 1
  • Gram-negative coverage based on local susceptibility patterns (e.g., fourth-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination) 1

• Duration of therapy:

  • Uncomplicated CRBSI with catheter removal: 10-14 days 1, 2
  • Coagulase-negative staphylococci: 5-7 days if catheter removed, 10-14 days if retained 2
  • Staphylococcus aureus: 4-6 weeks for complicated infections, 2 weeks for uncomplicated infections with prompt resolution 2
  • Persistent bacteremia or fungemia (>72h after catheter removal): 4-6 weeks 1

• Consider transesophageal echocardiography (TEE) to rule out endocarditis in patients with S. aureus bacteremia 2

Risk Factors for CRBSI

• Duration of catheterization (>1 week significantly increases risk) 1, 4
• Catheter site (femoral and jugular sites have higher infection rates than subclavian) 1, 4
• Length of ICU stay before catheter insertion 4
• Use of catheter for parenteral nutrition 4, 1
• Heavy microbial colonization at insertion site or catheter hub 4
• Neutropenia 4

Prevention Strategies

• Select optimal insertion site (subclavian preferred over jugular or femoral) 1
• Use maximal sterile barrier precautions during insertion 1, 6
• Implement proper hand hygiene 1, 4
• Use >0.5% chlorhexidine with alcohol for skin antisepsis 1, 7
• Apply sterile, transparent dressings and change according to protocol (every second day for gauze dressings, weekly for transparent dressings) 4, 1
• Choose catheters with minimum number of lumens necessary 1
• Consider antimicrobial-impregnated catheters for high-risk patients 1, 8
• Apply chlorhexidine-containing dressings for patients over two months of age 1
• Daily chlorhexidine bathing in ICU patients has shown benefit in CRBSI prevention 8
• Education and training of healthcare personnel regarding catheter insertion, maintenance, and infection control measures 4

Common Pitfalls to Avoid

• Failing to obtain appropriate cultures before initiating antimicrobial therapy 2, 3
• Delaying catheter removal for infections caused by S. aureus, Pseudomonas, or Candida 2
• Routine replacement of CVCs does not reduce infection rates 4, 2
• Using povidone-iodine instead of alcoholic chlorhexidine or alcohol for skin preparation 3
• Not allowing adequate drying time for antiseptics 3