Management of Tan Drainage Around Dialysis Catheter Site
Obtain cultures of the drainage and blood cultures immediately, then initiate empirical systemic antibiotics covering both Gram-positive organisms (including S. aureus) and Gram-negative bacilli while awaiting culture results. 1
Immediate Diagnostic Steps
- Swab the tan drainage for Gram stain and culture to identify the causative organism 1
- Obtain blood cultures from both a peripheral vein (avoiding vessels intended for future fistula creation) and through the catheter if peripheral access is unavailable 1
- Draw blood cultures before initiating antibiotics to maximize diagnostic yield 1
- Use proper skin preparation with alcoholic chlorhexidine (>0.5%), alcohol, or tincture of iodine rather than povidone-iodine 1
Clinical Assessment for Severity
Evaluate for signs that mandate immediate catheter removal 1:
- Purulent drainage at the exit site (not just tan/serous drainage)
- Erythema or induration extending beyond the immediate exit site suggesting tunnel infection
- Systemic signs of sepsis: fever, hypotension, altered mental status, or hemodynamic instability
- Persistent symptoms despite 2-3 days of appropriate antibiotic therapy
Empirical Antibiotic Regimen
Start vancomycin plus coverage for Gram-negative bacilli based on your local antibiogram 1:
- Vancomycin for Gram-positive coverage (including MRSA)
- Plus a third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination for Gram-negative coverage 1
- If culture reveals methicillin-susceptible S. aureus, switch vancomycin to cefazolin (20 mg/kg after dialysis, rounded to nearest 500-mg increment) 1
Catheter Management Algorithm
For Uncomplicated Exit Site Infection (tan drainage without purulence or systemic signs):
- Attempt catheter salvage with systemic antibiotics plus antibiotic lock therapy 1
- Administer antibiotic lock solution after each dialysis session for 10-14 days as adjunctive therapy 1
- Monitor closely with repeat blood cultures if symptoms persist beyond 2-3 days 1
Mandatory Catheter Removal Scenarios:
Remove the catheter immediately if any of the following are present 1:
- Infection with S. aureus, Pseudomonas species, or Candida species
- Purulent drainage at exit site
- Tunnel infection or port abscess
- Persistent bacteremia >72 hours despite appropriate antibiotics
- Clinical deterioration or hemodynamic instability
Catheter Replacement Strategy:
- If catheter must be removed: Insert temporary nontunneled catheter at a different anatomical site 1
- Place new long-term catheter only after obtaining negative blood cultures 1
- Guidewire exchange may be considered only for coagulase-negative staphylococci or other less virulent organisms if symptoms resolve within 2-3 days and no alternative sites exist 1
Antibiotic Duration
- Uncomplicated infection with catheter salvage: 10-14 days of systemic antibiotics plus antibiotic lock 1
- Coagulase-negative staphylococci with catheter removal: 5-7 days 1
- Persistent bacteremia >72 hours or complications: 4-6 weeks 1
- Endocarditis or suppurative thrombophlebitis: 4-6 weeks 1
- Osteomyelitis: 6-8 weeks 1
Critical Pitfalls to Avoid
- Do not delay blood cultures waiting for peripheral access; draw through catheter if necessary, but mark specimens appropriately 1
- Do not assume tan drainage is benign—while less concerning than purulent drainage, it still represents exit site infection requiring treatment 1
- Do not routinely remove catheters in stable patients with mild exit site findings; attempt salvage first unless high-risk organisms are identified 1
- Do not use vancomycin monotherapy empirically—always cover Gram-negatives until cultures exclude them 1
- Obtain surveillance blood cultures 1 week after completing antibiotics if catheter was retained to ensure cure 1
Special Consideration for S. aureus
Staphylococcus aureus is the leading cause of dialysis catheter infections and carries higher risk for complications 1, 2: