What is the management of Catheter-Related Bloodstream Infection (CRBSI) caused by Burkholderia?

Management of Catheter-Related Bloodstream Infection (CRBSI) Caused by Burkholderia

For Burkholderia CRBSI, the catheter must be removed immediately and systemic antibiotic therapy initiated, as Burkholderia behaves similarly to Pseudomonas species—a pathogen for which catheter retention has unacceptably high failure rates. 1, 2

Immediate Catheter Management

Remove the infected catheter immediately for any CRBSI caused by Burkholderia species. 1

• The IDSA guidelines explicitly mandate catheter removal for Pseudomonas species infections, and Burkholderia should be managed identically given its similar virulence profile and biofilm-forming capacity. 1
• For hemodialysis catheters specifically, the guidelines state that catheters "should always be removed" for infections due to Pseudomonas species, with a temporary catheter inserted at a different anatomical site. 1
• Clinical evidence demonstrates that antibiotic therapy alone fails to cure Burkholderia catheter infections—in one outbreak, all nine hemodialysis patients with B. cepacia CRBSI required catheter removal after antibiotic failure, with pathology showing numerous bacilli embedded in biofilm on the catheter's inner surface. 3

Empirical Antibiotic Therapy

Initiate broad-spectrum coverage immediately while awaiting susceptibility results. 1

• Start empirical therapy with vancomycin PLUS a gram-negative agent (fourth-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination). 1
• For severely ill or immunocompromised patients, use empirical combination therapy for multi-drug resistant gram-negative bacilli until culture data allows de-escalation. 1

Definitive Antibiotic Selection

Tailor therapy based on susceptibility testing, prioritizing ceftazidime, piperacillin/tazobactam, or carbapenems. 4

• Burkholderia cepacia strains typically show susceptibility to ceftazidime (95.5%), piperacillin/tazobactam (95.5%), and piperacillin (90.9%). 4
• Avoid ticarcillin/clavulanate due to high resistance rates (90.9%). 4
• Burkholderia species have intrinsic resistance to multiple antibiotics, making susceptibility testing essential. 4

Duration of Therapy

Treat for 10-14 days for uncomplicated CRBSI after catheter removal. 2, 5

• If bacteremia persists >72 hours after catheter removal despite appropriate antibiotics, extend therapy to 4-6 weeks. 1
• For complicated infections (endocarditis, suppurative thrombophlebitis, osteomyelitis), treat for 4-6 weeks. 1

Follow-Up Blood Cultures

Obtain repeat blood cultures 72 hours after initiating therapy to document clearance. 1

• Persistent positive cultures at 72 hours indicate treatment failure and may suggest metastatic infection requiring extended therapy. 1
• Obtain surveillance cultures 1 week after completing therapy. 6

Why Catheter Retention Fails for Burkholderia

The evidence strongly argues against catheter salvage attempts:

• Burkholderia forms robust biofilms that require antibiotic concentrations 100-1000 times higher than planktonic bacteria to eradicate. 6
• Even with antibiotic lock therapy, recurrence rates are high—50% of patients with B. cepacia exit-site infections experienced recurrence at 7.8 months despite treatment. 4
• The IDSA guidelines explicitly exclude Pseudomonas (and by extension, similar organisms like Burkholderia) from catheter salvage protocols, even for long-term catheters in patients with limited vascular access. 1

Special Considerations for Hemodialysis Patients

For hemodialysis catheters, insert a temporary catheter at a different anatomical site immediately. 1

• A long-term hemodialysis catheter can be placed once blood cultures are negative. 1
• If absolutely no alternative sites exist, exchange over a guidewire only as a last resort. 1

Critical Pitfalls to Avoid

• Never attempt catheter salvage with antibiotic lock therapy alone for Burkholderia CRBSI—this approach has documented failure rates requiring eventual catheter removal. 3
• Do not delay catheter removal while waiting for culture results if Burkholderia or other Pseudomonas-like organisms are suspected clinically. 1, 2
• Do not use aminoglycosides as monotherapy despite good in vitro susceptibility (80-100%), as clinical outcomes require β-lactam-based regimens. 4