Treatment of Klebsiella-Related CRBSI in Temporary Catheters
For Klebsiella-related CRBSI in temporary (non-tunneled) hemodialysis catheters, the catheter must be removed immediately and a new temporary catheter inserted at a different anatomical site, combined with systemic antibiotic therapy for 10-14 days. 1
Immediate Catheter Management
Remove the infected temporary catheter immediately - this is non-negotiable for gram-negative bacilli including Klebsiella in short-term catheters. 1
The IDSA guidelines explicitly state that "short-term catheters should be removed from patients with CRBSI due to gram-negative bacilli, S. aureus, enterococci, fungi, and mycobacteria." 1
For hemodialysis patients specifically, insert a temporary (non-tunneled) catheter at a different anatomical site - do not exchange over a guidewire unless absolutely no alternative sites exist. 1
A long-term hemodialysis catheter can be placed once blood cultures return negative. 1, 2
Empirical Antibiotic Therapy
Start empirical therapy immediately with vancomycin PLUS gram-negative coverage while awaiting culture susceptibility results. 1
The IDSA guidelines for hemodialysis CRBSI recommend: vancomycin + coverage for gram-negative bacilli based on local antibiogram (third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination). 1
Once Klebsiella is identified and susceptibilities are available, de-escalate to the most narrow-spectrum effective agent. 3
Common pitfall: Klebsiella species, particularly carbapenem-resistant strains, are increasingly prevalent and may require broader empirical coverage in high-risk settings. 4
Duration of Antibiotic Therapy
Treat for 10-14 days after catheter removal for uncomplicated CRBSI. 1, 3
If bacteremia persists >72 hours after catheter removal despite appropriate antibiotics, extend therapy to 4-6 weeks. 1
For complicated infections (endocarditis, suppurative thrombophlebitis, or osteomyelitis), treat for 4-6 weeks (or 6-8 weeks for osteomyelitis in adults). 1
Mandatory Follow-Up Blood Cultures
Obtain repeat blood cultures 72 hours after initiating therapy to document clearance of bacteremia. 1
If blood cultures remain positive at 72 hours, this indicates treatment failure and necessitates extended therapy (4-6 weeks) and evaluation for metastatic infection. 1, 5
For hemodialysis patients, blood samples should be obtained from peripheral vessels not intended for future fistula creation (e.g., hand veins). 1
Why Catheter Salvage is NOT an Option
Catheter salvage should NOT be attempted for Klebsiella CRBSI in temporary catheters, despite limited vascular access. 1
The IDSA guidelines reserve catheter salvage attempts only for long-term catheters with "pathogens other than S. aureus, P. aeruginosa, Bacillus species, Micrococcus species, Propionibacteria, fungi, or mycobacteria." 1
While this list doesn't explicitly name Klebsiella, the guidelines clearly state that "short-term catheters should be removed from patients with CRBSI due to gram-negative bacilli." 1
Research shows catheter retention is the strongest risk factor for relapse in gram-negative CRBSI (OR = 145.32), and catheter removal prevents relapse. 3
Special Considerations for Hemodialysis Patients
If the patient develops severe sepsis, unexplained persistent fever, or hemodynamic instability, remove the catheter immediately regardless of other factors. 1
Patients should wear surgical masks during catheter removal procedures, and healthcare staff must use appropriate PPE. 2
Monitor for post-removal site infection as a potential complication. 2
Critical caveat: Even in patients with extremely limited vascular access, temporary catheters infected with gram-negative bacilli like Klebsiella require removal due to unacceptably high failure rates with salvage attempts. 1, 3