What is the recommended treatment for central line infection?

Treatment of Central Line Infection

For suspected central line infection, immediately start empirical vancomycin through the catheter to cover Gram-positive organisms, particularly Staphylococcus species, while obtaining paired blood cultures from both the catheter and a peripheral vein. 1

Initial Diagnostic Approach

• Obtain paired blood cultures from the catheter and peripheral vein before starting antibiotics, measuring differential time to positivity (DTTP ≥2 hours indicates catheter-related bacteremia with high sensitivity and specificity) 1
• Swab any exit site exudate for culture and Gram staining 1
• Do not remove the catheter immediately if the patient is hemodynamically stable and lacks microbiological evidence of infection 1

Empirical Antibiotic Therapy

Start vancomycin as first-line empirical therapy, administered through the catheter when possible 1, 2. Teicoplanin is an acceptable alternative as it can be given once daily as a line lock 1.

Add anti-Gram-negative coverage (fourth-generation cephalosporin, carbapenem, or piperacillin-tazobactam with or without aminoglycoside) if: 1

• Patient presents with severe sepsis or septic shock
• High suspicion of Gram-negative infection based on local epidemiology
• Patient is neutropenic
• Extended-spectrum β-lactamase producing organisms are prevalent locally

The 2024 WHO guidelines specifically recommend piperacillin-tazobactam as first-choice for febrile neutropenia with suspected central line infection, with meropenem, aminoglycosides, and vancomycin added based on local epidemiology and clinical presentation 1.

Catheter Management Algorithm

Remove the catheter immediately if: 1, 2

• Tunnel infection or port pocket abscess present
• Persistent bacteremia despite 48-72 hours of appropriate antibiotics
• Severe sepsis or septic shock
• Blood cultures positive for S. aureus, fungi, or mycobacteria
• Signs of endocarditis, septic thrombophlebitis, or metastatic infection

Attempt catheter salvage only if: 1

• Patient is hemodynamically stable
• Infection caused by coagulase-negative Staphylococcus (CNS)
• No tunnel or exit site infection
• Long-term catheter (port system, Hickman catheter) where preservation is critical

For CNS infections, catheter retention has shown 93% success rates in stable patients, though recurrence risk increases, particularly with port systems 1. For S. aureus infections, the literature is divided, but the safest recommendation is catheter removal given the risk of metastatic spread 1, 2.

Targeted Therapy Based on Culture Results

Adjust antibiotics according to susceptibility testing once cultures return 1:

• Methicillin-sensitive S. aureus: Isoxazolylpenicillin for ≥2 weeks 1
• Methicillin-resistant S. aureus: Vancomycin, linezolid, or daptomycin for ≥2 weeks 1
• Coagulase-negative staphylococci: Susceptibility-guided therapy for 5-7 days after defervescence (longer in persistent neutropenia) 1
• Enterococci: Aminopenicillin; vancomycin plus aminoglycoside if ampicillin-resistant; linezolid for vancomycin-resistant strains 1
• Candida species: Remove catheter and treat with fluconazole (for C. albicans if patient stable) or echinocandin (for critically ill or non-albicans species) for ≥2 weeks 1

Antibiotic Lock Therapy

Consider antibiotic lock therapy (ALT) for 10-14 days when attempting catheter salvage in highly needed catheters 1. The lock solution (typically vancomycin, teicoplanin, daptomycin, or aminoglycosides with heparin) is instilled into the catheter lumen and allowed to dwell for several hours to days 1. ALT has shown cure rates up to 100% in small studies but is less effective for port-associated infections 1.

Treatment Duration

• Uncomplicated infections with catheter removal: 7 days after first sterile blood culture 1, 3
• CNS infections in neutropenic patients: 5-7 days after defervescence 1
• S. aureus infections: Minimum 2 weeks, regardless of catheter removal 1
• Candida infections: Minimum 2 weeks after catheter removal and first negative blood culture 1
• Complicated infections (endocarditis, septic thrombosis, metastatic infection): 4-6 weeks 4

A 2022 multicenter study of enterococcal central line infections found that 7-day treatment courses were safe in non-complicated cases with catheter removal, showing no increased 30-day mortality compared to longer courses 3.

Critical Pitfalls to Avoid

• Do not delay blood cultures before starting antibiotics, as this significantly reduces diagnostic yield 2
• Do not attempt catheter salvage with S. aureus infections unless absolutely necessary, as this is associated with treatment failure and metastatic complications 1, 2
• Do not add empirical vancomycin routinely in febrile neutropenia without evidence of catheter infection, as this does not improve outcomes and promotes resistance 1
• Do not exchange catheters over a guidewire with uncoated catheters, as this may contribute to persistent infection 1
• Do not underdose vancomycin or daptomycin, as inadequate levels contribute to treatment failure 2, 4