What is the management approach for Central Line-Associated Bloodstream Infections (CLABSI)?

Management of Central Line-Associated Bloodstream Infections (CRBSI)

Remove the catheter immediately for infections caused by Staphylococcus aureus, Pseudomonas aeruginosa, or Candida species, and initiate appropriate antimicrobial therapy for 10-14 days minimum after catheter removal. 1, 2, 3

Diagnostic Approach

Blood Culture Collection

• Obtain paired blood cultures from both the catheter hub and a peripheral vein before starting any antibiotics 4, 1, 2
• If peripheral access is impossible, draw two blood samples from different catheter lumens at different times 2
• Disinfect the catheter hub with alcohol, alcoholic chlorhexidine (>0.5%), or tincture of iodine before drawing cultures 1

Diagnostic Criteria

• Differential time to positivity (DTP) ≥2 hours between catheter-drawn and peripheral blood cultures is highly sensitive and specific for CRBSI 4, 1, 2
• Alternatively, catheter hub blood culture showing colony count ≥3-fold greater than peripheral vein confirms CRBSI 1
• Growth of >15 CFU from catheter tip by semiquantitative culture or >10² CFU by quantitative culture indicates catheter colonization 3

Immediate Catheter Management Decision

Mandatory Catheter Removal

Remove the catheter immediately if ANY of the following are present:

• Staphylococcus aureus infection 4, 1, 2, 3
• Pseudomonas aeruginosa infection 4, 1, 2
• Candida species or any fungal infection 4, 1, 2, 3
• Mycobacterial infection 4
• Severe sepsis or hemodynamic instability 4, 2
• Tunnel infection or port pocket infection 4, 1, 3
• Persistent bacteremia >72 hours despite appropriate antibiotics 4, 2
• Evidence of septic thrombosis 4
• Endocarditis 4

Consider Catheter Retention (Salvage Strategy)

Catheter may be retained ONLY if ALL of the following criteria are met:

• Infection caused by coagulase-negative staphylococci 4, 1, 2
• Patient is clinically stable without sepsis 1, 2
• Limited venous access alternatives 2
• No evidence of tunnel/pocket infection 4

Critical Pitfall: Attempting catheter salvage with S. aureus, Pseudomonas, or Candida significantly increases mortality and risk of metastatic complications including endocarditis and osteomyelitis 4, 2

Empirical Antimicrobial Therapy

Initial Coverage

• Start vancomycin as first-line empirical therapy in settings with elevated MRSA prevalence 1, 2, 3
• Switch to daptomycin if vancomycin MIC >2 μg/mL or in institutions with high prevalence of vancomycin-resistant strains 2
• In low MRSA prevalence areas, an anti-staphylococcal beta-lactam (nafcillin, oxacillin, cefazolin) may be used 3

Add Gram-Negative Coverage if:

• Severe illness or septic shock 3
• Neutropenic or immunocompromised patients 4, 3
• Femoral catheter site 3
• Use extended-spectrum penicillin, cephalosporin, or carbapenem based on local antibiogram 3

Add Empirical Antifungal Therapy if:

• Total parenteral nutrition use 2
• Prolonged broad-spectrum antibiotic exposure 2
• Hematologic malignancy 2
• Bone marrow or solid-organ transplant 2
• Femoral catheterization 2

Pathogen-Specific Treatment Duration

Coagulase-Negative Staphylococci

• With catheter removal: 5-7 days IV antibiotics 2
• With catheter retention: 10-14 days IV antibiotics PLUS antibiotic lock therapy 2

Staphylococcus aureus

• Uncomplicated (no metastatic infection): Minimum 10-14 days IV antibiotics after catheter removal 4, 1, 2
• Complicated (endocarditis, osteomyelitis, septic thrombosis): 4-6 weeks IV therapy 4, 2
• Mandatory: Obtain transesophageal echocardiography (TEE) to rule out endocarditis in ALL S. aureus bacteremia cases 4, 1
• If TEE unavailable and transthoracic echo negative, treat for 4-6 weeks given high rates of complicating endocarditis 4

Candida Species

• Mandatory catheter removal 4, 2, 3
• 14 days of antifungal therapy after first negative blood culture and resolution of symptoms 2

Gram-Negative Organisms (including Pseudomonas)

• Mandatory catheter removal 4, 1
• Minimum 14 days IV antibiotics 4

Special Populations

Neutropenic Patients

• Differential time to positivity >120 minutes suggests CLABSI 4
• For S. aureus, Pseudomonas, fungi, or mycobacteria: catheter removal plus ≥14 days systemic therapy 4
• For coagulase-negative staphylococci: catheter may be retained with systemic therapy with or without antibiotic lock 4

Hemodialysis Patients

• Always remove catheter for S. aureus, Pseudomonas, or Candida infections 2

Pediatric and Neonatal Patients

• Indications for catheter removal similar to adults unless no alternative access exists 2
• NICU patients have higher CLABSI rates (2.6-60 per 1000 catheter days in resource-limited settings) 4
• Implementation of care bundles has shown inconsistent outcomes in pediatric populations compared to adults 4

Evaluation for Metastatic Complications

After catheter removal, if persistent bacteremia/fungemia or lack of clinical improvement despite appropriate antibiotics, aggressively evaluate for:

• Septic thrombosis 4
• Infective endocarditis 4
• Osteomyelitis 4
• Other metastatic infections 4

S. aureus is particularly prone to causing secondary metastatic infections and requires heightened vigilance 4

Common Pitfalls to Avoid

• Never delay obtaining blood cultures before starting antibiotics - this complicates diagnosis and pathogen identification 2, 3
• Never attempt catheter salvage with S. aureus, Pseudomonas, or Candida - failure/delay increases mortality 4, 2
• Do not draw blood cultures solely from the catheter port - high false-positive rate from skin contaminants 4
• Do not routinely replace CVCs as a prevention strategy - this does not reduce infection rates 4, 1, 3
• Changing a "dirty" line within 24 hours may not be sufficient to reduce CRBSI risk if initial placement violated sterile technique 5
• Do not use antimicrobial prophylaxis during catheter insertion or while catheters are in place 4