What is the recommended treatment for Catheter-Related Bloodstream Infection (CRBSI) caused by Burkholderia?

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

Remove the infected catheter immediately for any CRBSI caused by Burkholderia species, as catheter retention has unacceptably high failure rates similar to Pseudomonas infections. 1

Immediate Catheter Management

• The catheter must be removed immediately for Burkholderia CRBSI, regardless of whether it is a short-term or long-term catheter 1
• For hemodialysis catheters specifically, insert a temporary catheter at a different anatomical site immediately after removal 1
• Guidewire exchange should only be considered as an absolute last resort if no alternative vascular access sites exist, though catheter removal remains strongly preferred 1
• The IDSA guidelines explicitly exclude Pseudomonas and similar organisms like Burkholderia from catheter salvage protocols, even in patients with limited vascular access, due to high failure rates 1

Critical distinction: Unlike coagulase-negative staphylococci or some other gram-negative organisms where catheter salvage may be attempted, Burkholderia behaves like Pseudomonas with similar virulence and biofilm-forming capacity, making retention futile 1

Empirical Antibiotic Therapy

• Start vancomycin PLUS a broad-spectrum gram-negative agent immediately while awaiting susceptibility results 1
• Acceptable gram-negative coverage options include: fourth-generation cephalosporin (cefepime), carbapenem (meropenem or imipenem), or β-lactam/β-lactamase combination (piperacillin-tazobactam) 1
• For severely ill or immunocompromised patients, use empirical combination therapy targeting multi-drug resistant gram-negative bacilli until culture data allows de-escalation 1

Duration of Antibiotic Therapy

For uncomplicated infections:

• Treat for 10-14 days after catheter removal if clinical and microbiological response occurs within 48-72 hours 1, 2

For complicated infections or treatment failure:

• If bacteremia persists >72 hours after catheter removal despite appropriate antibiotics, extend therapy to 4-6 weeks 1, 2
• Treat for 4-6 weeks if endocarditis, suppurative thrombophlebitis, or osteomyelitis develops 1, 2

Monitoring and Follow-Up

• Obtain repeat blood cultures 72 hours after initiating therapy to document clearance 1
• Persistent positive cultures at 72 hours indicate treatment failure and suggest metastatic infection requiring extended therapy 1
• For hemodialysis patients, a long-term catheter can be placed once blood cultures are negative 1

Common Pitfalls to Avoid

• Do not attempt catheter salvage with antibiotic lock therapy for Burkholderia CRBSI—this approach has unacceptably high failure rates and is associated with increased mortality 1
• Do not delay catheter removal while waiting for culture results if Burkholderia is suspected based on clinical context or Gram stain 1
• Do not use short-course therapy (≤7 days) for Burkholderia CRBSI, as this organism requires the full 10-14 day course minimum 1, 2
• Do not assume clinical improvement means microbiological cure—always obtain follow-up blood cultures at 72 hours to confirm clearance 1