What are the new guidelines for managing Central Line-Associated Bloodstream Infections (CLABSIs)?

Management of Central Line-Associated Bloodstream Infections (CLABSI)

Immediate Empirical Antimicrobial Therapy

Initiate vancomycin 15-20 mg/kg IV every 8-12 hours PLUS an anti-pseudomonal beta-lactam (cefepime, piperacillin-tazobactam, or meropenem) immediately upon suspicion of CLABSI, before culture results are available. 1

• Obtain at least 2 sets of blood cultures before starting antibiotics: one from the catheter and one from a peripheral vein 1, 2
• A differential time to positivity (DTP) >120 minutes between catheter and peripheral cultures confirms CLABSI 1, 2
• Adjust therapy based on culture results and antimicrobial susceptibilities once available 1
• In countries with low MRSA rates, an anti-staphylococcal beta-lactam may be used instead of vancomycin 2

Catheter Removal Decisions

Remove the catheter immediately for CLABSI caused by Staphylococcus aureus, Pseudomonas aeruginosa, Candida species, or mycobacteria. 1, 2

Mandatory catheter removal scenarios:

• S. aureus, P. aeruginosa, fungi, or mycobacteria 3, 1, 2
• Suppurative thrombophlebitis 1
• Endocarditis 1
• Tunnel infection or port pocket infection 3, 1, 2
• Persistent bacteremia >72 hours despite appropriate antimicrobial therapy 1
• Hemodynamic instability or septic shock 3

Catheter salvage may be attempted:

• Coagulase-negative staphylococci (CoNS) in long-term catheters using systemic antibiotics with or without antibiotic lock therapy 3, 1
• Uncomplicated catheter-related infection with defervescence and negative blood cultures within 72 hours in hemodynamically stable patients 3
• Corynebacterium jeikeium in hemodynamically stable patients with tunneled catheters on vancomycin 3

Important caveat: Guidewire exchange is not recommended in the setting of active bacteremia and should only be considered when reinsertion risk outweighs infection persistence 3

Duration of Antimicrobial Therapy

After catheter removal:

• For S. aureus, P. aeruginosa, fungi, or mycobacteria: Minimum 14 days of systemic therapy 1
• For gram-negative organisms (uncomplicated): 10-14 days, though recent evidence supports ≤7 days as equally safe and effective 1, 4
• For coagulase-negative staphylococci: 7-10 days if catheter removed 1; ≤3 days may be sufficient after catheter withdrawal 5
• For complicated CLABSI (endocarditis, osteomyelitis, metastatic infection): 4-6 weeks 3, 1

With catheter retention:

• Continue antibiotics for at least 7 days after first sterile blood culture 3
• Consider antibiotic lock therapy for 10-14 days in "highly needed" infected catheters 3

Pathogen-Specific Management

Staphylococcus aureus:

• Always remove catheter 3, 1, 2
• Obtain transesophageal echocardiography to exclude endocarditis 1
• Treat with isoxazolylpenicillin (methicillin-sensitive) or glycopeptide/linezolid (methicillin-resistant) for ≥2 weeks 3
• If bacteremia persists >72 hours after catheter removal, treat for at least 4 weeks 3

Pseudomonas aeruginosa:

• Always remove catheter 1, 2
• Treat according to susceptibility pattern for ≥2 weeks 3

Candida species:

• Always remove catheter 3, 1, 2
• Echinocandin preferred for initial therapy 1
• Fluconazole for C. albicans; amphotericin B lipid-based formulations or echinocandins for non-albicans species 3
• Treat for 14 days after first negative blood culture, minimum ≥2 weeks 3, 1

Coagulase-negative staphylococci:

• Treat according to susceptibility pattern; glycopeptides only if methicillin-resistant 3
• Duration: 5-7 days after defervescence in neutropenic patients 3

Enterococci:

• Aminopenicillin preferred; glycopeptide plus aminoglycoside if ampicillin-resistant 3
• Linezolid or quinupristin/dalfopristin for vancomycin resistance 3
• Duration: 7-14 days 3

Prevention Strategies

Hand hygiene is the single most effective intervention to prevent CLABSI. 1, 2, 6

• Use maximal sterile barrier precautions during catheter insertion 1, 2, 6
• Apply >0.5% chlorhexidine with alcohol for cutaneous antisepsis 1, 2, 6
• Remove catheters as soon as clinically appropriate 1
• Implement education and ongoing training for healthcare personnel 2
• Avoid routine catheter replacement as a prevention strategy 2
• Consider prophylactic antibiotic locks in patients with multiple prior CLABSI or facilities with rates >3.5/1,000 catheter days 3

Special Considerations for High-Risk Populations

Neutropenic/hematology-oncology patients:

• Do not add empiric vancomycin without proof of antibiotic-resistant gram-positive bacteria unless severe sepsis/shock present 3
• Catheter removal associated with lower mortality specifically in neutropenic patients with candidemia 3
• Prospective surveillance and intensive training reduce infection rates by up to 68% 3

Hemodialysis patients:

• Individualized approach based on patient health, dialysis circumstances, and vascular access options 3
• Options include catheter exchange via guidewire, removal and reinsertion, or salvage with antibiotic lock 3