What is the treatment for a tunneled catheter infection?

Treatment of Tunneled Catheter Infection

Remove the catheter immediately and administer 7-10 days of systemic antibiotics for tunnel infections without bacteremia; if bacteremia is present, extend treatment to 10-14 days for uncomplicated cases or 4-6 weeks for complicated infections. 1

Initial Assessment and Pathogen Identification

• Obtain blood cultures from both the catheter and a peripheral vein before initiating antibiotics to confirm catheter-related bloodstream infection (CRBSI) 1, 2
• Assess for complications including septic thrombosis, endocarditis, metastatic infections, port abscess, or tunnel infection through clinical examination and appropriate imaging 1
• Perform transesophageal echocardiography (TEE) if Staphylococcus aureus bacteremia is documented to rule out endocarditis 1, 3

Catheter Management Algorithm

Tunnel Infection or Port Abscess

• Remove the catheter immediately in all cases of tunnel infection or port abscess 1
• Perform incision and drainage if indicated 1
• Administer 7-10 days of systemic antibiotics if no concomitant bacteremia or candidemia is present 1

Uncomplicated Bacteremia (No Tunnel Infection)

The approach depends on the causative organism:

For Coagulase-Negative Staphylococci:

• Attempt catheter salvage with systemic antibiotics plus antibiotic lock therapy for 14 days 1, 2
• Remove catheter if clinical deterioration occurs or bacteremia persists 1

For Staphylococcus aureus:

• Remove the catheter due to high risk of metastatic infection 4
• Treat with 10-14 days of systemic antibiotics if TEE is negative and infection is uncomplicated 1
• Extend to 4-6 weeks if TEE shows endocarditis or other complications are present 1, 3

For Gram-Negative Bacilli (including Enterobacter cloacae):

• Attempt catheter salvage with systemic antibiotics plus antibiotic lock therapy for 14 days in uncomplicated cases 1, 2
• Remove catheter if bacteremia persists despite appropriate therapy, patient becomes unstable, or infection involves Pseudomonas species other than P. aeruginosa, Burkholderia cepacia, Stenotrophomonas, Agrobacterium, or Acinetobacter baumannii 1
• Use carbapenems or fourth-generation cephalosporins for Enterobacter species due to risk of inducible resistance 2

For Fungal Infections (Candida species):

• Remove the catheter immediately in all cases 1
• Administer antifungal therapy for 14 days after the last positive blood culture and resolution of symptoms 1
• Use amphotericin B for hemodynamically unstable patients or fluconazole-resistant organisms; fluconazole is acceptable for stable patients with susceptible organisms 1

For Bacillus, Corynebacterium, or Mycobacterial Infections:

• Remove the catheter as these organisms require catheter removal for cure 1

Antibiotic Lock Therapy Protocol (When Attempting Salvage)

• Prepare antibiotic lock solution with concentrations 100-1000 times higher than the minimum inhibitory concentration (MIC) 1, 2
• Instill into catheter lumen after each dialysis session and allow to dwell until the next session 2
• Continue for 14 days in conjunction with systemic antibiotics 1, 2
• Note that salvage rates for fungal infections are only approximately 30%, making this approach not recommended for Candida species 1

Empirical Antibiotic Selection

• Start with vancomycin or teicoplanin to cover staphylococci, the most common cause of tunneled catheter infections 5
• Add antipseudomonal coverage (ceftazidime, cefepime, piperacillin-tazobactam, or carbapenem) for neutropenic patients, severe sepsis, or gram-negative infection 1, 5
• Adjust therapy based on culture and susceptibility results once available 2

Catheter Reinsertion Timing After Removal

• Wait until blood cultures are negative and appropriate systemic antimicrobial therapy has been initiated 3
• For endocarditis or complicated infections requiring 4-6 weeks of antibiotics, complete the full course plus an additional 5-10 days, then obtain repeat surveillance blood cultures before placing a new catheter 3
• Place temporary non-tunneled catheters at anatomically separate sites if vascular access is needed during treatment 3

Critical Pitfalls to Avoid

• Do not attempt catheter salvage for tunnel infections, port abscesses, fungal infections, S. aureus bacteremia, or hemodynamically unstable patients 1, 4
• Do not treat endocarditis for less than 4-6 weeks, as this increases relapse risk 3
• Do not place a new catheter until surveillance blood cultures confirm clearance of bacteremia 3
• Monitor for persistent bacteremia (≥3 days after catheter removal despite appropriate antibiotics), which requires aggressive evaluation for septic thrombosis or metastatic infection 3
• Recognize that Enterobacter species can develop resistance during therapy, particularly to third-generation cephalosporins 2