When is Portacath (portable catheter) removal indicated in cases of infection?

Portacath Removal Indications in Infection

Portacath removal is mandatory for tunnel infection, port pocket abscess, fungal bloodstream infection (especially Candida species), S. aureus bacteremia, and any complicated infection including septic thrombosis, endocarditis, or persistent bacteremia ≥72 hours despite appropriate antibiotics. 1, 2

Absolute Indications for Immediate Removal

Local Complications

• Tunnel infection or port pocket abscess requires immediate removal plus incision/drainage if indicated, followed by 7-10 days of antibiotics 1, 2
• Purulent drainage at the insertion site mandates removal 1

Specific Pathogens

• Candida species (any): Remove catheter immediately and treat with antifungals for 14 days after the last positive blood culture 1, 2

  • Fungal infections have a 70% failure rate with catheter salvage attempts 1
  • High risk of metastatic infection and mortality 3

• S. aureus bacteremia: Remove catheter immediately 1, 2

  • Perform transesophageal echocardiography (TEE) to rule out endocarditis 1, 2
  • If TEE shows vegetations, treat for 4-6 weeks 1, 2
  • Even without endocarditis, high risk of metastatic complications necessitates removal 3

• Pseudomonas aeruginosa: Remove catheter due to poor response to antibiotics alone 1, 4

• Bacillus species, Stenotrophomonas maltophilia, Corynebacterium jeikeium, vancomycin-resistant enterococci: Remove catheter due to treatment failure rates 1, 4

Systemic Complications

• Persistent bacteremia or fungemia ≥72 hours after initiating appropriate antibiotics indicates complicated infection requiring removal 1, 2
• Septic thrombosis requires removal and 4-6 weeks of antibiotics 1, 2
• Endocarditis requires removal and 4-6 weeks of antibiotics 1, 2
• Osteomyelitis requires removal and 6-8 weeks of antibiotics 1
• Septic shock or hemodynamic instability mandates immediate removal 1
• Metastatic infection (septic emboli, retinitis, other distant foci) requires removal 1

Catheter Salvage May Be Attempted

Salvage is only appropriate for uncomplicated infections with coagulase-negative staphylococci or select gram-negative bacilli (excluding Pseudomonas) in hemodynamically stable patients without tunnel/pocket infection. 1, 2

Criteria for Salvage Attempt

• Hemodynamically stable patient 1
• No tunnel infection or port pocket abscess 1, 2
• No metastatic infection 1
• Symptoms resolve within 2-3 days of antibiotic initiation 1
• Blood cultures clear within 2-3 days 1

Salvage Protocol

• Combine systemic antibiotics with antibiotic lock therapy for 14 days 1, 2
• Antibiotic lock involves instilling high-concentration antibiotics into the catheter lumen with 12-24 hour dwell time 1, 2
• Success rate approximately 82.6% for bacterial infections, but only 30% for fungal infections 1

When Salvage Fails

• Remove catheter if symptoms persist beyond 2-3 days 1
• Remove if bacteremia persists or relapses 1
• Remove if clinical deterioration occurs 1

Gram-Negative Bacilli (Non-Pseudomonas)

For gram-negative bacilli other than Pseudomonas, initial empirical antibiotics without immediate removal is acceptable, but remove if symptoms persist >2-3 days or if severe sepsis develops. 1

Coagulase-Negative Staphylococci

Uncomplicated infections may be treated with systemic antibiotics plus antibiotic lock therapy for 14 days without removal, but remove if bacteremia persists or relapses. 1, 2

Timing of Portacath Reinsertion After Removal

• Start appropriate systemic antibiotics based on susceptibilities 1, 2
• Obtain negative repeat blood cultures after removal 1, 2
• Complete full antibiotic course 1, 2
• Wait additional 5-10 days after completing antibiotics 1, 2
• Obtain surveillance blood cultures before new port placement 1, 2

Pathogen-Specific Timing

• S. aureus with endocarditis: Complete 4-6 weeks antibiotics, then wait 5-10 days with negative cultures 2
• Candida species: Wait 14 days after last positive blood culture 2
• Uncomplicated coagulase-negative staphylococci: Wait 5-7 days after removal 2

Common Pitfalls to Avoid

• Do not attempt salvage for S. aureus or Candida infections - removal is mandatory due to high complication rates 1, 2, 3
• Do not delay TEE in S. aureus bacteremia - endocarditis rates are higher than previously recognized 1
• Do not reinstate portacath too early - wait for negative cultures and completion of antibiotics to prevent reinfection 1, 2
• Research shows simultaneous removal and reinsertion in bacteremic patients has 15.4% reinfection rate versus 4.8% with delayed reinsertion 5
• Do not use antibiotic lock therapy alone for complicated infections - this requires systemic antibiotics plus removal 1