Initial Treatment for Catheter-Related Exit Site Infection from Internal Jugular Catheter
For uncomplicated exit site infections without systemic signs, purulence, or positive blood cultures, start with topical antimicrobial therapy based on culture results—specifically mupirocin ointment for S. aureus or antifungal ointment for Candida. 1
Diagnostic Approach
Obtain cultures immediately:
- Culture any drainage from the exit site 1
- Draw blood cultures (at least one set from a peripheral vein and one through the catheter if bloodstream infection is suspected) 1
- Do not remove the catheter based solely on exit site findings without systemic signs 1
Treatment Algorithm Based on Severity
Uncomplicated Exit Site Infection
Definition: Erythema, tenderness, or induration at the exit site WITHOUT fever, purulent drainage, positive blood cultures, or systemic signs 1
Initial management:
- Apply topical mupirocin ointment for S. aureus 1
- Apply ketoconazole or clotrimazole ointment for Candida 1
- Monitor for clinical improvement over 48-72 hours 1
Complicated Exit Site Infection
Definition: Exit site infection WITH purulent drainage, systemic signs, or failure of topical therapy 1
Escalate to systemic antibiotics:
- Start empirical vancomycin if MRSA prevalence is high in your institution 2, 3
- Use cefazolin if MRSA prevalence is low and patient is stable 2
- Tailor antibiotics based on culture susceptibilities once available 1
- Duration: Continue until clinical resolution, typically 7-10 days 1
Remove the catheter if:
- Systemic antibiotics fail to resolve the infection 1
- Purulent drainage persists despite appropriate therapy 1
- Blood cultures remain positive after 72 hours of appropriate antibiotics 1
Pathogen-Specific Considerations
Coagulase-negative staphylococci (S. epidermidis):
- Most common pathogen in catheter-related infections 1
- Usually benign clinical course with fever and local inflammation 1
- Catheter can often be salvaged with systemic antibiotics (5-7 days if removed, 10-14 days if retained with antibiotic lock therapy) 1
Staphylococcus aureus:
- More virulent pathogen requiring aggressive management 1, 2
- Use β-lactam antibiotics (nafcillin, oxacillin, or cefazolin) for methicillin-susceptible strains 1
- Use vancomycin for MRSA (switch to daptomycin if vancomycin MIC ≥2 μg/mL) 2
- Consider catheter removal, especially if bacteremia develops 2, 3
Gram-negative organisms (Pseudomonas aeruginosa):
- Add empirical gram-negative coverage with ceftazidime, cefepime, or carbapenem if patient is severely ill, neutropenic, or has risk factors 1, 2
- Catheter removal strongly recommended for Pseudomonas species other than P. aeruginosa 2
Critical Pitfalls to Avoid
- Do not routinely remove IJ catheters for exit site infections without systemic involvement—this leads to unnecessary catheter loss and reinsertion complications 1
- Do not use vancomycin empirically in low MRSA prevalence settings—this promotes vancomycin resistance and has higher failure rates for susceptible organisms 1, 2
- Do not confuse exit site infection with tunnel infection—tunnel infections require catheter removal, incision and drainage if indicated, and 7-10 days of antibiotics 1
- Do not start systemic antibiotics for mild exit site infections without first attempting topical therapy—reserve systemic therapy for complicated cases 1
When Catheter Removal is Mandatory
Remove the catheter immediately if:
- Tunnel infection with purulence develops 1
- Severe sepsis or hemodynamic instability occurs 2, 3
- Bloodstream infection persists despite 72 hours of appropriate antibiotics 2, 3
- Complicated infections develop (endocarditis, septic thrombosis, metastatic infection) 2, 3
- Infection is caused by S. aureus with bacteremia, Candida species, mycobacteria, or Bacillus species 2, 3