Treatment of Line Sepsis
Initiate IV broad-spectrum antimicrobials within one hour of recognizing line sepsis, remove the infected catheter promptly after establishing alternative vascular access, and obtain blood cultures from both the line and a peripheral site before starting antibiotics. 1
Immediate Actions (Within 1 Hour)
Antimicrobial Therapy
- Administer IV antimicrobials within 60 minutes of recognition, as this is the single most critical intervention for reducing mortality in sepsis. 1, 2
- Start empiric broad-spectrum therapy covering both gram-positive organisms (particularly Staphylococcus aureus including MRSA) and gram-negative pathogens (Pseudomonas aeruginosa, E. coli, Klebsiella). 1, 3, 4
- For septic shock, use combination therapy with at least two antibiotics from different classes targeting the most likely bacterial pathogens. 1
Recommended Empiric Regimens
- Vancomycin PLUS an anti-pseudomonal beta-lactam (piperacillin-tazobactam, cefepime, or a carbapenem) is the standard approach for catheter-related bloodstream infections. 3, 5, 6
- Consider adding an aminoglycoside or fluoroquinolone if the patient has septic shock or risk factors for multidrug-resistant organisms. 1
Diagnostic Workup
- Obtain at least two sets of blood cultures before antibiotics: one drawn percutaneously and one through the suspected infected catheter (if <48 hours old). 1, 2
- Do not delay antimicrobials beyond 45 minutes if cultures cannot be obtained immediately. 1, 2
Source Control
Catheter Management
- Remove the intravascular access device promptly after establishing alternative vascular access, as infected catheters are a removable source of ongoing bacteremia. 1, 7
- Source control intervention should occur within the first 12 hours after diagnosis when feasible. 1, 7
- Send the catheter tip for culture if line infection is suspected. 7
De-escalation Strategy
Narrowing Therapy
- Discontinue combination therapy within 3-5 days once clinical improvement occurs and susceptibility data are available. 1
- Narrow to targeted single-agent therapy based on pathogen identification and sensitivities. 1
- Reassess antimicrobial regimen daily for potential de-escalation. 1, 7
Duration of Treatment
- Standard duration is 7-10 days for most catheter-related bloodstream infections. 1
- Longer courses (4-6 weeks) are required for:
Monitoring and Adjustment
Clinical Assessment
- Use procalcitonin levels to support decisions about therapy duration and discontinuation of empiric antibiotics if infection is not confirmed. 1, 7
- Monitor for clinical improvement within 48-72 hours of initiating appropriate therapy. 7
- Persistent bacteremia beyond 72 hours suggests inadequate source control or metastatic complications. 7
Common Pitfalls to Avoid
Antibiotic Selection Errors
- Both inadequate and unnecessarily broad empiric antibiotics are associated with higher mortality (odds ratio 1.19 and 1.22, respectively). 8
- While MRSA prevalence in community-onset sepsis is only 11.7%, empiric vancomycin is justified for line sepsis given the high risk of staphylococcal infection from indwelling catheters. 8
- Avoid routine antifungal therapy unless the patient has specific risk factors (prolonged broad-spectrum antibiotics, total parenteral nutrition, immunosuppression). 1, 3
Source Control Delays
- Modifying initially inadequate therapy after culture results does not improve outcomes—the initial choice and timing are critical. 5, 6
- Delaying catheter removal while continuing antibiotics leads to treatment failure and persistent bacteremia. 1