CRBSI Pathogens Requiring Catheter Removal
For short-term catheters, remove immediately for gram-negative bacilli (including all Enterobacterales), S. aureus, enterococci, fungi, and mycobacteria; for long-term catheters, remove for S. aureus, P. aeruginosa, fungi, and mycobacteria. 1
Short-Term (Non-Tunneled) Catheters
Mandatory removal pathogens include: 1
- Gram-negative bacilli (all species, including Enterobacterales, Pseudomonas, Acinetobacter) 1, 2
- Staphylococcus aureus 1
- Enterococci (all species) 1
- Fungi (Candida species and other fungi) 1
- Mycobacteria 1
The IDSA guidelines provide A-II level evidence for these recommendations, emphasizing that attempting catheter salvage with these pathogens in short-term catheters has unacceptably high failure rates and increased mortality risk. 1
Long-Term (Tunneled) Catheters and Ports
Mandatory removal pathogens include: 1
- Staphylococcus aureus (success rate <20% with catheter retention) 1, 3
- Pseudomonas aeruginosa 1
- Fungi (all Candida species and other fungi) 1, 3
- Mycobacteria 1
- Bacillus species 1
- Micrococcus species 1
- Propionibacteria 1
Catheter Salvage May Be Attempted For:
Only in uncomplicated cases with limited venous access: 1
- Coagulase-negative staphylococci 1
- Other gram-negative bacilli (excluding Pseudomonas) in hemodynamically stable patients 1
- Corynebacterium jeikeium 1
Critical caveat: Salvage requires both systemic antibiotics AND antibiotic lock therapy, with mandatory repeat blood cultures at 72 hours—if still positive, the catheter must be removed. 1
Clinical Situations Mandating Removal Regardless of Pathogen
Remove any catheter (short or long-term) if: 1
- Severe sepsis or septic shock 1
- Suppurative thrombophlebitis 1
- Endocarditis 1
- Bloodstream infection persisting >72 hours despite appropriate antimicrobial therapy 1
- Tunnel infection or port abscess 1
- Osteomyelitis or other metastatic infection 1
Key Management Principles
The pathogen-specific approach reflects differential mortality risk: S. aureus and Candida CRBSI carry high rates of metastatic complications (endocarditis, septic thrombophlebitis, deep abscesses), making immediate catheter removal essential to reduce mortality. 3, 4 Gram-negative bacilli, particularly Pseudomonas, form robust biofilms that are nearly impossible to eradicate with antibiotics alone in short-term catheters. 2, 4
For hemodialysis patients with gram-negative CRBSI: Insert a new temporary catheter at a different anatomical site—never exchange over a guidewire unless absolutely no alternative sites exist. 2
Common pitfall: Attempting catheter salvage with enterococci in short-term catheters has only 38% success rate even with combination therapy, compared to 83% with removal. 5 Despite this, the IDSA mandates removal for enterococcal CRBSI in short-term catheters. 1