What is the treatment for intravenous (IV) site infection?

Treatment of Intravenous (IV) Site Infection

Remove the peripheral IV catheter immediately if there is pain, induration, erythema, or exudate at the insertion site, and submit any drainage for culture. 1

Immediate Management for Peripheral IV Catheters

• Remove the catheter immediately when infection is suspected—this is the definitive treatment for peripheral IV site infections 1
• Submit any exudate at the insertion site for Gram staining and routine culture 1
• Obtain at least 2 separate blood cultures (one drawn percutaneously) before initiating antibiotics if systemic infection is suspected 1
• Culture the catheter tip semi-quantitatively after removal 1, 2

When to Initiate Systemic Antibiotics

Systemic antibiotics are NOT routinely required for simple peripheral IV site infections after catheter removal. 1 However, initiate empirical IV antimicrobial therapy if:

• The patient has systemic signs of infection (fever, chills, hemodynamic instability) 1
• There is evidence of spreading cellulitis beyond the immediate insertion site 3
• The patient is immunocompromised 1

Empirical Antibiotic Regimen (When Needed)

Start vancomycin plus gram-negative coverage based on local antibiogram if systemic infection is present 1, 4:

• Vancomycin for gram-positive coverage (including MRSA)
• Plus a third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination for gram-negative coverage 1, 4
• Switch to cefazolin if cultures reveal methicillin-susceptible S. aureus 1, 4

Duration of Antibiotic Therapy

The duration depends on the pathogen and complications 1:

• 5-7 days for uncomplicated coagulase-negative staphylococcal infection with catheter removal 1
• 10-14 days for gram-negative bacteremia without complications 1
• 4-6 weeks for persistent bacteremia >72 hours, endocarditis, or suppurative thrombophlebitis 1

Special Pathogen Considerations

Staphylococcus aureus

• Always remove the catheter 1, 4
• Consider transesophageal echocardiography to rule out endocarditis 4, 5
• Evaluate for metastatic infections (septic thrombosis, osteomyelitis) if bacteremia persists >72 hours 4

Candida species

• Remove the catheter immediately 1
• Initiate amphotericin B for hemodynamically unstable patients or fluconazole for stable patients with susceptible organisms 1
• Treat for 14 days after the last positive blood culture 1

Gram-negative bacilli

• Remove the catheter for Pseudomonas species (other than P. aeruginosa), Burkholderia cepacia, Stenotrophomonas, and Acinetobacter baumannii, especially if bacteremia continues despite appropriate therapy 1

Critical Pitfalls to Avoid

• Never leave a peripheral IV catheter in place when infection is suspected—removal is the cornerstone of treatment 1
• Do not use topical antibiotic ointment at insertion sites (except for dialysis catheters) due to risk of promoting fungal infections and antimicrobial resistance 1
• Avoid prolonged IV fluid infusion >24 hours and lower extremity insertion sites, as these significantly increase infection risk 3

Prevention Strategies

• Replace peripheral IV catheters inserted during emergencies within 48 hours 1
• Use chlorhexidine-based skin preparation (>0.5% with alcohol) before insertion 1, 4
• Change gauze dressings every 2 days and transparent dressings every 7 days 1
• Remove any catheter that is no longer essential 1