What is the management approach for Central Line-Associated Bloodstream Infections (CLABSI)?

Management of Catheter-Related Bloodstream Infections (CRBSI)

For suspected CRBSI, obtain paired blood cultures from both the catheter and a peripheral vein before starting antibiotics, then immediately remove short-term non-tunneled central lines if the patient has severe sepsis, erythema/purulence at the insertion site, or if cultures grow S. aureus, Pseudomonas, or Candida species. 1, 2

Diagnostic Approach

Obtain diagnostic cultures before any antimicrobial therapy:

• Draw paired blood cultures simultaneously from the catheter hub and a peripheral vein 1, 2
• Disinfect catheter hubs with alcohol, alcoholic chlorhexidine (>0.5%), or tincture of iodine before drawing 2
• A differential time to positivity (DTP) ≥2 hours (catheter sample grows ≥2 hours before peripheral sample) is highly sensitive and specific for CRBSI 1, 2, 3
• Alternatively, quantitative cultures showing ≥3-fold higher colony count from catheter versus peripheral sample confirms CRBSI 1, 2
• If the catheter is removed, culture the tip using semi-quantitative (>15 CFU) or quantitative (>10² CFU) methods 4

Immediate Catheter Management Decision

Remove the catheter immediately in these situations:

• Erythema, purulence, or induration at the exit site 1
• Clinical signs of septic shock or severe sepsis 1, 2
• Tunnel infection or port pocket infection 1, 2, 4
• Persistent bacteremia/fungemia >72 hours despite appropriate antibiotics 1, 3

Pathogen-specific mandatory removal:

• S. aureus—always remove the catheter 1, 2, 4, 3
• Pseudomonas aeruginosa—always remove the catheter 1, 4, 3
• Candida species—always remove the catheter 1, 2, 4, 3
• Mycobacteria—always remove the catheter 1

Catheter retention may be considered only for:

• Coagulase-negative staphylococci in clinically stable patients with limited venous access 1, 2, 3
• Use systemic antibiotics with or without antibiotic lock therapy 1, 3

Critical pitfall: Attempting catheter salvage with S. aureus, Pseudomonas, or Candida dramatically increases mortality and risk of endocarditis, septic thrombosis, and metastatic infections 1, 3. The evidence is unequivocal—these pathogens require immediate catheter removal.

Empirical Antimicrobial Therapy

Start empirical therapy immediately after obtaining cultures:

• Vancomycin for gram-positive coverage in settings with elevated MRSA prevalence 2, 4, 3
• In low MRSA prevalence areas, an anti-staphylococcal beta-lactam (nafcillin, oxacillin, cefazolin) is acceptable 4
• Switch to daptomycin if vancomycin MIC >2 μg/mL or in institutions with high prevalence of vancomycin-resistant strains 3

Add gram-negative coverage for:

• Severe illness, hemodynamic instability, or septic shock 4, 3
• Neutropenic or immunocompromised patients 4, 3
• Femoral catheter insertion site 4, 3
• Use extended-spectrum penicillin, cephalosporin, or carbapenem based on local antibiogram 4

Add empirical antifungal therapy (echinocandin preferred) for:

• Total parenteral nutrition use 3
• Prolonged broad-spectrum antibiotic exposure 3
• Hematologic malignancy or bone marrow/solid organ transplant 3
• Femoral catheterization 3

Pathogen-Specific Treatment Duration

Coagulase-negative staphylococci:

• With catheter removal: 5-7 days IV antibiotics 3
• With catheter retention: 10-14 days IV antibiotics plus antibiotic lock therapy 3

S. aureus (uncomplicated):

• Minimum 10-14 days IV antibiotics after catheter removal and first negative blood culture 1, 2, 3
• Obtain transesophageal echocardiography (TEE) to rule out endocarditis—S. aureus has high rates of complicating endocarditis 1, 2

S. aureus (complicated—endocarditis, septic thrombosis, osteomyelitis, persistent bacteremia):

• 4-6 weeks of IV antimicrobial therapy 1, 3

Gram-negative organisms (Pseudomonas, Enterobacteriaceae):

• 10-14 days IV antibiotics after catheter removal 1

Candida species:

• Mandatory catheter removal plus 14 days of antifungal therapy after first negative blood culture and symptom resolution 4, 3

Critical pitfall: Inadequate treatment duration for S. aureus CRBSI leads to relapse and metastatic complications. Always obtain TEE and treat for minimum 10-14 days even if uncomplicated 1, 2.

Special Populations

Neutropenic patients with cancer:

• Differential time to positivity >120 minutes suggests CLABSI 1
• For S. aureus, P. aeruginosa, fungi, or mycobacteria: remove catheter plus ≥14 days systemic therapy 1
• For coagulase-negative staphylococci: catheter may be retained with systemic therapy ± antibiotic lock 1

Neonatal intensive care unit:

• CLABSI rates are 2.6-60 per 1000 catheter-days in resource-limited settings versus 2.9 per 1000 in the US 1
• Mortality related to bloodstream infections is 21% in neonates 1
• Indications for catheter removal are similar to adults unless no alternative access exists 3

Hemodialysis patients:

• Always remove catheter for S. aureus, Pseudomonas, or Candida infections 3

Prevention Strategies (Brief Overview)

Insertion bundle:

• Hand hygiene and maximal sterile barrier precautions 1, 2, 4
• Chlorhexidine >0.5% with alcohol for skin antisepsis 2, 4
• Subclavian site preferred over jugular or femoral 2, 4

Maintenance bundle:

• Replace transparent dressings and perform site care with chlorhexidine-based antiseptic every 7 days 1
• Gauze dressings every 2 days 1
• Disinfect catheter hubs before each access 1
• Use needleless connectors instead of three-way stopcocks 1

What NOT to do:

• Do not routinely replace CVCs as a prevention strategy—this does not reduce infection rates 1, 4
• Do not use antimicrobial prophylaxis during insertion or while catheters are in place 1
• Do not use antibiotic lock therapy routinely for prevention—evidence shows it is ineffective except possibly in neutropenic patients with long-term access 1