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

Management of Catheter-Related Bloodstream Infections (CRBSI)

Remove the catheter immediately and start empirical antibiotics after obtaining paired blood cultures from both the catheter and a peripheral vein, particularly when S. aureus, Pseudomonas, Candida species are suspected, or when the patient shows severe sepsis, purulence at the insertion site, or hemodynamic instability. 1, 2

Diagnostic Approach

Obtain paired blood cultures simultaneously from both the catheter hub and a peripheral vein before initiating any antimicrobial therapy 1, 2, 3. This is non-negotiable for proper diagnosis.

• Disinfect the catheter hub with alcohol, alcoholic chlorhexidine (>0.5%), or tincture of iodine before drawing cultures 1, 2
• A differential time to positivity (DTP) ≥2 hours between catheter and peripheral blood cultures is highly sensitive and specific for CRBSI 1, 3, 4
• Growth of >15 CFU from a 5-cm catheter tip segment (semiquantitative culture) or >10² CFU (quantitative culture) confirms catheter colonization 3

Immediate Catheter Removal Indications

The catheter must be removed immediately in the following situations 1, 2, 3:

• Erythema, purulence, or induration at the exit site 1
• Clinical signs of septic shock or severe sepsis 1
• Tunnel infection or port pocket infection 1, 2, 3
• Persistent bacteremia/fungemia >72 hours despite appropriate antibiotics 1
• S. aureus infection (mandatory removal) 1, 2, 3
• Candida species infection (mandatory removal) 1, 2, 3
• Pseudomonas infection (mandatory removal) 1

When Catheter Retention May Be Considered

Catheter retention is acceptable only for coagulase-negative staphylococci in clinically stable patients with limited venous access, using systemic antibiotics with or without antibiotic lock therapy 1, 2. This is the sole exception to aggressive catheter management.

Empirical Antimicrobial Therapy

Start empirical therapy immediately after obtaining cultures 1, 2, 3:

Gram-Positive Coverage

• Vancomycin for settings with elevated MRSA prevalence 1, 2
• In low MRSA prevalence areas, an anti-staphylococcal beta-lactam may be first-line 3

Gram-Negative Coverage (Add for)

• Severe illness or hemodynamic instability 1
• Septic shock 1
• Neutropenic or immunocompromised patients 3
• Femoral catheterization 3
• Use extended-spectrum penicillin, cephalosporin, or carbapenem based on local antibiogram 3

Antifungal Coverage (Add for)

• Total parenteral nutrition use 1
• Prolonged broad-spectrum antibiotic exposure 1
• Hematologic malignancy or bone marrow/solid organ transplant 1
• Femoral catheterization 1

Pathogen-Specific Treatment Duration

S. aureus

• Minimum 10-14 days IV antibiotics after catheter removal for uncomplicated infections 1, 2
• 4-6 weeks IV antimicrobial therapy for complicated infections (endocarditis, septic thrombophlebitis, osteomyelitis) 1
• Obtain transesophageal echocardiography (TEE) to rule out endocarditis 2

Gram-Negative Organisms

• 10-14 days IV antibiotics after catheter removal 1, 2

Candida Species

• Mandatory catheter removal plus 14 days of antifungal therapy after first negative blood culture and symptom resolution 1, 2

Coagulase-Negative Staphylococci

• 10-14 days with catheter removal 2
• If catheter retained: systemic therapy ± antibiotic lock 1

Special Population: Neutropenic Cancer Patients

• Remove catheter plus ≥14 days systemic therapy for S. aureus, P. aeruginosa, fungi, or mycobacteria 1
• Catheter may be retained with systemic therapy ± antibiotic lock for coagulase-negative staphylococci 1

Common Pitfalls to Avoid

• Never start antibiotics before obtaining paired blood cultures 2, 3 - this is the most common error that compromises diagnosis
• Do not delay catheter removal for S. aureus, Pseudomonas, or Candida infections 2 - waiting increases mortality risk 4
• Avoid routine replacement of CVCs as a prevention strategy - this does not reduce infection rates 2, 3
• Do not underestimate the mortality risk - CRBSI is an independent risk factor for in-hospital mortality (adjusted OR: 1.93) 4

Prevention Strategies for Future Lines

Insertion Bundle

• Hand hygiene and maximal sterile barrier precautions 1, 3, 5
• Chlorhexidine >0.5% with alcohol for skin antisepsis 1, 3
• Subclavian site preferred over jugular or femoral 1, 2, 3

Maintenance Bundle

• Replace transparent dressings and perform site care with chlorhexidine-based antiseptic every 7 days 1
• Disinfect catheter hubs before each access 1
• Daily evaluation of line necessity for prompt removal 6, 7
• Proper hand hygiene remains the single most crucial nursing intervention 5