What is the management approach for a patient with central line associated sepsis (CLAS)?

Management of Central Line-Associated Sepsis

Remove the central line promptly after establishing alternative vascular access and initiate broad-spectrum IV antimicrobials within one hour of recognition, as each hour of delay increases mortality by 7.6%. 1, 2

Immediate Actions (Within First Hour)

Source Control - Central Line Removal

• Remove the infected central line as soon as alternative vascular access is secured 1
• Remove immediately if any of the following are present: 1
  • Erythema or purulent drainage at the exit site
  • Clinical signs of septic shock
  • Persistent bacteremia/fungemia despite appropriate antimicrobials
  • Positive blood cultures for fungi or highly virulent bacteria (e.g., S. aureus, Candida)
• Do not exchange over a guidewire in the setting of suspected line sepsis 1

Antimicrobial Therapy

• Administer broad-spectrum IV antibiotics within 60 minutes of recognition - this is the single most critical intervention for survival 1, 2
• Empiric regimen should include: 1, 2, 3
  • Vancomycin (for MRSA and coagulase-negative staphylococci coverage)
  • PLUS piperacillin-tazobactam or a carbapenem (for gram-negative coverage including Pseudomonas)
• Use maximum recommended dosages initially given high mortality risk 2

Diagnostic Workup (Do Not Delay Antibiotics)

• Obtain at least two sets of blood cultures before antimicrobials if this causes no delay beyond 45 minutes: 1
  • One set drawn percutaneously
  • One set drawn through the central line (if still in place)
• Measure serum lactate immediately as a marker of tissue hypoperfusion 2
• Culture the removed catheter tip using quantitative or semi-quantitative methods 1

Hemodynamic Resuscitation

Fluid Therapy

• Administer 30 mL/kg IV crystalloid bolus within the first 3 hours for sepsis-induced hypoperfusion or lactate ≥4 mmol/L 1, 4, 2
• Use balanced crystalloids or normal saline as initial fluid of choice 1
• Continue fluid challenges as long as hemodynamic parameters improve (based on blood pressure, heart rate, urine output, capillary refill) 1

Vasopressor Support

• Initiate norepinephrine as first-line vasopressor if hypotension persists after initial fluid resuscitation 1, 4
• Target mean arterial pressure (MAP) ≥65 mmHg 1, 4
• Add epinephrine if additional agent needed to maintain adequate blood pressure 1, 4
• Vasopressin 0.03 units/minute can be added to norepinephrine to raise MAP or decrease norepinephrine dosage 1

Antimicrobial De-escalation and Duration

Reassessment

• Reassess antimicrobial regimen daily for potential de-escalation once culture and susceptibility results are available 1
• Narrow to the most appropriate single agent based on susceptibility profile within 3-5 days 1

Duration of Therapy

• Typical duration: 7-10 days for uncomplicated catheter-related bloodstream infection 1
• Longer courses (4-6 weeks) required for: 1
  • S. aureus bacteremia (obtain transesophageal echocardiography to rule out endocarditis)
  • Persistent bacteremia/fungemia after line removal
  • Complicated infections (endocarditis, septic thrombosis, metastatic infections)
  • Immunocompromised patients or neutropenia

Special Considerations for Long-Term Catheters

For tunneled catheters or implanted ports, attempt catheter salvage with systemic antibiotics ONLY if: 1

• No tunnel infection or port abscess present
• No signs of septic shock
• No fungemia or highly virulent bacteria
• No evidence of endocarditis or septic thrombosis

Mandatory removal criteria for long-term devices: 1

• Tunnel infection or port abscess
• Septic shock
• Fungemia or S. aureus bacteremia
• Complicated infection (endocarditis, septic thrombosis)

Monitoring and Supportive Care

Continuous Monitoring

• Blood pressure, heart rate, respiratory rate, temperature, oxygen saturation 4, 2
• Urine output (target ≥0.5 mL/kg/hour) 4
• Repeat lactate within 2-6 hours if initially elevated 2

Glucose Control

• Target blood glucose ≤180 mg/dL (NOT ≤110 mg/dL, as tight control increases harm) 1, 4
• Monitor glucose every 1-2 hours until stable, then every 4 hours 1, 4

Respiratory Support

• Maintain head of bed elevated 30-45 degrees to prevent ventilator-associated pneumonia 1, 4
• If mechanical ventilation required, use low tidal volume strategy (6 mL/kg predicted body weight) 1, 4

Critical Pitfalls to Avoid

• Never delay antibiotic administration beyond one hour - mortality increases 7.6% per hour of delay 2
• Never exchange the catheter over a guidewire in suspected line sepsis 1
• Do not wait for culture results before starting empiric antimicrobials 1, 2
• Do not continue aggressive fluid resuscitation without hemodynamic response - initiate vasopressors 1, 4
• Do not fail to obtain transesophageal echocardiography for S. aureus bacteremia to rule out endocarditis 1