What is the treatment for a patient with a central line-associated bloodstream infection (CLABSI) due to Coagulase-Negative Staphylococci (CONS)?

Treatment of CONS-Associated Central Line Infections

For coagulase-negative staphylococci (CONS) central line-associated bloodstream infections in clinically stable patients, attempt catheter salvage with systemic vancomycin therapy (10-14 days) combined with antibiotic lock therapy, but remove the catheter immediately if bacteremia persists beyond 72 hours of appropriate treatment. 1, 2, 3

Initial Management Decision

The critical first step is determining whether to salvage or remove the catheter:

• Attempt catheter retention if the patient is hemodynamically stable, has no signs of tunnel/port pocket infection, and has limited venous access options 4, 1
• Remove the catheter immediately if any of the following are present:
  • Severe sepsis or septic shock 1, 3
  • Tunnel infection or port pocket infection 4, 3
  • Persistent bacteremia >72 hours despite appropriate antibiotics 4, 1, 3
  • Erythema, purulence, or induration at the exit site 3
  • Suppurative thrombophlebitis or endocarditis 4, 3

Antibiotic Therapy

Systemic vancomycin is the treatment of choice for CONS-CLABSI:

• Administer vancomycin 15-20 mg/kg IV every 8-12 hours, maintaining trough levels at 15-20 mcg/mL 1, 2
• In institutions with methicillin-resistant isolates showing vancomycin MIC >1 mg/mL, consider alternative agents like daptomycin 4
• Duration depends on catheter management:
  • 7-10 days if catheter is removed 1, 3
  • 10-14 days if catheter is retained, combined with antibiotic lock therapy 4, 1, 2

Antibiotic Lock Therapy

When attempting catheter salvage:

• Use vancomycin as catheter lock therapy in addition to systemic antibiotics 4
• Teicoplanin is an alternative that can be administered once daily as a line lock 4
• This combined approach increases salvage success rates, though 20% of cases will still fail 4

Monitoring and Follow-Up

Obtain repeat blood cultures to guide management:

• Draw paired cultures (one from catheter, one peripheral) before starting antibiotics 1, 3
• Differential time to positivity ≥2 hours strongly suggests catheter-related infection 4, 3
• Repeat cultures 48-72 hours after initiating therapy to document clearance 2, 3
• If cultures remain positive at 72 hours, remove the catheter 4, 1, 2

Special Considerations for Salvage Failure

Catheter retention carries specific risks:

• Success rates for CONS catheter salvage range from 46% in neonates to 93% in adults, but recurrence rates can reach 8% over 4 months 4
• Salvage should only be attempted once—if recurrent CONS-CLABSI occurs despite prior salvage therapy, remove the catheter and place new access at a different site 2
• Catheter retention is a significant risk factor for recurrence even when initial bacteremia resolves 4

When Catheter Removal is Required

If removal becomes necessary:

• Place new catheter at a different anatomical site—avoid guidewire exchange in the setting of active bacteremia 2, 3
• Wait until blood cultures are negative before placing new long-term access if clinically feasible 2
• Complete 7-10 days of systemic vancomycin after catheter removal 1, 3
• Obtain blood cultures one week after completing therapy to confirm eradication 2

Common Pitfalls to Avoid

• Do not attempt repeated salvage therapy—if the first salvage attempt fails or infection recurs, catheter removal is mandatory 2
• Do not delay catheter removal if bacteremia persists beyond 72 hours, as this increases risk of metastatic complications 4, 2, 3
• Do not use guidewire exchange for catheter replacement in the setting of active CONS bacteremia 4, 2
• Do not rely on systemic antibiotics alone when attempting salvage—antibiotic lock therapy is essential 4, 1