What is the approach to treating central line-associated bloodstream infection (CLABSI) due to Coagulase-Negative Staphylococci (CONS) in patients with End-Stage Renal Disease (ESRD)?

Treatment of CONS-CLABSI in ESRD Patients

For ESRD patients on hemodialysis with CONS-CLABSI, administer vancomycin 20 mg/kg (actual body weight) after each dialysis session, attempt catheter salvage with antibiotic lock therapy only if the patient is hemodynamically stable and has no tunnel infection, and remove the catheter immediately if bacteremia persists beyond 72 hours. 1, 2

Initial Catheter Management Decision

The decision to retain or remove the hemodialysis catheter in ESRD patients with CONS-CLABSI differs from general populations because the catheter serves as both the infection source and the essential vascular access for ongoing dialysis 1:

• Attempt catheter salvage if the patient is hemodynamically stable, has no signs of tunnel infection, no port pocket infection, and has limited venous access options 2
• Remove the catheter immediately if any of the following are present: severe sepsis or septic shock, tunnel or port pocket infection, persistent bacteremia >72 hours despite appropriate antibiotics, erythema/purulence/induration at the exit site, or suppurative thrombophlebitis 1, 2
• Intravenous antibiotics alone without catheter removal have a 5-fold higher failure rate in hemodialysis patients compared to those who undergo catheter removal 1

Antibiotic Selection and Dosing for ESRD

Vancomycin is the first-line agent with specific dosing requirements for hemodialysis patients 1, 2:

• Loading dose: 20 mg/kg (actual body weight) administered during the last hour of dialysis 1
• Maintenance dose: 500 mg during the last 30 minutes of each subsequent dialysis session 1
• Target trough levels: 15-20 mcg/mL 2
• Vancomycin is preferred because its pharmacokinetic characteristics permit dosing after each dialysis session 1

Alternative agents if vancomycin resistance or intolerance 1, 3:

• Daptomycin: 6 mg/kg after each dialysis session for vancomycin-resistant organisms 1, 3
• Consider daptomycin in institutions where CONS isolates show vancomycin MIC >1 mg/mL 2
• Daptomycin protein binding decreases in ESRD patients (86% in hemodialysis vs 90-93% in normal renal function), but dosing remains 6 mg/kg post-dialysis 3

Critical dosing principle: Avoid aminoglycosides entirely in ESRD patients due to irreversible ototoxicity risk 1

Antibiotic Lock Therapy for Catheter Salvage

When attempting catheter salvage in ESRD patients, combine systemic antibiotics with antibiotic lock therapy 2, 4:

• Vancomycin lock solution should be instilled into the catheter lumen between dialysis sessions 2, 4
• Antimicrobial lock solutions have demonstrated HD-CLABSI rate reductions in 94% of studies (32 of 34 studies) 4
• Teicoplanin can be used as an alternative lock solution administered once daily 2
• Lock therapy should only be attempted once—if recurrent CONS-CLABSI occurs despite prior salvage therapy, catheter removal is mandatory 2

Duration of Antibiotic Therapy

Treatment duration depends on catheter management and clinical response 1, 2:

• If catheter is removed: 7-10 days of systemic vancomycin 2
• If catheter is retained with salvage attempt: 10-14 days of systemic vancomycin combined with antibiotic lock therapy 1, 2
• If persistent bacteremia >72 hours or complications develop: Extend to 4-6 weeks 1
• For patients with endocarditis or suppurative thrombophlebitis: 4-6 weeks 1
• For osteomyelitis: 6-8 weeks 1

Monitoring Requirements

Blood culture protocol specific to hemodialysis patients 1, 2:

• Obtain paired blood cultures before starting antibiotics (from catheter and peripheral vein if possible, though peripheral access may be limited in ESRD patients) 1
• Repeat blood cultures 48-72 hours after initiating therapy to document clearance 2
• Remove catheter if cultures remain positive at 72 hours 2
• Surveillance blood cultures 1 week after completing antibiotics if catheter was retained 1

Vancomycin monitoring: Check trough levels to maintain 15-20 mcg/mL 2

Catheter Replacement Strategy

When catheter removal is required in ESRD patients 1:

• Do not perform guidewire exchange in the setting of active bacteremia 1
• Place new long-term dialysis catheter at a different anatomical site 1
• Wait until blood cultures are negative before placing new long-term access if clinically feasible 1, 2
• Temporary dialysis access may be needed during the treatment period 1

Success Rates and Salvage Limitations

Catheter salvage outcomes vary significantly 2:

• Success rates for CONS catheter salvage range from 46% in neonates to 93% in adults 2
• Recurrence rates can reach 8% over 4 months even with successful initial salvage 2
• Critical pitfall: Salvage should only be attempted once—repeated salvage attempts are not recommended 2

Common Pitfalls in ESRD Patients

Avoid these errors that increase morbidity and mortality 1, 2:

• Never use aminoglycosides in hemodialysis patients due to irreversible ototoxicity risk 1
• Do not delay catheter removal if bacteremia persists beyond 72 hours, as this increases risk of metastatic complications including endocarditis and osteomyelitis 1, 2
• Do not attempt repeated salvage therapy—if the first salvage attempt fails or infection recurs, catheter removal is mandatory 2
• Do not dose vancomycin on non-dialysis days unless trough levels indicate need for supplemental dosing 1
• It is not necessary to confirm negative culture results before guidewire exchange if the patient is asymptomatic, though this practice is generally discouraged in active bacteremia 1