What are the Infectious Diseases Society of America (IDSA) guidelines for treating Central Line-Associated Bloodstream Infections (CLABSI)?

IDSA Guidelines for Central Line-Associated Bloodstream Infections (CRBSI/CLABSI)

Immediate Catheter Management

Remove the catheter immediately for short-term catheters infected with gram-negative bacilli, S. aureus, enterococci, fungi, or mycobacteria. 1

Remove long-term catheters immediately if any of the following are present: 1

• Severe sepsis or hemodynamic instability
• Suppurative thrombophlebitis
• Endocarditis
• Bloodstream infection persisting >72 hours despite appropriate antimicrobial therapy
• Infections caused by S. aureus, P. aeruginosa, fungi, or mycobacteria
• Tunnel infection or port pocket infection

Catheter retention may be attempted only for uncomplicated CRBSI in long-term catheters caused by pathogens OTHER than S. aureus, P. aeruginosa, Bacillus species, Micrococcus species, Propionibacteria, fungi, or mycobacteria, using both systemic antibiotics AND antibiotic lock therapy. 1 This applies primarily to patients with limited venous access (hemodialysis patients, short-gut syndrome). 1

If catheter salvage is attempted, obtain repeat blood cultures at 72 hours and remove the catheter if cultures remain positive. 1

Empirical Antimicrobial Therapy

Initiate vancomycin 15-20 mg/kg IV every 8-12 hours PLUS an anti-pseudomonal beta-lactam (cefepime, piperacillin-tazobactam, or meropenem) immediately after obtaining blood cultures. 2, 3

Add empirical antifungal coverage (echinocandin preferred) for patients with: 1, 2

• Total parenteral nutrition use
• Prolonged broad-spectrum antibiotic exposure
• Hematologic malignancy or transplant recipients
• Femoral catheterization
• Candida colonization at multiple sites

For femoral catheters in critically ill patients, empirical coverage must include gram-negative bacilli and Candida species. 1

Use fluconazole for empirical candidemia treatment only if: no azole exposure in the previous 3 months AND healthcare setting has very low risk of C. krusei or C. glabrata. 1

Diagnostic Approach

Obtain at least 2 sets of blood cultures: one from the catheter hub and one from a peripheral vein before initiating antibiotics. 2, 3

For a single positive blood culture growing coagulase-negative Staphylococcus, obtain additional cultures from both the catheter and peripheral vein before starting antibiotics or removing the catheter to confirm true bloodstream infection. 1

Differential time to positivity (DTP) ≥120 minutes between catheter and peripheral cultures strongly suggests CRBSI. 2, 3

Duration of Antimicrobial Therapy

For uncomplicated CRBSI after catheter removal: 2, 3, 4

• S. aureus: minimum 14 days
• Gram-negative organisms: 10-14 days
• Coagulase-negative staphylococci: 7-10 days
• Candida species: 14 days after first negative blood culture

For complicated CRBSI (persistent bacteremia >72 hours, endocarditis, suppurative thrombophlebitis): 4-6 weeks of therapy. 1, 4

For osteomyelitis: 4-6 weeks in pediatric patients; 6-8 weeks in adults. 1

Pathogen-Specific Management

For S. aureus CRBSI: 2, 3

• Always remove the catheter
• Obtain transesophageal echocardiography to exclude endocarditis
• Minimum 14 days therapy; 4-6 weeks if complicated

For P. aeruginosa CRBSI: Always remove the catheter. 1, 2

For Candida CRBSI: Always remove the catheter and use echinocandin as initial therapy. 2, 3

For coagulase-negative staphylococci in long-term catheters: Catheter retention may be attempted with systemic antibiotics plus antibiotic lock therapy in clinically stable patients. 2, 3

Antibiotic Lock Therapy

Use antibiotic lock therapy for catheter salvage attempts. 1 If antibiotic lock therapy cannot be used, administer systemic antibiotics through the colonized catheter. 1

Special Populations

Hemodialysis patients: 1, 4

• Remove infected catheter for S. aureus, Pseudomonas species, or Candida species
• Insert temporary catheter at a different anatomical site
• Exchange over guidewire only if absolutely no alternative sites exist
• Obtain peripheral blood cultures from vessels not intended for future fistula creation

Pediatric patients: 1

• Indications for catheter removal are similar to adults
• Antibiotic lock therapy should be used for catheter salvage attempts
• Monitor closely with repeat blood cultures if catheter is retained

Critical Pitfalls to Avoid

Do NOT use urokinase or other thrombolytic agents as adjunctive therapy for CRBSI. 1

Do NOT exchange catheters over a guidewire except in rare circumstances where no alternative vascular sites exist and the patient has increased bleeding risk without exit site or tunnel infection. 1

Do NOT delay catheter removal in patients with severe sepsis, persistent positive cultures at 72 hours, or high-risk pathogens (S. aureus, P. aeruginosa, fungi, mycobacteria). 1