What is the recommended treatment for a patient with a catheter-related infection and signs of potential sepsis, such as fever, hypotension, or altered mental status?

Management of Catheter-Related Infection with Signs of Sepsis

For patients with catheter-related infection presenting with fever, hypotension, or altered mental status, immediately remove the catheter, obtain blood cultures (at least one peripheral and one from the catheter before removal), and initiate empirical broad-spectrum antibiotics covering both gram-positive and gram-negative organisms. 1

Immediate Actions for Seriously Ill Patients

Catheter Removal

• Remove the catheter immediately if the patient exhibits hypotension, hypoperfusion, or signs of organ failure 1
• Culture the catheter tip using semiquantitative (roll-plate) or quantitative (sonication) methods 1
• Insert a new catheter at a different anatomical site—do not exchange over a guidewire in severely ill patients 1
• For hemodialysis catheters specifically, remove immediately if the patient remains symptomatic beyond 36 hours or is clinically unstable 1

Blood Culture Protocol

• Obtain at least 2 sets of blood cultures before initiating antibiotics 1
• Draw one set from a peripheral site (percutaneous) and one from the catheter before removal 1
• Label each blood culture bottle with the anatomic site or catheter used for collection 1

Empirical Antibiotic Therapy

Initial Regimen

• Start vancomycin PLUS gram-negative coverage immediately for empirical therapy 1, 2, 3
• Gram-negative coverage options include: third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination based on local antibiogram 1, 2
• For neutropenic patients, burn patients, or those with severe sepsis, ensure antipseudomonal coverage (ceftazidime, cefepime, piperacillin/tazobactam, or carbapenem) 3

Antibiotic Adjustment Based on Organism

For Staphylococcus aureus:

• Switch from vancomycin to cefazolin (20 mg/kg actual body weight, rounded to nearest 500-mg increment) if methicillin-susceptible and no β-lactam allergy 1, 2
• Never use vancomycin for β-lactam-susceptible S. aureus—it has higher failure rates and slower bacteremia clearance 1
• Treat for 5-7 days if uncomplicated (fever and bacteremia resolve within 72 hours) 1
• Extend to 4-6 weeks if bacteremia persists >72 hours after catheter removal and appropriate antibiotics, or if endocarditis or septic thrombosis is present 1
• Consider transesophageal echocardiography (TEE) to rule out endocarditis—transthoracic echo has low sensitivity and is inadequate 1

For Coagulase-Negative Staphylococci:

• Remove catheter and treat with systemic antibiotics for 5-7 days if uncomplicated 1
• Extend to 4-6 weeks for complicated infections (endocarditis, thrombophlebitis) 1

For Enterococcus:

• Remove catheter and treat for 7-14 days 1
• For vancomycin-resistant enterococci in dialysis patients, use daptomycin (6 mg/kg after each dialysis session) or linezolid (600 mg every 12 hours) 1

For Gram-Negative Bacilli:

• Remove catheter and treat for 7-14 days 1
• For Pseudomonas species (other than P. aeruginosa), Burkholderia cepacia, Stenotrophomonas, Agrobacterium, or Acinetobacter baumannii, strongly consider catheter removal even with appropriate antibiotics due to high failure rates 1
• Extend to 4-6 weeks if bacteremia persists despite catheter removal and appropriate therapy, especially with underlying valvular heart disease 1

For Candida species:

• Remove catheter immediately—this is mandatory 1
• Use amphotericin B for hemodynamically unstable patients or those with recent fluconazole exposure 1
• Use fluconazole for stable patients without recent azole therapy and fluconazole-susceptible organisms 1
• Treat for 14 days after the first negative blood culture and resolution of symptoms 1
• For Candida krusei, use amphotericin B (fluconazole-resistant) 1

Monitoring and Follow-Up

Assessment for Complications

• If bacteremia or fungemia persists >72 hours despite catheter removal and appropriate antibiotics, aggressively evaluate for: 1
  • Septic thrombosis
  • Infective endocarditis (obtain TEE if not contraindicated)
  • Metastatic infections (osteomyelitis requires 6-8 weeks of therapy)

Repeat Blood Cultures

• Obtain follow-up blood cultures if fever persists or clinical deterioration occurs 1, 2
• For hemodialysis patients, obtain surveillance blood cultures 1 week after completing antibiotics if catheter was retained 1

Common Pitfalls to Avoid

• Never exchange a catheter over a guidewire in severely ill patients with sepsis—this maintains the infected site and increases risk of persistent infection 1
• Do not use vancomycin empirically if β-lactam-susceptible organisms are identified—this promotes vancomycin resistance and has inferior outcomes 1
• Do not retain catheters infected with S. aureus, Pseudomonas species, or Candida species—these organisms have high rates of complications and treatment failure without catheter removal 1
• Do not rely on transthoracic echocardiography alone to exclude endocarditis—TEE is required for adequate sensitivity 1
• Do not place a new permanent catheter until blood cultures are negative for at least 48 hours after antibiotic cessation 1