In a hemodialysis patient with an internal jugular dialysis catheter colonized by Pseudomonas aeruginosa, still febrile during dialysis, currently receiving cefepime and awaiting final culture and sensitivity results, and with no alternative vascular access, should the catheter be removed or exchanged, and what is the optimal antimicrobial management?

Management of Pseudomonas aeruginosa Hemodialysis Catheter-Related Bloodstream Infection

The internal jugular catheter must be removed immediately and a temporary catheter inserted at a different anatomical site, as Pseudomonas aeruginosa catheter-related bloodstream infection (CRBSI) in hemodialysis patients requires mandatory catheter removal according to IDSA guidelines. 1

Immediate Catheter Management

Remove the IJ catheter now—do not wait for final culture results. The preliminary identification of Pseudomonas aeruginosa is sufficient to mandate removal, and the patient's persistent chills during dialysis indicate ongoing infection despite cefepime therapy. 1

Catheter Removal Strategy:

• Insert a new temporary (nontunneled) catheter at a completely different anatomical site (e.g., contralateral IJ, subclavian, or femoral vein). 1, 2
• Only if absolutely no alternative sites exist should you consider guidewire exchange, though this is suboptimal for Pseudomonas CRBSI. 1
• Do not place a new long-term catheter until blood cultures are negative, which typically requires 48-72 hours after catheter removal and appropriate antibiotic therapy. 1, 3

Why Catheter Removal is Non-Negotiable:

The IDSA guidelines provide A-II level evidence that hemodialysis CRBSI due to Pseudomonas species requires catheter removal, with catheter salvage success rates being unacceptably low (typically <40% even with combination therapy). 1 Your patient's persistent symptoms during dialysis despite cefepime therapy further confirms treatment failure with the catheter in place. 1

Antimicrobial Management

Current Cefepime Assessment:

Cefepime is appropriate empiric coverage for Pseudomonas aeruginosa, but you must verify the dosing is adequate for hemodialysis patients. 1

• Standard dosing for hemodialysis patients: 1-2 grams after each dialysis session (typically every 48 hours for thrice-weekly dialysis). 4, 5
• Critical consideration: Cefepime is significantly removed during high-flux dialysis, and inadequate dosing may explain persistent symptoms. 5
• Adjust based on final susceptibility results once available—if the MIC is ≥8 mcg/mL, consider adding an aminoglycoside or switching to a different agent. 4, 6

Combination Therapy Consideration:

Add tobramycin or amikacin to cefepime if the patient remains clinically unstable after catheter removal. 1, 4

• Combination therapy significantly enhances killing of Pseudomonas aeruginosa, particularly mucoid strains. 4, 6
• For hemodialysis patients, aminoglycosides should be dosed after dialysis sessions with monitoring of trough levels. 1
• Monotherapy with cefepime may be insufficient for mucoid Pseudomonas strains despite adequate drug concentrations. 4

Alternative Agents if Cefepime-Resistant:

• Carbapenem (meropenem 500-1000 mg after each dialysis session) if cefepime MIC is elevated or patient fails to improve. 1
• Piperacillin-tazobactam (dosing adjusted for hemodialysis) is another option based on susceptibilities. 1

Duration of Antimicrobial Therapy

Treat for 14 days total after catheter removal if blood cultures clear within 72 hours and no metastatic complications exist. 1

Extended Therapy Indications:

• 4-6 weeks of therapy if bacteremia persists >72 hours after catheter removal, or if endocarditis or suppurative thrombophlebitis develops. 1, 2
• 6-8 weeks if osteomyelitis or other metastatic infection is identified. 1

Monitoring Requirements:

• Obtain repeat blood cultures 48-72 hours after catheter removal to document clearance. 1, 3
• Do not place a long-term catheter until negative blood cultures are confirmed. 1, 3

Critical Pitfalls to Avoid

Do Not Attempt Catheter Salvage:

The 2017 ACR guidelines explicitly state that catheter preservation may be attempted for certain organisms in clinically stable patients, but Pseudomonas aeruginosa is specifically excluded from salvage attempts due to high failure rates and risk of metastatic complications. 1

Do Not Delay Catheter Removal:

Your patient has persistent symptoms (chills during dialysis) despite antibiotic therapy, which indicates treatment failure. The risk of developing endocarditis, vertebral osteomyelitis, or other metastatic infections increases significantly with each additional day the infected catheter remains in place. 1, 7

Femoral Site Caution:

If you must use a femoral site for temporary access, remove and replace it within 7 days as femoral catheters have a 3.1-fold higher risk of bacteremia compared to internal jugular catheters. 7, 8

Exit Site Monitoring:

After placing the new temporary catheter, remove it immediately if exit site infection develops, as the risk of bacteremia increases from 1.9% on day 1 to 13.4% by day 2 of exit site infection. 7

Vascular Access Planning

Urgently consult vascular surgery or interventional radiology for permanent access creation (arteriovenous fistula or graft) to eliminate dependence on central venous catheters, which carry ongoing infection risk. 1

• Temporary catheters should be viewed as a bridge to permanent access, not a long-term solution. 1
• Internal jugular site preservation for future access should be considered when obtaining peripheral blood cultures (avoid hand veins that may be needed for fistula creation). 1