What are the latest guidelines for changing a central venous catheter (CVC)?

Central Venous Catheter Replacement Guidelines

Do not routinely replace central venous catheters on a scheduled basis to prevent infection—replacement should only occur when clinically indicated, such as catheter malfunction, confirmed infection with specific organisms, or when the catheter is no longer needed. 1

Routine Scheduled Replacement: Not Recommended

• Routine replacement of CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections is not recommended. 1
• Scheduled replacement every 3 or 7 days does not reduce infection rates per day of catheter use, though it may decrease infections per catheter inserted. 2
• The daily risk of CVC infection remains constant regardless of scheduled replacement, making routine changes ineffective at reducing overall infection burden. 2
• Routine replacement at new sites increases mechanical complications (approximately 3% per insertion), including pneumothorax, arterial puncture, and bleeding. 2, 3

Guidewire Exchange: Limited Indications Only

Guidewire exchanges should not be used routinely for infection prevention and are contraindicated when infection is suspected. 1, 4

When Guidewire Exchange Is Acceptable:

• Only for replacing a malfunctioning non-tunneled catheter when there is no evidence of infection. 1, 4
• Use new sterile gloves before handling the new catheter during guidewire exchanges. 1
• Always verify the guidewire has been completely removed after the procedure to prevent retained guidewire complications. 4

When Guidewire Exchange Is Contraindicated:

• Never use guidewire exchange to replace a catheter suspected of infection—this increases the risk of catheter-related bloodstream infection. 1, 4
• Guidewire-assisted exchanges are associated with higher rates of catheter colonization and bloodstream infection compared to new site insertion (6% vs 0% after 3 days). 3

When to Remove and Replace CVCs

Non-Tunneled CVCs (Short-Term):

Mandatory removal indications: 1

• Evident signs of local infection at the exit site (erythema, pus) 1
• Clinical signs of sepsis or septic shock 1
• Positive culture of catheter exchanged over guidewire 1
• Positive paired blood cultures (peripheral and catheter) 1

Do not remove based on fever alone—use clinical judgment to assess for other infection sources or non-infectious causes of fever. 1

Organism-Specific Removal Guidelines:

Staphylococcus aureus:

• Catheter must be removed immediately with systemic antibiotic therapy for minimum 14 days. 1
• Transesophageal echocardiography (TEE) is indicated due to 25-32% risk of endocarditis, performed at 5-7 days after bacteremia onset unless cultures and clinical assessment are negative at 72 hours. 1

Candida (fungal infection):

• Catheter must be removed immediately and antifungal therapy initiated. 1, 5

Pseudomonas:

• Catheter should be removed. 5

Coagulase-negative Staphylococcus:

• Catheter salvage may be attempted with systemic antibiotics for 10-14 days plus antibiotic lock therapy if no complications present. 1

Enterococcus:

• Catheter can be retained with systemic antibiotic therapy (ampicillin preferred, vancomycin for resistance). 1

Gram-negative bacilli:

• Systemic antibiotic therapy indicated; antibiotic lock therapy should be used if catheter salvage attempted. 1

Long-Term Venous Access Devices (Tunneled CVCs, Ports):

Mandatory removal indications: 1

• Tunnel infection or port abscess 1
• Clinical signs of septic shock 1
• Positive blood cultures for fungi or highly virulent bacteria 1
• Complicated infection (endocarditis, septic thrombosis, metastatic infections) 1

Catheter salvage may be attempted in uncomplicated infections using antibiotic lock technique for 2 weeks combined with systemic therapy. 1

Clinical Indications for Replacement

Replace when: 5, 6

• Catheter is no longer clinically necessary (evaluate daily) 5
• Catheter malfunction that cannot be resolved 1, 4
• Confirmed catheter-related thrombosis worsening despite anticoagulation 6
• Persistent bacteremia/fungemia despite appropriate antimicrobial therapy after 72 hours 1

After removal for infection:

• Non-tunneled catheters may be reinserted at a new site after appropriate systemic antimicrobial therapy is begun. 1
• If persistent bacteremia occurs, aggressively evaluate for septic thrombosis, endocarditis, and metastatic infections before reinsertion. 1

Key Pitfalls to Avoid

• Never perform routine prophylactic guidewire replacement—it provides no benefit and increases complications. 4, 2, 3
• Never attempt guidewire exchange when infection is suspected—always use a new insertion site. 1, 4
• Do not remove CVCs based solely on fever—obtain blood cultures and assess for other infection sources first. 1
• Do not delay removal when S. aureus, Candida, or Pseudomonas are identified—these require immediate catheter removal. 1, 5