What are the indications for removal of a permanent (tunneled) catheter?

Indications for Permanent (Tunneled) Catheter Removal

Remove a tunneled dialysis catheter immediately if the patient has catheter-related bacteremia with clinical instability, persistent symptoms beyond 36 hours of appropriate antibiotics, tunnel or exit site infection unresponsive to therapy, or infection with high-risk organisms like S. aureus or Candida species. 1

Infection-Related Indications

Catheter-Related Bacteremia (Most Critical)

Mandatory removal scenarios:

• Patient remains symptomatic (fever, hemodynamic instability) after 36 hours of appropriate antibiotic therapy 1
• Any clinically unstable patient with suspected catheter-related bacteremia 1
• Bacteremia with tunnel tract involvement - this always requires catheter removal 1
• Persistent bacteremia ≥72 hours despite appropriate antibiotics 2

Organism-specific removal indications:

• S. aureus bacteremia - nontunneled catheters should be removed immediately; tunneled catheters should be removed if tunnel/pocket/exit-site infection present, or removed in most cases given high risk of metastatic complications including endocarditis 1, 2
• Candida species - requires immediate catheter removal plus antifungals for 14 days after last positive blood culture 2
• Pseudomonas species (non-aeruginosa), Burkholderia cepacia, Stenotrophomonas, Agrobacterium, Acinetobacter baumannii - serious consideration for removal, especially if bacteremia continues despite therapy 1
• Bacillus and Corynebacterium species - vast majority require catheter removal 1
• Mycobacteria (M. fortuitum, M. chelonae) - require catheter removal 1
• Enterobacter cloacae - remove if patient remains symptomatic after 36 hours, is clinically unstable, or has tunnel infection 3

Exit Site and Tunnel Infections

Exit site infection alone (redness, crusting, exudate without systemic symptoms):

• Apply topical antibiotics with proper local care; do not remove catheter 1

Tunnel drainage with exit site infection:

• Treat with parenteral antibiotics (anti-staphylococcal, anti-streptococcal)
• Remove catheter only if infection fails to respond to therapy 1
• Replace using different tunnel and exit site if removal needed 1

Port pocket abscess or tunnel infection:

• Immediate removal required plus 7-10 days of antibiotics and incision/drainage if indicated 2

Complicated Infections Requiring Removal

• Septic thrombosis - requires removal and 4-6 weeks of antibiotics 2
• Endocarditis - requires removal and 4-6 weeks of antibiotics 2
• Septic emboli - requires catheter removal 1
• Metastatic infection - requires removal 3

Catheter Salvage Approach (Limited Scenarios)

Salvage may be attempted only in highly selected stable patients:

• Uncomplicated coagulase-negative staphylococcal bacteremia in hemodynamically stable patients without tunnel/pocket infection 2
• Stable, asymptomatic patient without exit site or tunnel involvement who becomes afebrile within 48 hours of antibiotics - may consider guidewire exchange plus 3 weeks systemic antibiotics 1, 3
• Combine systemic antibiotics with antibiotic lock therapy for 2 weeks 2

Treatment failure mandates removal:

• Persistent fever, persistent positive blood cultures, or relapse after antibiotics discontinued 1

Non-Infectious Indications

Catheter No Longer Needed

• Remove catheter promptly once permanent access (AV fistula or graft) is functional 4, 5
• Delayed removal increases cumulative risk of catheter-associated bloodstream infections 4
• Prolonged unnecessary catheter retention can lead to fibrosis around the catheter, making removal difficult or impossible 6

Catheter Malfunction

• Non-infected malfunctioning catheter can be exchanged over guidewire if no evidence of infection present 1

Critical Timing Considerations

Do not routinely replace catheters to prevent infection - only remove when clinically indicated 1

Do not remove based on fever alone - use clinical judgment regarding appropriateness if infection evidenced elsewhere or noninfectious cause suspected 1

After removal for infection, timing for new access:

• Blood cultures must be negative for at least 48 hours after cessation of antibiotic treatment before placing new permanent access 1
• For S. aureus with endocarditis: complete 4-6 weeks antibiotics, wait 5-10 days with negative cultures 2
• For uncomplicated coagulase-negative staphylococci: wait 5-7 days after removal 2
• For Candida: wait 14 days after last positive blood culture 2

Common Pitfalls

Avoid these errors:

• Attempting catheter salvage with S. aureus bacteremia in unstable patients or those with tunnel involvement 1
• Delaying removal in persistently symptomatic patients beyond 36 hours of appropriate antibiotics 1
• Leaving catheter in place unnecessarily after permanent access is functional - this significantly increases infection risk 4, 5
• Using guidewire exchange for suspected infected catheters - this is contraindicated 1