For an adult patient with a tunneled cuffed dialysis catheter exit‑site infection caused by Pseudomonas, how does KDOQI recommend administering systemic anti‑pseudomonal antibiotics (choice, dosing, route, and duration)?

Treatment of Pseudomonas Exit-Site Infection in Tunneled Cuffed Dialysis Catheters

For a Pseudomonas exit-site infection of a tunneled cuffed catheter, KDOQI recommends parenteral (intravenous) antibiotics with anti-pseudomonal coverage, typically for 7-14 days, without removing the catheter unless the infection fails to respond to therapy. 1

Initial Management Algorithm

Step 1: Obtain Cultures Before Starting Antibiotics

• Collect exit-site drainage cultures prior to initiating any antimicrobial therapy 1
• If systemic signs or symptoms are present, also obtain blood cultures from the catheter 1

Step 2: Initiate Empiric Parenteral Antibiotics

• Start parenteral (IV) antibiotics immediately after obtaining cultures 1
• Empiric coverage should target both Gram-positive organisms (Staphylococcus, Streptococcus) AND Gram-negative organisms including Pseudomonas 1
• The rationale for broad initial coverage is that exit-site infections with tunnel drainage often involve mixed organisms 1

Step 3: Adjust to Definitive Therapy

• Once culture results confirm Pseudomonas, narrow antibiotics to anti-pseudomonal agents based on susceptibility testing 1
• Continue parenteral antibiotics for 7-14 days for isolated exit-site infections 1

Catheter Management Decision Tree

Do NOT Remove the Catheter If:

• The infection is limited to the exit site without tunnel involvement 1
• The patient responds appropriately to antibiotic therapy 1
• There are no systemic signs of sepsis or bacteremia 1

Remove the Catheter and Replace at a Different Site If:

• The infection fails to respond to appropriate antibiotic therapy 1
• There is evidence of tunnel tract involvement with drainage 1
• The patient develops catheter-related bacteremia that persists beyond 36 hours of treatment 1
• The patient becomes clinically unstable at any point 1

Key Differences from Other Organisms

Important caveat: While Staphylococcus aureus bacteremia typically mandates catheter removal, Pseudomonas exit-site infections can often be salvaged with aggressive antibiotic therapy alone if there is no tunnel or bloodstream involvement 2. However, Pseudomonas carries a higher risk of treatment failure compared to coagulase-negative staphylococci, so close monitoring is essential 3.

Monitoring During Treatment

• Reassess the exit site every 2-3 days during antibiotic therapy 4
• If systemic symptoms develop or the exit site worsens, obtain repeat blood cultures 1
• Document resolution of drainage and improvement in exit-site appearance before discontinuing antibiotics 4

Common Pitfalls to Avoid

• Do not use topical antibiotics alone for exit-site infections with drainage—parenteral therapy is required 1
• Do not delay catheter removal if tunnel infection develops or if the patient fails to improve after 7-10 days of appropriate antibiotics 1
• Do not assume the infection is purely Pseudomonas—initial empiric coverage must include Gram-positive organisms until cultures finalize 1
• Do not place a new permanent access until blood cultures (if obtained) remain negative for at least 48 hours after completing antibiotics 1