Catheter-related bloodstream infection (CRBSI)

[Clin Infect Dis 2009;49:1-45]

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Prevention:

• Hand hygiene
• Use maximal sterile barrier precautions (cap, mask, sterile gown and gloves, sterile full body drape) during catheter insertion.
• Use skin antisepsis (chlorhexidine > 0.5% with alcohol for central venous catheters and arterial catheters).

Peripheral venous catheters

• If infection suspected, remove catheter. Send blood cultures (BCs) (2-4 bottles).
• Start systemic antibiotic therapy. NB: For coagulase negative Staph (CoNS), catheter removal may be sufficient if patient not systemically ill.

Short-term (<14 days) central venous catheters (CVC)/peripherally inserted central catheter (PICC)/arterial catheter (AC)

Diagnosis:

• Recommend two sets of BCs, one from the catheter and one peripherally.
• Differential time to positivity (DTP) > 2h between blood culture taken from CVC and peripherally suggests CRBSI.

Management:

• Remove CVC/PICC/AC if:
  • signs & symptoms of sepsis, septic thrombophlebitis, endocarditis, osteomyelitis
  • bacteremia that persists despite > 72h of appropriate antibiotic therapy
  • CRBSI due to Gram negative bacilli, S. aureus, enterococci, fungi, or mycobacteria
  • > 1 BC bottle positive for CoNS, Bacillus spp, Micrococcus spp, or Propionibacteria spp
  • erythema or purulence at CVC exit site
  • CVC tip (from line exchanged over a guidewire) has colony count ≥15 CFU.
• If coagulase negative Staph (CoNS) – remove CVC and give systemic antibiotic therapy x 5-7 days, or retain CVC and give systemic antibiotic therapy + antibiotic lock therapy x 10-14 days.
• If S. aureus, rule out endocarditis. Remove catheter and treat with systemic antibiotic therapy for ≥ 14 days. If persistent bacteremia or lack of clinical improvement > 3 days after catheter removal and appropriate antibiotic therapy, investigate for septic thrombophlebitis, endocarditis, or metastatic infection.
• If Enterococcus spp or Gram negative bacilli, remove catheter and treat with systemic antibiotic therapy for 7-14 days.
• If Candida spp, remove catheter and treat with systemic antifungal therapy for 14 days after first negative BC. Rule out endocarditis and/or endophthalmitis.

Long-term/tunneled CVCs (e.g. Hickman, Broviac) & implantable vascular access devices (IVAD) (e.g. Port-a-cath)

• Complicated: tunnel infection, port abscess - Remove CVC/IVAD and treat with antibiotics x 7-10 days.
• Uncomplicated:

- CoNS: Retain CVC/IVAD; treat with systemic antibiotic therapy + antibiotic lock therapy x 10-14 days. Remove CVC if clinical deterioration or persistent (> 72h) or relapsing bacteremia and work-up for complicated infection and treat accordingly.

- S. aureus/MRSA/S. lugdunensis: Remove CVC/IVAD; treat with systemic antibiotic therapy x 14 days after first negative BC if TEE negative. If salvage of CVC/IVAD essential, give systemic + antibiotic lock therapy x 4 weeks. Remove CVC if clinical deterioration or persistent (> 72h) or relapsing bacteremia and work-up for complicated infection and treat accordingly. If complicated infection not present, treat with systemic antibiotic therapy x 14 days.

- Enterococcus spp: Retain CVC/IVAD; treat with systemic antibiotic therapy + antibiotic lock therapy x 7-14 days. Remove CVC/IVAD if clinical deterioration or persistent (> 72h) or relapsing bacteremia and work-up for complicated infection and treat accordingly.

- Gram negative organisms: Remove CVC/IVAD; treat with systemic antibiotic therapy x 7-14 days. If salvage of CVC/IVAD essential, give systemic + antibiotic lock therapy x 10-14 days. Remove CVC if clinical deterioration or persistent (> 72h) or relapsing bacteremia and work-up for complicated infection and treat accordingly. If complicated infection not present, treat with systemic antibiotic therapy x 10-14 days.

- Candida spp: Rule out endocarditis and/or endophthalmitis. Remove CVC/IVAD; treat with systemic antifungal therapy x 14 days after first negative BC.

Hemodialysis catheters – increased risk of S. aureus/MRSA infection.

Antibiotic Lock Therapy

NB: Always use in combination with systemic antibiotics.

NB: Various concentrations have been studied. Further study is required to establish standard effective concentrations.

Recommended concentrations based on available literature:

• Gram positive - cefazolin: 10mg/mL, vancomycin: 5-10mg/mL
• Gram negative - gentamicin: 5-10mg/mL, amikacin: 10mg/mL, ciprofloxacin: 5-10mg/mL

Mix antibiotic with normal saline or 50-100 units of heparin (if compatible) to 2-5mL luminal volume (volume should be printed on outside of line; if not, contact manufacturer). Fill catheter lumen when not in use (e.g. 12h period overnight). Remove solution before infusion of next IV medication or solution.

NB: Antibiotic lock therapy to prevent CRBSI is not generally recommended unless multiple episodes of CRBSI despite optimal adherence to aseptic technique [Clin Infect Dis 2011;52:e1-32].

Coagulase negative Staph (CoNS)
S. aureus
S. lugdunensis
Enterococcus spp
Corynebacterium spp
Leuconostoc spp
Enterobacteriaceae
Pseudomonas spp
Yeast

Antifungal therapy