View source for Intravascular catheter-related infections (IDSA 2009)

= Background =

* Short-term catheters are those left in for less than 14 days
** More commonly skin flora on the external surface
* Long-term catheters are ≥14 days
** Increasingly likely to have intraluminal spread from the catheter hub
* CRBSIs involve the insertion site, the hub, or both

== Organisms ==

* Percutaneously-inserted catheters
** Coagulase-negative staphylococci
** ''Staphylococcus aureus''
** ''Candida'' spp
** Enteric Gram-negative bacilli
* Surgically-implanted catheters and peripherally-inserted central lines
** Coagulase-negatives staphylococci
** Enteric Gram-negative bacilli
** ''Staphylococcus aureus''
** ''Pseudomonas aeruginosa''

= Diagnosis =

== Catheter Cultures ==

* Should be done when a catheter-related bloodstream infection is suspected
* Culture the tip, either with a 5 cm roll-plate culture or sonication
** Positive when &gt; 15 cfu from roll-tip or &gt;10^2^ cfu from sonication
* Catheter site swab when there is drainage

== Blood Cultures ==

* However, positive cultures for typical organisms in the abscense of another focus of infection is suggestive
* They should be obtained prior to starting antibiotics
* Make sure skin and hub are cleaned with alcohol prior to drawing cultures
* Growth from the central line detected at least 2 hours before growsth from the peripheral blood culture (i.e. differential time-to-positivity) is most predictive
** They should be done at the same time with the same volume of blood per bottle

== Summary ==

![Figure 1: Methods for the diagnosis of acute fever for a paitent suspected of having short-term central venous catheter infection or arterial cather infection](Figure 1.png)

= General Management =

* Day 1 is the first day of negative blood culture results

== Empiric antimicrobials ==

* Empiric treatment must include Gram-positives
** Vancomycin is the preferred empiric choice for settings with high rates of MRSA; daptomycin if there are high rates of MIC &gt;2
** Linezolid is to be avoided
* For femoral catheters in critically ill patients, also cover Gram-negative bacilli and ''Candida''
* May need to cover ''Candida'' in the following situations:
** TPN
** Prolonged broad-spectrum antibiotics
** Hematologic malignancy
** Bone marrow or solid-organ transplant
** Femoral catheterization
** Colonization from ''Candida'' at many sites
* Empiric candidal coverage should be with an echinocandin
** Fluconazole is an alternative if no azole exposure in 3 months and hospital has low risk of ''C. krusei'' or ''C. glabrata''
* If fungemia or bacteremia persists after removing the line beyond 72 hours, treat for 4 to 6 weeks

== Removing the line ==

* Long-term catheters should be removed if:
** Severe sepsis
** Suppurative thrombophlebitis
** Endocarditis
** Bloodstream infection despite &gt;72 hours of therapy
** Infections due to ''S. aureus'', ''P. aeruginosa'', fungi, or mycobacteria
* Short-term catheters should be removed if:
** Gram-negative bacilli, ''S. aureus'', enterococci, fungi, or mycobacteria
* Both catheters should generally be removed in cases of difficult-to-treat bacteria: ''Bacillus'' spp, ''Micrococcus'' spp, or ''Propionibacterium''

== Salvaging the line ==

* Only do it if not meeting the above criteria
* Additional blood cultures should be obtained, and line removed if persistently positive
* Lock therapy should be used concurrently with systemic antimicrobials

= Short-term PIVs =

* IVs that have pain, induration, erythema, or exudate should be removed
* Exudate should be sent for culture, including fungi and AFB if immunocompromised

= Short-term CVCs and arterial lines =

![Figure 2](Figure 2.png)

= Long-term CVCs =

![Figure 3](Figure 3.png)

= Tunneled lines =

![Figure 4](Figure 4.png)

= Specific antimicrobial therapy =

{|
! Pathogen
! Preferred agent
! Alternative
|-
| MSSA
| Clox 2 g q4h
| Cefaz 2 g q8h, or<br/>Vanco 15 mg/kg q12h
|-
| MRSA
| Vanco 15 mg/kg q12h
|
|-
| MS-CoNS
| Clox 2 g q4h
| Cefaz or vanco or Septra
|-
| MR-CoNS
| Vanco 15 mg/kg q12h
| Dapto 6 mg/kg q24h, or<br/>Linezolid, or Quin/Dalf
|-
| Amp-S Enterococcus
| Amp 2g q4-6h<br/>± Gent 1 mg/kg q8h
| Vanco
|-
| Vanco-S Enterococcus
| Vanco 15 mg/kg q12h<br/>± Gent 1 mg/kg q8h
| Linezolid, or<br/>Dapto 6 mg/kg q24h
|-
| Vanco-R Enterococcus
| Linezolid 600mg q12, or<br/>Dapto 6 mg/kg q24h
| Quin/dalf 7.5 mg/kg q8h
|-
| ''E. coli'' &amp; ''Klebsiella''
| Ceftriax 1-2 g q24h
| Cipro or Aztreonam
|-
| ESBL ''E. coli'' &amp; ''Klebsiella''
| Erta 1 g q24h
| Cipro or Aztreonam
|-
| ''Enterbacter'' and ''Serratia''
| Erta 1 g q24h
| Cefipime or Cipro
|-
| ''Acinetobacter''
| Amp/Sulb 3g q6h, or<br/>Mero 1g q8h
|
|-
| ''Pseudomonas aeruginosa''
| Cefipime 2g q8h, or<br/>Mero 1g q8h, or<br/>Pip/tazo 4.5g q6h
|
|-
| ''Burkholderia cepacia''
| Septra 3-5 mg/kg q8h, or<br/>Mero 1g q8h
|
|-
| ''Candida'' spp.
| Caspo 70 mg load then 50 mg daily, or<br/>Mica 100 mg daily, or<br/>Anidula 200 mg load then 100 mg daily, or<br/>Fluc 400-600 mg daily
| Lipid Amphotericin B
|-
| ''Corynebacterium jeikeium''
| Vanco 15 mg/kg q12h
| Linezolid
|-
| ''Chryseobacterium''
| Levo 750 mg
| Septra or Mero
|-
| ''Ochrobacterium anthropi''
| Septra 3-5 mg/kg q8h, or<br/>Cepri 400 mg q12h
| Mero or Erta plus AG
|-
| ''Malassezia furfur''
| Ampho B
|
|-
| ''Mycobacterium'' spp.
| Based on susceptibility
|
|}

[[Category:Healthcare-associated infections]]