Central line-associated bloodstream infection

Background

Microbiology

• May differ between oncology and non-oncology patients1
• In that study, the most common causes were coagulase-negative staphylococci, Staphylococcus aureus, Enterobacterales, and enterococci
• Others common causes include Pseudomonas aeruginosa and Candida species
• Far less common causes included streptococci and Stenotrophomonas

Definition

Infection Control

• For surveillance purposes, a CLABSI is essentially a bloodstream infection attributed to a catheter that was in place within 48 hours of blood culture

IDSA

• Catheter-related bloodstream infection (CRBSI) is defined by the IDSA
• Confirmed
  • Peripheral culture and catheter tip culture both positive for same organism
  • Peripheral culture and catheter lumen culture both positive for same organism with either
    • Quantitative cultures showing ≥3-fold higher CFU from the catheter
    • Time-to-positivity of the catheter culture 2 hours earlier than that of the the peripheral
• Possible
  • Quantitative cultures from two different lumens of the same catheter positive for the same organism with ≥3-fold difference in CFU between lumens

Management

Short-term CVC or arterial line infection

• Uncomplicated: no other foci of infection, fever resolves promptly ≤72h, no other intravascular hardware, no evidence of endocarditis or suppurative thrombophlebitis, and (if S. aureus) no active malignancy or immunosuppression
  • Coagulase-negative staphylococci: remove catheter and treat with antibiotic for 5-7 days; if catheter not removed, do lock therapy and treat for 10-14 days
  • Staphylococcus aureus: remove catheter and treat with antibiotic for ≥14 days
  • Enterococcus: remove catheter and treat with antibiotic for 7-14 days
  • Gram-negative bacillus: remove catheter and treat with antibiotic for 7-14 days
  • Candida: remove catheter and treat with antifungal for 14 days from first negative blood culture
• Complicated: anyone not meeting above definition of uncomplicated
  • Remove catheter and treat with antimicrobial for 4-6 weeks, or for 6-8 weeks if osteomyelitis

Long-term CVC or port infection

• Definitions of complicated and uncomplicated are same as above
• Uncomplicated
  • Coagulase-negative staphylococci: may retain and treat with lock therapy and antibiotic for 10-14 days; remove catheter if clinical deterioration or relapse
  • Staphylococcus aureus: remove catheter and treat with antibiotic for 4-6 weeks (some exceptions apply)
  • Enterococcus: may retain and treat with lock therapy and antibiotic for 7-14 days; remove catheter if clinical deterioration or relapse
  • Gram-negative bacillus: remove catheter and treat with antibiotic for 7-14 days; if attempting salvage, treat with lock therapy and antibiotic for 10-14 days and reassess
  • Candida: remove catheter and treat with antifungal for 14 days from first negative blood culture

Salvage

• Success is highest with coagulase-negative staphylococci (75%), and much lower with gram-negatives, Staphylococcus aureus, and polymicrobial infections (around 50% each)2
• Success rates are likely higher when systemic antibiotics are combined with lock therapy

Prevention

• Perform hand hygiene, use aseptic technique when manipulating catheter, use barrier precaution for insertion
• Remove catheters as soon as they are no longer needed
• Antimicrobial-impregnated catheters may be helpful

Further Reading

• Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update. Clin Infect Dis. 2009:49(1):1-45. doi: 10.1086/599376