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 > 15 cfu from roll-tip or >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


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 >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 >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


Long-term CVCs


Tunneled lines


Specific antimicrobial therapy

Pathogen	Preferred agent	Alternative
MSSA	Clox 2 g q4h	Cefaz 2 g q8h, or 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 Linezolid, or Quin/Dalf
Amp-S Enterococcus	Amp 2g q4-6h ± Gent 1 mg/kg q8h	Vanco
Vanco-S Enterococcus	Vanco 15 mg/kg q12h ± Gent 1 mg/kg q8h	Linezolid, or Dapto 6 mg/kg q24h
Vanco-R Enterococcus	Linezolid 600mg q12, or Dapto 6 mg/kg q24h	Quin/dalf 7.5 mg/kg q8h
E. coli & Klebsiella	Ceftriax 1-2 g q24h	Cipro or Aztreonam
ESBL E. coli & Klebsiella	Erta 1 g q24h	Cipro or Aztreonam
Enterbacter and Serratia	Erta 1 g q24h	Cefipime or Cipro
Acinetobacter	Amp/Sulb 3g q6h, or Mero 1g q8h
Pseudomonas aeruginosa	Cefipime 2g q8h, or Mero 1g q8h, or Pip/tazo 4.5g q6h
Burkholderia cepacia	Septra 3-5 mg/kg q8h, or Mero 1g q8h
Candida spp.	Caspo 70 mg load then 50 mg daily, or Mica 100 mg daily, or Anidula 200 mg load then 100 mg daily, or 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 Cepri 400 mg q12h	Mero or Erta plus AG
Malassezia furfur	Ampho B
Mycobacterium spp.	Based on susceptibility