• Despite advances in prevention of catheter-related infections, tens of thousands of patients continue to experience bloodstream infections (BSI) every year.
  • Results in prolonged hospitalization, increased morbidity and mortality, healthcare cost.
• Definition:
  • Catheter-related bloodstream infection (CRBSI): clinical definition that requires microbiologic data (e.g., catheter tip culture, quantitative blood cultures, differential time to positivity [DTP]).
  • Central-line associated bloodstream infection (CLABSI): surveillance definition that identifies patients with a central venous catheter who experiences a BSI not attributable to another source.
    • Overestimates true incidence of CRBSI since some BSIs are due to sources other than the catheter.
•  Risk factors:
  • Host factors:
    • Immunosuppression
    • Bone marrow transplantation
    • Malnutrition
    • Total parenteral nutrition
    • Previous BSI
    • Extremes of age
    • Loss of skin integrity, as with burns
  • Catheter factors:
    • Extrinsic factors:
      • Duration and type of catheter
      • Catheter-site care
    • Comparatively elevated risk in the following circumstances:
      • Femoral or internal jugular vein compared with subclavian vein
      • Use for hemodialysis compared with other indications
      • Multiple-lumen compared with single-lumen PICCs

• Clinical presentation:
  • Local catheter infections are characterized by inflammatory manifestations:
    • Induration, erythema, warmth, and pain or tenderness at or around catheter exit site.
    • High specificity but very low sensitivity for CRBSI.
  • Systemic catheter infections (CRBSI) should be considered when a patient with a CVC presents with bacteremia or fungemia in the presence of signs and symptoms of systemic infection:
    • Fevers, chills, hypotension, altered mental status.
    • Fever/chills is most sensitive clinical finding, but has poor specificity.
•  Complications: suspect in patients with CRBSI and persistent bacteremia after >72 hours of appropriate antibiotic therapy.
  • Septic thrombophlebitis: venous thrombosis associated with inflammation in setting of bacteremia.
  • Infective endocarditis.
  • Metastatic MSK infections: septic arthritis, osteomyelitis, orthopedic hardware infection.
• Investigations:
  • CBC
  • Lactate
  • CRP
  • Blood cultures x 2: if positive for S. aureus, coagulase-negative staphylococci, or Candida species, in absence of other identifiable sources of infection, should increase suspicion for CRBSI.
  • There is NO role for routine catheter culture at time of catheter removal as positive culture is not diagnostic of CRBSI.
• Approach:
  • Patients with fevers, chills, or hypotension in setting of catheter placed at least 48 hours prior to symptoms: suspect CRBSI.
  • Two sets of blood cultures from separate peripheral sites should be obtained, preferably prior to antimicrobial therapy.
  • If not possible, one blood culture set may be drawn from the catheter, while the other set is drawn peripherally.
  • Exception: frequently not feasible to obtain a peripheral blood sample from patients receiving hemodialysis.
    • Blood samples may be drawn during hemodialysis from bloodlines connected to the CVC.
  • Following results may be attributable to CRBSI:
    • 1 or more blood culture bottles positive for: S.aureus, Enterococci, Enterobacteriaceae, Pseudomonas, Candida.
    • 2 or more blood culture bottles positive for Coag Neg Staph (CoNS), Cutibacterium, Viridans group streptococci.

• In general, management consists of catheter removal and systemic antibiotic therapy.

Catheter Management

• Indications for catheter removal:
  • Sepsis
  • Hemodynamic instability
  • Presence of concomitant endocarditis, septic thrombophlebitis, metastatic MSK infection.
  • Persistent bacteremia after 72 hours of appropriate antibiotic therapy.
  • Subcutaneously tunneled CVC, tunnel tract infection, or subcutaneous port reservoir infection.
  • CRBSI due to the following pathogens: S.aureus, P.aeruginosa, drug-resistant gram-negative bacilli, Candida.
• Indications for catheter salvage:
  • No alternative access site or sites are limited.
  • Patient has bleeding diathesis (thrombocytopenia).
  • Patient declines removal.
  • Quality of life takes priority over need for catheter reinsertion.
  • In absence of complications, catheter salvage is reasonable in setting of CRBSI due to CoNS and drug-susceptible Enterobacteriaceae.
  • In patients with CRBSI due to Enterococcus, catheter removal is preferred but salvage may be attempted if not feasible.
• Hemodialysis patients:
  • For patients whose symptoms resolve after 2-3 days of IV antibiotic therapy and who do not have complications, guidewire exchange of catheter is associated with cure rates comparable to those associated with immediate removal.
  • If CRBSI due to gram-negative pathogens or CoNS, catheter may be retained and treated with adjunctive antibiotic lock therapy.

• Empiric therapy should cover gram-positive organisms: typically IV vancomycin.
• Indications for gram-negative bacilli coverage:
  • Critical illness
  • Neutropenia
  • Hemodynamic instability
  • Severe burns
  • Femoral catheter-related BSI
  • Choice of agent for Gram-negative bacilli: antipseudomoal beta-lactam such as Ceftazidime, Cefepime, Piperacillin-Tazobactam, Imipenem, Meropenem.
• Indications for Candida coverage:
  • Critical illness
  • Prolonged exposure to broad-spectrum antibiotics
  • Recent GI surgery
  • Femoral catheter-related BSI
  • Hematologic malignancies
  • Hematopoietic stem cell transplantation
  • Solid organ transplantation
  • Patients on TPN
  • Presence of candida colonization at multiple body sites
  • Choice of agent for Candida: Echinocandins or Fluconazole
• Hemodialysis patients:
  • Antibiotic selection should be made on basis of pharmacokinetic characteristics that permit dosing after each dialysis session (vancomycin, ceftazidime, cefazolin) or antibiotics that are unaffected by dialysis (ceftriaxone).
• If patients have persistent bacteremia or fungemia after catheter removal (>72 hr), duration of therapy should be extended to 4-6 weeks and consider TTE to rule out infective endocarditis if appropriate.

• LITFL: https://litfl.com/central-line-infections-and-central-line-associated-blood-stream-infections-clabsi/
• EMCrit: Line infection – EMCrit Project
• YouTube: Central Catheter-associated Bloodstream Infections – Richard L Oehler, MD – YouTube

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