Definition
Positive blood culture via line OR line tip > 15 cfu of an organism AND positive peripheral blood culture for same organism
AND no other site of infection.
OR Time to positivity: blood culture via the line is positive 2 or more hours before the peripheral blood culture.
If catheter related infection is suspected: Draw blood culture via catheter AND peripherally
- NEVER draw a single blood culture.
- NEVER culture a catheter tip in the absence of signs/symptoms of infection.
- NEVER culture a catheter tip without also obtaining a peripheral blood culture.
Management
ID CONSULT MANDATORY for candidemia and Staphylococcus aureus bacteremia. It is recommended for ESBL, highly resistant pseudomonas infection, persistent (> 72h) symptoms or bacteremia despite appropriate antibiotics, tunnel infections or for use of antibiotic lock therapy.
Removing Lines
- All non-tunneled central lines should be removed if possible
- Tunneled and non-tunneled central lines MUST be removed if:
- Certain pathogens isolated: Staphylococcus aureus, Candida spp. or other fungi
- Persistent bacteremia or fungemia, signs/symptoms of ongoing infection > 72h despite appropriate antibiotics
- Tunnel infection: induration, erythema +/-tenderness extending > 2 cm beyond catheter insertion point
- Clinical deterioration despite appropriate antimicrobial coverage
Special Considerations
Staphylococcus aureus CRBSI
- Removal of infected catheter
- Duration of therapy is 2-6 weeks depending on risk status, clinical response and duration of bacteremia
- Low risk patients: line-related S.aureus bacteremia with rapid (< 4 days) clearance and NO permanent implanted cardiac device, endocarditis or metastatic foci of infection. Consider 14 days IV therapy
- High risk patients: presence of risk factors listed above
Coagulase-Negative Staphylococcus CRBSI
- Treat 5-7 days if uncomplicated infection and if catheter removed
- Consider ID consult if other hardware in situ (prosthetic valves, joints, aortic grafts) or persistently positive blood cultures
- Treat 10-14 days with IV antibiotics and antibiotic lock therapy if catheter retained
Enterococcus CRBSI
- Treat 7-10 days if uncomplicated infection
- Consider TEE if: new murmur or septic emboli, bacteremia or fever > 72 hours of appropriate antibiotics, radiographic evidence of septic pulmonary emboli, presence of a prosthetic valve or other endovascular foreign body
Gram-Negative Bacilli CRBSI
- Patients with suspected CRBSI should receive empiric Gram-negative antibiotic therapy if they are critically ill, septic, neutropenic, have a femoral line or have a known focus of Gram-negative infection elsewhere.
- Antibiotic selection depends on patient’s risk for multi drug-resistant organisms
- Treat 7-14 days if uncomplicated infection
Candida CRBSI
- Always remove the catheter if Candida CRBSI
- A positive catheter tip for Candida is considered to represent a positive blood culture
- All patients with candidemia should be treated for a minimum of 14 days after the first negative blood culture and resolution of signs and symptoms of infection.
- All patients with candidemia need a retinal exam to rule out endophthalmitis.
References
- IDSA Guideline: Management of Intravascular Catheter-related Infections. CID 2009;40: 000
- Tunneled line: VasCath, Groshong, Hickman, Broviac, Port-a-Cath
- Corynebacterium JK is treated with vancomycin. Penicillin-sensitive diptheroids are rarely true pathogens.