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

  1. IDSA Guideline: Management of Intravascular Catheter-related Infections. CID 2009;40: 000
  2. Tunneled line: VasCath, Groshong, Hickman, Broviac, Port-a-Cath
  3. Corynebacterium JK is treated with vancomycin. Penicillin-sensitive diptheroids are rarely true pathogens.