Guideline sources The following summarized guidelines for the evaluation and management of catheter-related bloodstream infection (CRBI) are prepared by our editorial team based on guidelines from the Society for Healthcare Epidemiology of America (SHEA 2022), the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC/SEMICYUC 2018), and the Infectious Diseases Society of America (IDSA 2009). 1 2 3 Guidelines 1. Screening and diagnosis Diagnosis: As per SEIMC 2018 guidelines, suspect CRBI in patients with IV catheters and fever, chills or other signs of sepsis, even in the absence of local signs of infection and especially if no alternative source is identified. B Show 4 more https://web.pathway.md/diseases/recP5PSGQERIJSUCt 1/7 6/29/23, 3:45 AM Catheter-related bloodstream infection Pathway As per IDSA 2009 guidelines, establish a definitive diagnosis of CRBI if: the same organism grows from at least one percutaneous blood culture and from a culture of the catheter tip A two drawn blood samples, one from a catheter hub and the other from a peripheral vein, meet CRBI criteria for quantitative blood cultures or differential time to positivity. B Show 3 more 2. Diagnostic investigations Initial blood culture: As per SEIMC 2018 guidelines, obtain blood cultures using an aseptic technique and before the initiation of antimicrobial therapy. A Show 8 more As per IDSA 2009 guidelines, obtain blood samples for culture before initiating antibiotic therapy. A Show 7 more Additional blood cultures: Obtain additional blood cultures and then remove the catheter if blood culture results (such as two sets of blood cultures obtained on a given day, one set of blood cultures is acceptable for neonates) remain positive when blood samples are obtained 72 hours after the initiation of appropriate therapy in patients with CRBI if catheter salvage is attempted. B Obtain additional cultures of blood samples collected through the suspected catheter and from a peripheral vein before the initiation of antimicrobial therapy and/or catheter removal to ascertain that the patient has true bloodstream infection and that the catheter is the likely source if a catheterized patient has a single positive blood culture growing coagulase-negative Staphylococcus species. B Catheter culture: As per SEIMC 2018 guidelines, obtain catheter cultures with catheter withdrawal only when CRBI is suspected. B Show 10 more As per IDSA 2009 guidelines, obtain catheter cultures when a catheter is removed for suspected CRBI. Do not obtain routine catheter cultures. B Show 9 more Transesophageal echocardiogram: Obtain TEE in the vast majority of patients with S. aureus bacteremia. Do not obtain or consider delaying TEE in patients without the following risk factors: prolonged bacteremia hemodialysis metastatic foci of infection https://web.pathway.md/diseases/recP5PSGQERIJSUCt 2/7 6/29/23, 3:45 AM Catheter-related bloodstream infection Pathway IV drug abuse implantable central venous catheters intracardiac device prosthetic valve previous infective endocarditis cardiac structural abnormality. B Individualize the need for TEE in episodes of CRBIs caused by other pathogens. Consider ruling out infective endocarditis in all patients with persistent bacteremia (or fungemia). B 3. Medical management General principles: consider formulating automated standardized treatment advice after a positive blood culture result is reported likely to represent CRBI, to improve compliance with published evidence-based guidelines. C Antimicrobial lock therapy: As per SEIMC 2018 guidelines, do not attempt conservative treatment in patients with metastatic or local septic complications. D Show 6 more As per IDSA 2009 guidelines, administer antibiotic lock therapy for catheter salvage. B Administer systemic antibiotics through the colonized catheter if antibiotic lock therapy cannot be used in this situation. B Empiric antibiotic therapy: As per SEIMC 2018 guidelines, initiate antimicrobial therapy as soon as possible with an agent active against S. aureus and coagulase-negative Staphylococci in patients with suspected CRBI, especially if associated with sepsis or septic shock. B Show 8 more As per IDSA 2009 guidelines, decide on empirical coverage for Gram-negative bacilli based on local antimicrobial susceptibility data and the severity of disease (such as a fourth-generation cephalosporin, carbapenem, or -lactam/ -lactamase combination with or without an aminoglycoside). B Show 7 more Empiric antifungal therapy: As per SEIMC 2018 guidelines, evaluate the need for empirical antifungal therapy in patients with suspected catheter-related candidemia along with the possibility of catheter removal. B Show 3 more As per IDSA 2009 guidelines, initiate empirical therapy for suspected catheter-related candidemia in patients with sepsis and any of the following risk factors: TPN prolonged use of broad-spectrum antibiotics https://web.pathway.md/diseases/recP5PSGQERIJSUCt 3/7 6/29/23, 3:45 AM Catheter-related bloodstream infection Pathway hematologic malignancy receipt of bone marrow or solid organ transplant femoral catheterization colonization due to Candida species at multiple sites. B Show 2 more Specific antibiotic therapy (Staphylococcus spp.): administer cloxacillin or cefazoline as the treatment of choice for an episode of methicillin-susceptible S. aureus CRBI. B Show 13 more Specific antibiotic therapy (Enterococcus spp.): withdraw the catheter and initiate an active antimicrobial agent for 7-14 days in patients with enterococcal CRBI. B Show 2 more Specific antibiotic therapy (Gram-negative bacilli): choose directed therapy for Gram-negative bacilli CRBI on the basis of the susceptibility results. B Show 2 more Specific antibiotic therapy (nontuberculous mycobacteria): Remove the infected catheter B followed by a combination antimicrobial treatment appropriate for the involved species for the treatment of CRBI caused by nontuberculous mycobacteria. B Continue treatment for 6-12 weeks to prevent recurrence of infection and the development of septic metastases. B Specific antifungal therapy: de-escalate from an echinocandin or a lipid formulation of amphotericin B to fluconazole for susceptible isolates in clinically stable patients with Candida spp. CRBI undergone catheter removal. B Show 3 more Thrombolytic therapy: do not use urokinase ir other thrombolytic agents as adjunctive therapy in patients with CRBI. D Management of insertion site infection: remove peripheral venous catheters if there is local pain, induration, erythema, or exudate. A Show 3 more Management of tunnelitis: remove the catheter, perform incision and drainage if indicated, and initiate a 7-10-day course of systemic antimicrobials in the absence of concomitant bacteremia or candidemia in patients with tunnelitis not associated with a hemodialysis catheter. B Show 2 more Management of subcutaneous port infection: Remove the port, drain the affected tissue and initiate systemic antibiotic therapy in the presence of signs of local inflammation at the reservoir pocket. B Administer a combination of systemic antibiotics and antibiotic lock therapy if a conservative strategy is the only option, recognizing that this approach is associated with a high failure rate. B Management of suppurative thrombophlebitis: https://web.pathway.md/diseases/recP5PSGQERIJSUCt 4/7 6/29/23, 3:45 AM Catheter-related bloodstream infection Pathway Rule out suppurative thrombophlebitis in all episodes of CRBIs with persistent bacteremia. B Remove the catheter, initiate prolonged antibiotic treatment, and obtain an individualized assessment of the need for anticoagulation after confirming the diagnosis of suppurative thrombophlebitis (mainly by ultrasound). B 4. Therapeutic procedures Catheter removal: As per SEIMC 2018 guidelines: Do not remove the central venous catheter immediately when CRBI is suspected in hemodynamically stable patients without immunosuppressive therapy, intravascular foreign bodies or organ transplantation, no suppuration at the insertion site or bacteremia/fungemia. D View any clinical condition or catheter dysfunction prompting catheter removal as a failure of conservative management. A As per IDSA 2009 guidelines, remove long-term catheters from patients with CRBI associated with any of the following conditions: severe sepsis suppurative thrombophlebitis endocarditis bloodstream infection persisting despite > 72 hours of antimicrobial therapy to which the infecting microbes are susceptible infections due to S. aureus, P. aeruginosa, fungi, or mycobacteria. B Show 3 more Guidewire exchange: do not replace the central venous catheter by guidewire exchange routinely as this strategy is associated with a higher risk of associated infectious complications. D Do not perform guidewire exchange in patients with documented catheter-related infections. D Show 2 more 5. Specific circumstances Patients on hemodialysis: obtain paired blood samples from the central venous catheter and a peripheral vein, whenever possible, for the diagnosis of CRBI in patients on hemodialysis. B Show 4 more 6. Follow-up and surveillance Serial blood culture: obtain follow-up blood cultures in all patients with S. aureus or Candida spp. CRBIs. B Show 4 more https://web.pathway.md/diseases/recP5PSGQERIJSUCt 5/7 6/29/23, 3:45 AM Catheter-related bloodstream infection Pathway New catheter insertion: Consider waiting, if feasible, before placing a new catheter after an episode of CRBI. Determine the waiting period by the resolution of signs and symptoms. Insert a new catheter without delay if the patient urgently needs vascular access. C Consider inserting a new catheter after a diagnosis of CRBI if the patient's clinical condition dictates the need for a new vascular access. B 7. Quality improvement Preventive strategies for hospitals (pre-insertion requirements): provide easy access to an evidence-based list of indications for central venous catheter use to minimize unnecessary central venous catheter placement. B Show 2 more Preventive strategies for hospitals (insertion requirements): ensure that ICU and non-ICU settings have a process in place, such as a checklist, to ensure adherence to infection prevention practices at the time of central venous catheter insertion. B Show 6 more Preventive strategies for hospitals (post-insertion requirements): ensure appropriate nurse-to- patient ratio and limit the use of float nurses in ICUs. A Show 6 more Preventive strategies for hospitals (additional measures): use antiseptic- or antimicrobial- impregnated central venous catheters both in pediatric B and adult patients. A Show 7 more Clinical findings Symptoms Past medical history Fever Inserted central venous catheter Inserted venous catheter Vital signs Sepsis Hypotension Neurological exam Tachycardia Tachypnea Altered mental status Microbiological findings blood bacterial culture blood candida culture Studies https://web.pathway.md/diseases/recP5PSGQERIJSUCt 6/7 6/29/23, 3:45 AM Catheter-related bloodstream infection Pathway 2020 CAMERA2 In hospitalized adults with MRSA bacteremia, combination therapy was not superior to standard therapy with respect to death, persistent bacteremia at day 5, microbiological relapse, or microbiological treatment failure at 90 days. Steven Y C Tong et al. JAMA. 2020 Feb 11. References 1. Mermel LA, Allon M, Bouza E et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2009 Jul 1;49 1 1 45. Open 2. F Chaves, J Garnacho-Montero, J L Del Pozo et al. Diagnosis and treatment of catheter-related bloodstream infection: Clinical guidelines of the Spanish Society of Infectious Diseases and Clinical Microbiology and SEIMC and the Spanish Society of Spanish Society of Intensive and Critical Care Medicine and Coronary Units SEMICYUC . Med Intensiva Engl Ed). Jan-Feb 2018;42 1 5 36. Open 3. Niccol Buetti, Jonas Marschall, Marci Drees et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol. 2022 Apr 19;1 17. Open 4. Nasia Safdar, John C O'Horo, Aiman Ghufran et al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis. Crit Care Med. 2014 Jul;42 7 1703 13. Open https://web.pathway.md/diseases/recP5PSGQERIJSUCt 7/7