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    Line-Related Infections

    Hematological / Oncological

    Last Updated Jan 19, 2022
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    By Joseph Chong, Tracy Huynh


    • 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

    Diagnostic Approach

    • 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 Antibiotic 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.

    Quality Of Evidence?


    Majority of articles are guidelines and there are no randomized control studies.


    Other Relevant Information

    Related Information

    Reference List

    1. Buetti N, Timsit J-F. Management and Prevention of Central Venous Catheter-Related Infections in the ICU. Semin Respir Crit Car Med. 2019; 40: 508-523.

    2. Calderwood MS, Harris A, Kaplan S, Hall KK. Intravascular non-hemodialysis catheter-related infection: Clinical manifestations and diagnosis. UpToDate. Retrieved January 8, 2022, from uptodate.com

    3. Calderwood MS, Harris A, Kaplan S, Hall KK. Intravascular non-hemodialysis catheter-related infection: Treatment. UpToDate. Retrieved January 8, 2022, from uptodate.com

    4. 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; 49(1): 1-45.

    5. Raad I, Hanna H, Maki D. Intravascular catheter-related infections: advances in diagnosis, prevention, and management. Lancet Infect Dis. 2007; 7: 645-57.

    6. Rupp ME, Karnatak R. Intravascular Catheter-Related Bloodstream Infections. Infect Dis Clin N Am. 2018; 32: 765-787

    7. Shah H, Bosch W, Thompson KM, Hellinger WC. Intravascular Catheter-Related Bloodstream Infection. The Neurohospitalist. 2013; 3(3): 144-151.


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