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Managing bloodstream infections in patients who have short-term central venous catheters

Cleveland Clinic Journal of Medicine. 2011 January;78(1):10-17 | 10.3949/ccjm.77a.10015
January 1, 2011|Cleveland Clinic Journal of Medicine
Naomi P. O'Grady, MD;Daniel S. Chertow, MD
Author and Disclosure Information

Naomi P. O’Grady, MD
Staff Clinician, Critical Care Medicine Department; Medical Director, Procedures, Vascular Access, and Conscious Sedation Services, National Institutes of Health, Bethesda, MD. Co-author of the 2009 Infectious Diseases Society of America’s Guidelines for Management and Treatment of Catheter-Related Infections

Daniel S. Chertow, MD
Critical Care Medicine Department, National Institutes of Health, Bethesda, MD

Address: Naomi P. O’Grady, MD, Critical Care Medicine Department, National Institutes of Health, Building 10 Room 2C142, 10 Center Drive MSC 1662, Bethesda, MD 20892; e-mail nogrady@mail.cc.nih.gov

ABSTRACTCatheter-related bloodstream infections can be complicated to manage, but a growing body of evidence supports specific recommendations. In 2009, the Infectious Diseases Society of America published updated guidelines for the diagnosis and management of all intravascular catheter-related infections. Here we provide a focused review on the management of bloodstream infections in adult patients with short-term (not surgically implanted and not tunneled) central venous catheters, including peripherally inserted central catheters. This review should serve as a ready reference for providers (eg, hospitalists, surgeons, physician assistants, nurse practitioners, intensivists) managing adult patients with short-term central venous catheters in place.

KEY POINTS

  • Most bloodstream infections related to central venous catheters occur in patients with short-term central venous catheters; these infections result in significant morbidity and health care costs.
  • Initial management of suspected cases requires decisions about whether to retain or remove the catheter and the choice of empiric antibiotic therapy.
  • Management should be based on the specific pathogen isolated.
  • An infectious disease specialist should be consulted in complicated cases or when multidrug-resistant bacteria or uncommon pathogens are isolated.

Gram-negative bacilli

Given the propensity of many gram-negative bacilli to form a biofilm, a number of studies have advocated removing CVCs infected with gram-negative bacilli.15,16,44 Recent studies examining the role of combination systemic antibiotic therapy and antibiotic lock therapy of gram-negative infections have found high success rates.45,46

The IDSA recommends routine removal of short-term CVCs infected with gram-negative bacilli and 7 to 14 days of systemic antibiotic therapy based on microbial susceptibility data. Antibiotic options generally include fourth-generation cephalosporins, carbapenems, or a combination beta-lactam and beta-lactamase inhibitor. The first-line treatment for Stenotrophomonas maltophilia and Burkholderia cepacia is trimethoprim-sulfamethoxazole (Bactrim). Extended-spectrum beta-lactamase-producing Klebsiella pneumoniae and Escherichia coli should not be treated with cephalosporins or piperacillin-tazobactam (Zosyn) even if the organisms are susceptible in vitro, as doing so has been associated with poor clinical outcomes.11,47

There is growing concern over multiple-drug-resistant gram-negative bacilli with carbapenemases that confer resistance to carbapenems. No controlled study has evaluated treatment of multiple-drug-resistant gram-negative bacilli that require therapy with polymyxin (Colistin).

Candida species

The benefit of removing the CVC in the setting of candidemia is supported by six prospective studies.48–53 Patients with catheter-related bloodstream infections due to Candida species should have the catheter removed. C albicans and azole-susceptible candidal strains can be effectively treated with fluconazole at a dosage of 400 mg daily, continued for 14 days following the first negative blood culture.54 Echinocandins as first-line therapy and lipid formulations of amphotericin B (Abelcet) as an alternative are both highly effective for the treatment of Candida species with decreased susceptibility to azoles (eg, C glabrata and C krusei).55–57

Other gram-positive microorganisms

The isolation of Corynebacterium, Bacillus, and Micrococcus species from a single blood culture does not prove bloodstream infection, and confirmation requires at least two positive results drawn from different sites. CVC infections with these organisms are difficult to treat unless the infected catheter is removed.58,59

ADDITIONAL RECOMMENDATIONS

Infectious disease consultation should be considered for patients with complicated bloodstream infection related to a short-term CVC. Complicated cases include catheter infections in patients with hemodynamic instability, endocarditis, suppurative thrombophlebitis, persistent bloodstream infection despite 72 hours of appropriate antimicrobial therapy, osteomyelitis, active malignancy, or immunosuppression.

Infectious disease consultation should also be sought for assistance with determining if a patient is a candidate for antibiotic lock therapy; for management, dosing, and course of antibiotic lock therapy; for assistance with antibiotic choice and course for multiple-drug-resistant gram-negative bacilli; and for recommendations on management of infections due to uncommon pathogens (eg, Corynebacterium jeikeium, Chryseobacterium species, Malassezia furfur, and Mycobacterium species).

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