Epidemiology and Microbiology
Management
Nontunneled central venous catheters (CVCs) (see Figures 48-1 and 48-2)2
CVCs in patients with fever and mild to moderate symptoms do not need to be routinely removed
CVCs should be removed and cultured if the patient has a tunnel infection (erythema or purulence overlying the catheter exit site) or clinical signs of sepsis
If blood culture results are positive or if the CVC is exchanged over the guidewire and has significant colonization according to results of quantitative or semiquantitative cultures, the catheter should be removed and placed into a new site
In some patients without evidence of persistent bloodstream infection, or if the infecting organism is a coagulase-negative staphylococci and if there is no suspicion of local or metastatic complications, the CVC may be retained
A transesophageal echocardiogram (TEE) should be obtained to rule out vegetations (endocarditis) in patients with a catheter-related S. aureus bloodstream infection if less than 4 weeks of therapy is being considered
If a TEE is not available and the results of transthoracic echocardiography are negative, the duration of therapy for S. aureus bacteremia should be 4–6 weeks
After removal of a colonized catheter associated with bloodstream infection, if there is persistent bacteremia or fungemia or a lack of clinical improvement, aggressive evaluation for septic thrombosis, infective endocarditis, and other metastatic infections should commence
Febrile patients with valvular heart disease or patients with neutropenia whose catheter tip culture reveals significant growth of S. aureus or Candida species on semiquantitative or quantitative culture with no bloodstream infection should be followed up closely for development of infection, and samples of blood for culture should be obtained accordingly
After a catheter is removed from a patient with a catheter-related bloodstream infection, nontunneled catheters may be reinserted after appropriate systemic antimicrobial therapy is begun
Tunneled CVCs and intravascular devices (see Figure 48-3)
Clinical assessment is recommended to determine whether the CVC or the ID is the source of infection or bloodstream infection
For complicated infections, the CVC or the ID should be removed
For salvage of the CVC or the ID in patients with uncomplicated infections, antibiotic lock therapy should be used for 2 weeks with standard systemic therapy for treatment of catheter-related bacteremia caused by S. aureus, coagulase-negative staphylococci, and Gram-negative bacilli for suspected intraluminal infection in the absence of tunnel or pocket infection
Tunneled catheter pocket infections or port abscess require removal of a catheter and usually 7–10 days of appropriate antibiotic therapy
Reinsertion of tunneled intravascular devices should be postponed until after appropriate systemic antimicrobial therapy is begun, based on susceptibilities of the bloodstream isolate and after repeated cultures of blood samples yield negative results