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Intravascular catheter-related bloodstream infections

Last updated: September 22, 2021

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Intravascular catheter-related bloodstream infection (CRBSI) is a primary bloodstream infection that is attributable to the presence of an intravascular catheter, typically a central venous catheter or an arterial catheter. Peripheral intravenous catheters (with or without suppurative thrombophlebitis) are rarely responsible for bloodstream infections. Coagulase-negative staphylococci and Staphylococcus aureus are the most common causative pathogens; however, gram-negative bacilli and Candida spp. are also frequently responsible, especially in critically ill patients and those with femoral intravascular catheters. CRBSI can manifest with fever with or without features of sepsis and evidence of infection at the catheter insertion site (e.g., localized erythema, induration, exudate). Isolation of the same pathogen on cultures obtained from at least 2 different sites (e.g., blood cultures from a peripheral venipuncture and the suspected infected catheter) confirms the diagnosis. Empiric antibiotic therapy should be initiated as soon as appropriate cultures are obtained. Inadequate response to empiric antibiotic therapy should prompt evaluation for complications of CRBSI (e.g., infective endocarditis, suppurative thrombophlebitis) and typically necessitates removal of the catheter and prolonged antibiotic therapy.

The criteria for CRBSI are used for diagnosis and management, while the criteria for CLABSI are used primarily for epidemiologic surveillance to track healthcare-associated infections.

Reference: [1][2]

Common pathogens [2]

Risk factors [3][4]

Mechanism of infection [4]

  • Extraluminal migration
    • Pathogens (e.g., bacterial or fungal) at the percutaneous exit site migrate along the outer surface of the catheter to the bloodstream.
    • Tends to occur in short-term catheters (placed for < 14 days)
  • Intraluminal migration
    • Pathogens (e.g., bacterial or fungal) infect the catheter hub and migrate within the lumen of the catheter into the bloodstream.
    • Can occur in both long-term catheters (placed for ≥ 14 days) and short-term catheters
    • Infusion contamination (e.g., infected blood transfusion, TPN)
  • Hematogenous seeding (from other sites)

Biofilms help pathogens avoid host defense mechanisms and play a role in the development of CRBSIs. [3]

The following recommendations relate primarily to CRBSI secondary to central lines and arterial catheters. Peripheral intravenous catheters (with or without suppurative thrombophlebitis) are rarely responsible for bloodstream infections. However, exudates from any intravascular line (including peripheral lines) should be submitted for Gram stain and culture.

Routine initial diagnostics [2]

Cultures

  • Should be obtained preferably prior to starting antibiotics from two different sites simultaneously
  • One of the cultures should be either a blood culture from the catheter lumen or, if the catheter has been removed, the catheter tip.
  • Any exudate at the catheter insertion site should also be cultured.
  • The same organism should be isolated from the different sites to confirm CRBSI.
Diagnostic criteria for catheter-related bloodstream infection [2]
Culture sites

Diagnostic culture results
(CFU: colony forming units)

Peripheral venipuncture AND intravascular catheter lumen
  • Quantitative cultures: CFU from catheter lumen sample ≥ 3 times the CFUs of peripheral blood sample
  • OR differential time to positivity : cultures from catheter lumen becomes positive ≥ 2 hours before the peripheral vein sample becomes positive. [5]
Peripheral venipuncture AND intravascular catheter tip [4]
  • Quantitative cultures of the catheter tip
    • Roll-plate culture : > 15 CFU from a 5 cm segment of the catheter
    • Broth culture: > 102 CFU
≥ 2 samples from different catheter lumens [3]
  • CFUs from the sample drawn from the infected catheter lumen are ≥ 3 times the CFUs from other lumens.

A diagnosis of CRBSI requires the same organism to be grown in at least two cultures obtained from different sites. [2]

If the diagnostic criteria for CRBSI are not fulfilled, investigate for alternative sources of infection. If another primary source cannot be found and signs and symptoms persist, remove the catheter and culture the catheter tip. [2]

Transesophageal echocardiogram (TEE)

A negative TEE alone does not rule out infective endocarditis. TEE may need to be repeated if concern for endocarditis remains. [2]

Overview

Empiric antibiotic therapy [2]

  • Should be administered as soon as appropriate cultures have been obtained
  • Coverage required:
    • All patients require gram-positive coverage.
    • Further pathogen coverage (e.g., gram-negative, pseudomonal, fungal) may be required based on the following factors
      • Severity of illness
      • Sites of catheter insertion
      • Patient risk factors and comorbidities
      • Local antimicrobial susceptibility data
Empiric antibiotic therapy for CRBSI
Coverage Indications [2][6] Example regimens for adult patients [2][7]
Gram-positive
  • All patients
Gram-negative bacilli (including Pseudomonas aeruginosa)
Candida spp.

Empiric antibiotics for CRBSI should always provide gram-positive coverage. Empiric antibiotics for CRBSI in patients with femoral catheters should include coverage for gram-positive pathogens, gram-negative bacilli, and Candida spp. [2]

In patients with fungemia, obtain an ophthalmologic examination to rule out fungal retinitis. [7]

Indications for intravascular catheter removal [2]

Hemodynamically instability or end-organ damage likely due to CRBSI necessitates immediate catheter removal. [2]

In patients who require continued vascular access, establish intravascular access at a new site or consider catheter salvage in patients with limited venous access. [2]

Catheter salvage [2]

If blood cultures remain positive despite 72 hours of appropriate antibiotic therapy, the catheter should be removed.

Supportive care

Further management

Switch to culture-specific antibiotic therapy in consultation with a specialist once the antibiogram is available. Obtain surveillance blood cultures to confirm eradication of infection.

Specialists (e.g., in infectious disease) should be actively involved in the management of all patients with complicated CRBSIs.

A new central venous catheter can be placed once follow-up blood cultures are negative.

See also the “Acute management checklist for sepsis.”

Reference: [2]

We list the most important complications. The selection is not exhaustive.

See “Prevention of intravascular catheter-related infections.”

  1. National Healthcare Safety Network (NHSN) Patient Safety Component Manual.
  2. 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): p.1-45. doi: 10.1086/599376 . | Open in Read by QxMD
  3. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the Prevention of Intravascular Catheter-related Infections. Clin Infect Dis. 2011; 52 (9): p.e162-e193. doi: 10.1093/cid/cir257 . | Open in Read by QxMD
  4. Shah H, Bosch W, Thompson KM, Hellinger WC. Intravascular Catheter-Related Bloodstream Infection. The Neurohospitalist. 2013; 3 (3): p.144-151. doi: 10.1177/1941874413476043 . | Open in Read by QxMD
  5. Böll B, Schalk E, Buchheidt D, et al. Central venous catheter–related infections in hematology and oncology: 2020 updated guidelines on diagnosis, management, and prevention by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Hematol. 2020; 100 (1): p.239-259. doi: 10.1007/s00277-020-04286-x . | Open in Read by QxMD
  6. Marschall J. Current strategies for the prevention and management of central line-associated bloodstream infections. Infect Drug Resist. 2010 : p.147. doi: 10.2147/idr.s10105 . | Open in Read by QxMD
  7. Guenezan J, Drugeon B, Marjanovic N, Mimoz O. Treatment of central line-associated bloodstream infections. Crit Care. 2018; 22 (1). doi: 10.1186/s13054-018-2249-9 . | Open in Read by QxMD
  8. Lachiewicz AM, Hauck CG, Weber DJ, Cairns BA, van Duin D. Bacterial Infections After Burn Injuries: Impact of Multidrug Resistance. Clin Infect Dis. 2017; 65 (12): p.2130-2136. doi: 10.1093/cid/cix682 . | Open in Read by QxMD