Intravascular catheter-related bloodstream infections

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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.

See also “Sepsis,” “Bacteremia,” “Blood cultures,” “Device-related infections,” and “Hospital-acquired infections.”

• Intravascular catheter-related bloodstream infection (CRBSI): primary BSI in a patient with an intravascular catheter accessed > 48 hours prior or within 48 hours of catheter removal that can be attributed to the presence of an intravascular catheter (see also “Criteria for CRBSI”)
• Central line-associated bloodstream infection (CLABSI) : primary BSI in patients with a central line accessed > 48 hours prior or within 48 hours of central line removal

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: ^[2][3]

Common pathogens ^[3]

• Gram-positive: coagulase-negative staphylococci and S. aureus (most common)
• Fungal: Candida spp.
• Gram-negative: Pseudomonas aeruginosa

Risk factors for CRBSI ^[4][5]

• Patient-related factors
  • Immunosuppression
  • Bone marrow transplant
  • Burns
• Catheter-related factors
  • Central venous catheters (especially nontunneled)
  • Pulmonary artery catheters
  • Multiple lumens
  • Femoral and inguinal insertion sites
  • Prolonged duration of catheter placement
  • Frequent catheter access
  • Catheter used for parenteral nutrition (e.g., TPN)

Mechanism of infection ^[5]

• 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. ^[4]

• Local features: swelling, pain, redness, exudates, and/or purulence at catheter insertion sites
• Systemic features: features of sepsis (e.g., fever, hemodynamic instability, altered mental status)

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 ^[3]

• CBC, inflammatory markers, BMP, liver chemistries (similar to the diagnostic workup for sepsis)
• Consider additional tests (e.g., urinalysis, chest x-ray) as needed to rule out other potential primary sources of infection.

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.

A diagnosis of CRBSI requires the same organism to be grown in at least two cultures obtained from different sites. ^[3]

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. ^[3]

Transesophageal echocardiogram (TEE)

• Indications: to evaluate for infective endocarditis in patients who have any of the following ^[3]
  • Clinical features of infective endocarditis
  • Risk factors for infective endocarditis
  • Radiographic imaging to suggest septic pulmonary embolism
  • Prolonged fever or bacteremia despite ≥ 72 hours of appropriate antibiotic therapy
  • Confirmed S. aureus bacteremia if considering a shorter duration of treatment (i.e., < 4–6 weeks)
• Important consideration: TEE should ideally be performed 5–7 days after the onset of BSI to minimize the likelihood of false negatives.

A negative TEE alone does not rule out infective endocarditis. TEE may need to be repeated if concern for endocarditis remains. ^[3]

Overview

• Signs of sepsis or septic shock: Initiate hemodynamic support (see “Acute management checklist for sepsis”).
• Obtain appropriate cultures before administering antibiotics.
• Initiate empiric antibiotic therapy for CRBSI.
• Remove the catheter if indications for intravascular catheter removal are met.
• Start supportive care and monitor response to treatment.

Empiric antibiotic therapy ^[3]

• 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 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. ^[3]

In patients with fungemia, obtain an ophthalmologic examination to rule out fungal retinitis. ^[8]

Indications for intravascular catheter removal ^[3]

• Any peripheral venous catheter with signs of local infection
• Long-term (≥ 14 days) central lines or arterial catheters: if any of the following are present
  • Severe sepsis or septic shock
  • Suppurative thrombophlebitis
  • Infective endocarditis
  • Evidence of persistent BSI (symptoms or positive cultures) despite 72 hours of appropriate therapy
  • Obvious signs of infection at the catheter site
  • Confirmed infection with S. aureus, P. aeruginosa, enterococci, fungi, or mycobacteria
  • Catheter dysfunction (e.g., cracked and/or clotted lumen)
• Short-term (< 14 days) central access and confirmed infection with S. aureus, Enterococci, fungi, mycobacteria, or gram-negative bacilli
• Consider removal of long-term or short-term catheters with CRBSI due to less virulent pathogens that are difficult to eradicate (e.g., Bacillus spp., Micrococcus spp., propionibacteria, coagulase-negative Staphylococci)

Hemodynamically instability or end-organ damage likely due to CRBSI necessitates immediate catheter removal. ^[3]

In patients who require continued vascular access, establish intravascular access at a new site or consider catheter salvage in patients with limited venous access. ^[3]

Catheter salvage ^[3]

• Consider in patients with long-term catheters who do not have any indications for intravascular catheter removal
• Consider in patients who fulfill indications for removal but require long-term vascular access (e.g., for hemodialysis) and have limited vascular access
• Consider antibiotic lock therapy under specialist guidance.

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

Supportive care

• Appropriate strategies for IV fluid therapy, specialized nutritional support, antipyretic therapy, VTE prophylaxis (see “Supportive therapy” in “Sepsis”)
• Monitor patients in an appropriate care setting with repeat clinical assessments and laboratory studies.

Further management

Switch to culture-specific antibiotic therapy in consultation with a specialist once antibiotic sensitivities are known. Obtain surveillance blood cultures to confirm eradication of infection.

• Uncomplicated CRBSI ^[3]
  • Resolution of symptoms and negative blood cultures within 72 hours of appropriate antibiotic therapy in a patient without any of the features of complicated CRBSI
  • Continue antibiotics for 7–14 days after the first negative blood culture, depending on the cultured organism.
  • There is insufficient evidence to recommend repeat cultures following the completion of antimicrobial therapy. ^[3]
• Complicated CRBSI ^[3]
  • Defined as CRBSI in a patient with any of the following:
    • Persistent fever and/or bacteremia or fungemia despite 72 hours of appropriate treatment
    • Active malignancy, immunosuppression, or an intravascular device
    • Development of complications of CRBSI
  • Management
    • Imaging studies to rule out complications: e.g., TEE for infective endocarditis; ultrasound or CT for suppurative thrombophlebitis ^[3][8]
    • Remove the catheter and send the tip for culture. ^[5]
    • Prolonged (4–8 weeks) antibiotic therapy
    • Surgical intervention may be required to manage complications.

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.”

• ABCDE approach
• Immediate hemodynamic support (e.g., IV fluids, vasopressors) and respiratory support as needed.
• Order at least 2 blood cultures from different sites (e.g., peripheral venipuncture and catheter lumen).
• Consult an infectious disease specialist early.
• Start empiric antibiotic therapy for CRBSI.
• If indications for intravascular catheter removal are met:
  • Remove the intravascular catheter and send the tip for culture.
  • Establish a new IV access site at a different site.
  • Consider catheter salvage in patients with limited vascular access.
• Admit to appropriate care setting (e.g., ICU for critically ill patients).
• Ensure appropriate supportive care (e.g., IV, fluids, antipyretic therapy, VTE prophylaxis).

• Infective endocarditis
• Suppurative thrombophlebitis
• Osteomyelitis
• Septic emboli
• Port abscess
• Tunnel infection

Reference: ^[3]

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

See “Prevention of intravascular catheter-related infections.”

• One-Minute Telegram 49-2022-3/3: A care bundle to reduce bloodstream infections in hemodialysis
• One-Minute Telegram 36-2021-3/3: Replacement of peripheral IV catheters and incidence of bloodstream infections

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