Infected Long-term Intravascular Access Devices in Adults

Publication: 01/04/2009  
Next review: 20/07/2025  
Clinical Guideline
CURRENT 
ID: 1680 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

INFECTED LONG-TERM INTRAVASCULAR ACCESS DEVICES IN ADULTS

DIAGNOSTICS

Clinical definitions

Intravascular catheter-related infections (CRI) in long-term lines include:

  • Exit site infection
    • Erythema (>1cm) and/or purulent discharge +/- pain
  • “Tunnel” infection
    • Inflammation +/- tenderness along the subcutaneous (tunnelled) portion of the line
  • Blood stream infection (Catheter Related Blood Stream Infections, CRBSI)
    • Positive blood cultures
    • Fever or other signs of systemic inflammatory response
    • Sepsis or Severe Sepsis may be present
    • May or may not be accompanied by evidence of tunnel or exit site infection.
    • Rigors, chills or fevers after line use is highly suggestive, but not definitive, and this feature may be absent.

Laboratory tests
The following diagnostic tests should be taken to confirm diagnosis of CRI:

Signs of Exit site infection
  • Pus sample (in sterile container) for MC&S
  • If pus cannot be aspirated, then pus swab is an alternative

Fever or signs of sepsis in any patient with a long-term line

  • Paired peripheral and through-line blood cultures (same volume, same time) from ALL lumens PRIOR to antibiotics
  • If the patient has multiple long lines, then please send blood cultures from each lumen of each line, and peripheral set
  • Clearly label from which lumen (and which line) each bottle has been taken
  • Document clearly on PPM+ if a line/lumen will not bleed back. 

Patients who have their lines removed for presumed catheter related infection

  • Line tip for MC&S

Differential Time to Positivity (DTP)

This is a blood-culture based method for diagnosing luminal colonisation or CRBSI.  It is the difference in time taken for positive result to occur for the same organism, in the same bottle (aerobic or anaerobic) in both a line and peripheral culture that were sent as a ‘paired’ set.
A DTP of >2 hours in favour of the line blood culture is highly suggestive of CRBSI (sensitivity 72-94% and specificity 91-95%), however, absence of DTP does not exclude the line as the source.

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EMPIRICAL TREATMENT

All doses presume normal renal and hepatic function, dose adjust as required.

Duration of treatment for CRBSI is dependent on the organism isolated and whether or not the line is removed; see directed treatment section. Please review previous microbiology results and contact microbiology if the patient is known to have recent multi-drug resistant bacteria.

 

Recommended (1st line) treatment

2nd line treatment

Notes

Exit site infection with  no systemic signs of infection

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin PO 500mg 6-hourly

Allergy to penicillin or known MRSA (check susceptibility results)

Doxycycline electronic Medicines Compendium information on Doxycycline PO 200mg once daily

Antibiotic duration is typically 5-14 days, line can usually be used

Severe or extensive exit site or tunnel infection
AND/OR
Systemic symptoms suggesting CRBSI

Teicoplanin electronic Medicines Compendium information on Teicoplanin IV 12mg/kg dosing as per the prescribing guideline

If on haemodialysis use  IV Vancomycin instead

Contact microbiology

Stop using line if possible, gain alternative access

Signs of Severe sepsis

Teicoplanin electronic Medicines Compendium information on Teicoplanin IV 12mg/kg dosing as per the prescribing guideline
PLUS
Ceftazidime electronic Medicines Compendium information on Ceftazidime IV 2g 8-hourly (<65s)
OR
Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam IV 4.5g 6 hourly

Teicoplanin electronic Medicines Compendium information on Teicoplanin IV 12mg/kg as per the prescribing guideline
PLUS
Aztreonam electronic Medicines Compendium information on Aztreonam IV 2 g 8- hourly  

 

Stop using line, gain alternative access

Patients receiving PN

Please see the parenteral nutrition (PN) appendix (link to be added to appendix)

 

 

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REVIEW BY 72

By 72 hours of antimicrobial treatment, diagnostics should have proven your initial diagnosis or guided to a new diagnosis. Please be aware that CRBSIs can arise from another source (e.g. intra-abdominal infection), and occasionally both sites of infection require targeted management. If your patient is on IV treatment this should be reviewed daily. If the diagnosis is still correct your options are now:

Stop

If no signs of infection and diagnostics support this decision.

Change

If the patient is not clinically responding, check microbiology results to see if directed therapy is required.  Successful attempts at salvage are dependent on a number of factors and such attempts must be kept under review (see table below for further guidance).   Line removal should usually be discussed with the patient’s consultant.

Continue

If the patient is improving but does not fully meet ACED criteria. Review daily until ready to switch. Document the reason for continuing.

RECOMMENDATIONS FOR LINE SALVAGE AND REMOVAL BASED ON BLOOD CULTURE ORGANISM AND CLINICAL PARAMETERS

Line salvage likely to be successful

Line salvage NOT USUALLY recommenced

Line salvage NEVER recommended

 

Rapid resolution of clinical features of infection

MSSA/MRSA infection

Candida infection

Rapid resolution of fever

Pseudomonas spp. infection

Fungal infection

Long term need for intra-vascular access (e.g. renal or PN patients)

Stenotrophomonas maltophilia infection

Mycobacterial infection

Luminal cultures positive only, peripheral set remain negative. Though salvage can also be attempted when both sets positive.

Persistent fever >72 hours after targeted therapy commenced

Tunnel infection

No previous infection with the same organism <90 days

Persistent bacteraemia despite appropriate therapy

Disseminated infection e.g. endocarditis or osteomyelitis

Alternative IV access is available and antibiotic lock therapy can be continuous for 14 days

Line no longer in use, or being kept ‘just in case’ when alternative access would suffice (e.g. treatment is complete but blood products may be needed)

Clinical deterioration (e.g. sepsis) despite appropriate therapy

No evidence of severe sepsis

Non-tunnelled lines (e.g. PICC or midlines).

Damage to line e.g. blocked, break or cuff dislodged

 

Lumens cannot be locked with antimicrobials as blocked or in constant use

 

The decision to salvage or remove a line is clinical and should be made by the Consultant looking after the patient.

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DIRECTED THERAPY (based on blood culture results)

Durations can include empirical treatment IF organism is susceptible (either if salvage or if line out prior to directed therapy)

For patients receiving parenteral nutrition please refer to the appendix for additional information.  The duration for salvage in well patients is normally reduced to 10 days in these patients.

ANTIMICROBIAL THERAPY FOR GRAM POSITIVE CRBSIs

Pathogen

Treatment with line removal

Attempted line salvage

 

Antibiotic

Duration post line removal

Antibiotic

Duration

Staphylococcus aureus (MSSA)

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin IV 2g 6-hourly .

In case of penicillin allergy treat as for MRSA

14 days

Not usually recommended

MRSA

Teicoplanin  IV 12mg/kg dosing as per the prescribing guideline

14 days

Not usually recommended

Coagulase-negative Staphylococci

methicillin (flucloxacillin) susceptible

Line removal is sufficient in most cases with no further antibiotics needed

Flucloxacillin electronic Medicines Compendium information on Flucloxacillin IV 2g 6-hourly3
PLUS
Antimicrobial lock therapy

14 days in total (of antimicrobial lock therapy; intravenous course usually shorter3)

Coagulase- negative Staphylococci

methicillin (flucloxacillin) resistant

Line removal is sufficient in most cases with no further antibiotics needed

Teicoplanin  IV 12mg/kg3 dosing as per the prescribing guideline
PLUS
Antimicrobial lock therapy

14 days in total
(of antimicrobial lock therapy; intravenous course usually shorter3)

Corynebacterium species

Line removal is sufficient in most cases with no further antibiotics needed

Teicoplanin  IV 12mg/kg3 dosing as per the prescribing guideline
PLUS
Antimicrobial lock therapy

14 days in total
(of antimicrobial lock therapy; intravenous course usually shorter3)

Viridans-type Streptococci (penicillin susceptible)

Benzyl penicillin electronic Medicines Compendium information on Benzyl penicillin IV 1.2g 6 hourly

2-7 days

Benzyl penicillin electronic Medicines Compendium information on Benzyl penicillin IV 1.2g 6 hourly3
PLUS
Antimicrobial lock therapy

14 days in total
(of antimicrobial lock therapy; intravenous course usually shorter3)

Enterococcus spp (amoxicillin susceptible)

Amoxicillin electronic Medicines Compendium information on Amoxicillin IV 1g 6-hourly

If allergy to penicillin treat as amoxicillin resistant

5 days

Amoxicillin electronic Medicines Compendium information on Amoxicillin IV 1 g 6-hourly for
+/-Gentamicin4 synergistic dosing3
PLUS
Antimicrobial lock therapy
 

14 days in total (of antimicrobial lock therapy; intravenous course usually shorter3)

Enterococcus spp (amoxicillin resistant, teicoplanin susceptible)

Teicoplanin electronic Medicines Compendium information on Teicoplanin dosing as per the prescribing guideline

5 days

Teicoplanin electronic Medicines Compendium information on Teicoplanin  IV 12mg/kg dosing as per the prescribing guideline
+/- Gentamicin4 synergistic dosing3
PLUS
Antimicrobial lock therapy

14 days in total
(of antimicrobial lock therapy; intravenous course usually shorter3)

Vancomycin resistant Enterococci spp (VRE)

Contact microbiology

5 days

Not usually recommended

 

ANTIMICROBIAL THERAPY FOR GRAM NEGATIVE CRBSIs

Pathogen

Treatment with line removal

Attempted line salvage

 

Antibiotic

Duration post line removal

Antibiotic

Duration

Enterobacterales (e.g E coli, Klebsiella spp, Enterobacter spp)

1st choice

Amoxicillin electronic Medicines Compendium information on Amoxicillin 1 g 6 hourly IV

2 to 7 days

Amoxicillin electronic Medicines Compendium information on Amoxicillin 1 g 6 hourly IV3
PLUS
Antimicrobial lock therapy

14 days in total
(of antimicrobial lock therapy; intravenous course usually shorter3)

 

2nd choice

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam 4.5 g 8 hourly IV

Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam 4.5 g 8 hourly IV3
PLUS
Antimicrobial lock therapy

3rd choice

Ceftazidime electronic Medicines Compendium information on Ceftazidime 1 g 8 hourly IV

Ceftazidime electronic Medicines Compendium information on Ceftazidime 1 g 8 hourly IV3
PLUS
Antimicrobial lock therapy

4th choice

Meropenem electronic Medicines Compendium information on Meropenem 1 g 8 hourly IV

Meropenem electronic Medicines Compendium information on Meropenem 1 g 8 hourly IV3
PLUS
Antimicrobial lock therapy

5th choice
(oral options)

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 750 mg 12 hourly PO
OR
Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole 960mg 12 hourly PO

2 to 7 days

May be appropriate if the line is not in use.

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 750 mg 12 hourly PO
OR
Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole 960mg 12 hourly PO
PLUS
Antimicrobial lock therapy

Pseudomonas aeruginosa

1st choice

Piperacillin tazobactam 4.5 g 6 hourly IV

7 days

Not usually recommended

2nd choice

Ceftazidime electronic Medicines Compendium information on Ceftazidime 1 g 8 hourly IV

3rd choice

Meropenem electronic Medicines Compendium information on Meropenem 1 g 8 hourly IV

4th choice

Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 400 mg 8 hourly IV
OR
Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 750 mg 12 hourly PO if adequate enteral absorption

Stenotrophomonas maltophilia

1st choice

Co-trimoxazole electronic Medicines Compendium information on Co-trimoxazole 1.44 g 12 hourly IV or PO (if adequate enteral absorption)

7 days if neutropenic.
2 days if not.

Not usually recommended

Second choice

Ceftazidime electronic Medicines Compendium information on Ceftazidime 1 g 8 hourly IV

ANTIMICROBIAL TABLE FOR CANDIDAL OR FUNGAL CRBSIs

Pathogen

Treatment with line removal

Attempted line salvage

 

 

Antibiotic

Duration

 

 

Candida spp -fluconazole susceptible

Fluconazole electronic Medicines Compendium information on Fluconazole 400 mg once daily IV or PO (if adequate enteral absorption)

14 days post line removal or post first negative blood culture, whichever is later

Duration will be extended if there are deep-seated sources identified

Not recommended

Candida spp - fluconazole susceptible dose-dependent

Fluconazole electronic Medicines Compendium information on Fluconazole 800 mg once daily IV or PO (if adequate enteral absorption)

Not recommended

Candida spp - fluconazole resistant

Caspofungin electronic Medicines Compendium information on Caspofungin 70 mg loading dose on day 1 then 50 mg once daily IV

Not recommended

ANTIMICROBIAL LOCK THERAPY

  • If the patient has been receiving prophylactic taurolidine locks, then an alternative agent should be used for salvage therapy
  • The volume used should match the volume of the lumen to be locked
  • Wherever possible antimicrobial lock therapy should be used for the longest dwell time possible (up to the stated maximum), and alternative access sought if other IV treatments are required
  • All lumens need to be treated for salvage attempts.
  • If there are two (or more) lumens and it is not possible to lock off all lumens concurrently, consider alternating the lumen locked with that used for IV access (including systemic antimicrobials where required) on a 24 hourly basis. The antibiotic must be given down the unlocked lumen.
  • For patients who are not already established on regular appropriate IV antibiotics, it is advised that antimicrobial lock therapy is administered immediately after a dose of IV antibiotic has been given via a peripheral cannula.  Rationale: It has been observed that some patients suffer from a ‘septic shower’ following administration of line locks, as bacteria present within the lumen end up forced into their circulation. This has been noted in PN patients with gram negative bacteria in their lines, although the clinical deterioration could occur with other high-virulence pathogens
  • When treating long line infection, alternative IV access should be sought and the IV antibiotics given via this, whilst antimicrobial lock therapy is used in the lumens of the infected line. If no alternative access is possible, then IV antibiotics should be given via the infected lumens, with antimicrobial lock therapy following on from this once the patient is systemically better

Agent

Concentration

Minimum dwell time

Maximum dwell time

Taurolidine
First line

Pre-prepared Taurolock

8 hours out of every 24 hours, preferably antimicrobial lock is continuous 24 hours/day

7 days2

If the patient has been receiving prophylactic taurolidine lock therapy, then an alternative agent should be used for salvage therapy

Susceptible Gram positive bacteria

Vancomycin

5 mg/ml

8 hours out of every 24 hours, preferably antimicrobial lock is continuous 24 hours/day

7 days

 Susceptible Gram negative bacteria

Gentamicin

10 mg/mL

8 hours out of every 24 hours, preferably antimicrobial lock is continuous 24 hours/day

7 days

FOOTNOTES

  1. Systemically better includes the absence of fever for 48 hours, improving CRP and clinical improvement.
  2. Taurolock can be left for longer than 7 days if required, up to a maximum of 30 days as treatment
  3. Systemic antimicrobials to continue 2-7 days until systemically better (see footnote 1)
  4. If high level gentamicin susceptible

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APPENDIX - Parenteral Nutrition (PN) patients

Parental Nutrition catheter salvage advice
Definitive management is catheter removal, but for many patients with difficult access / lifelong requirements, their central venous access device (CVAD) is a life line.  Because of this, catheter salvage should be attempted if safe.  The decision to remove the catheter should be based on:

  • Clinical condition of the patient
  • The likelihood the CVAD is the source of the infection
  • The organism grown
  • The number of potential alternatives for venous access9.

If possible, the decision to remove a dedicated PN feeding catheter must be discussed with the nutrition team.
Salvage should NOT usually be attempted in the following situations:

  • Significant shock not responding to treatment
  • Bacteraemia persisting after 72 hours of appropriate treatment
  • Microorganisms known to be difficult to eradicate e.g. S. aureus, Mycobacterium spp, Pseudomonas spp, Stenotrophomonas maltophilia and fungi
  • Presence of metastatic complications e.g. endocarditis or infected pulmonary embolism
  • Relapse of a CRBSI caused by the same bacteria after an appropriate course of antibiotics has been completed
  • Blocked CVADs or those that are not possible to bleed where there is a high clinical suspicion that the CVAD is the source of infection
  • Exit site infection in patients with a peripherally inserted central catheter (PICC) and infections that involve the cuff in patients with a tunnelled catheter

During catheter salvage

  • The CVAD should NOT be used for PN or delivery of any medications other than the appropriate antibiotics being used to treat the infection
  • Alternative access should be sought.  Particularly with patients dependent on PN, it is important that they are not left without fluids.  A cannula for short term fluids is appropriate whilst blood cultures are awaited.
  • If the patient is asymptomatic after a minimum of 72 hours of appropriate catheter salvage therapy, a midline catheter can be inserted. PN may be administered through this until the long term CVAD can be re-used.
  • If the patient demonstrates a good response to catheter salvage therapy (apyrexial by day 5 of therapy and no evidence of on-going infection), treatment should continue for a total of 10 days. The catheter may be used for the administration of intravenous therapies without the need for repeat blood cultures.
  • If a patient spikes a temperature ≥38oC after re-starting infusions via the long term CVAD, and there are no other septic foci, stop infusions and consider line removal. This decision should be made in consultation with the nutrition team if not under their direct care.

Following CVAD removal:

  • Always site the new catheter away from inflamed skin
  • A new long term catheter should not be inserted until the bacteraemia has ended.  It is difficult to define specific criteria on which to make this assessment but consideration should be given to the success of source control i.e. catheter removal, drainage of any abscess, and clinical improvement e.g. resolution of cellulitis and improvement in inflammatory markers.

Provenance

Record: 1680
Objective:
  • To provide evidence-based recommendations for appropriate investigation of suspected infection of long-term intravascular access devices in adults
  • To make recommendations regarding removal of infected intravascular catheters.
  • To provide evidence-based recommendations for appropriate empirical or directed antimicrobial therapy of intravascular catheter-related infection in adults.
  • To recommend appropriate dose, route of administration and duration of antimicrobial agents.
  • To advise in the event of antimicrobial allergy.
  • To standardise the approach to management of intravascular catheter-related infection affecting long-term intravascular access devices in adults.
  • To document the principles underlying management of infected long-term intravascular access devices.
Clinical condition:

Infected long-term intravascular access devices

Target patient group:
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

  • There are no NICE treatment guidelines for line infections
  • Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America.  Leonard A. MermelMichael AllonEmilio BouzaDonald E. CravenPatricia FlynnNaomi P. O'GradyIssam I. RaadBart J. A. RijndersRobert J. SherertzDavid K. WarrenClinical Infectious Diseases, Volume 49, Issue 1, 1 July 2009, Pages 1–45,
  • Central Venous Catheter Care for the Patient With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Charles A. Schiffer, Pamela B. Mangu, James C. Wade, Dawn Camp-Sorrell, Diane G. Cope, Bassel F. El-Rayes, Mark Gorman, Jennifer Ligibel, Paul Mansfield, and Mark Levine Journal of Clinical Oncology 2013 31:10, 1357-1370
  • British Intestinal Failure Alliance (BIFA) Recommendation Management of Catheter Related Blood Stream Infections (CRBSIs) Authors: Simon Lal, Paul Chadwick, Jeremy Nightingale and the BIFA Committee January 2019
  • Comparing success rates in central venous catheter salvage for catheter-related bloodstream infections in adult patients on home parenteral nutrition: a systematic review and meta-analysis Michelle Gompelman,1 Carmen Paus,1 Ashley Bond,2 Reinier P Akkermans,3,4 Chantal P Bleeker-Rovers,5 Simon Lal,2,6 and Geert JA Wanten
  • Diagnosis and management of catheter-related bloodstream infections in patients on home parenteral nutrition Ashley Bond ,1 Paul Chadwick,2 Trevor R Smith,3 Jeremy M D Nightingale,4 Simon Lal1

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.0

Related information

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