Catheter-Related Bloodstream Infections (CRBSI)

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Intravenous catheters inserted into central veins such as the internal jugular vein, subclavian vein or femoral vein provide the only and vital access for hemodialysis for patients with no arterio-venous fistulas. Introduction of catheters including venous and urinary catheters increases the risk of bloodstream infections.

In most cases CRBSI can be prevented by simple interventions:

  • Hand hygiene
  • Using full barrier precautions during the insertion of central venous catheters,
  • Cleaning the skin with chlorhexidine,
  • Avoiding the femoral site if possible
  • Removing unnecessary catheters including urinary catheters as soon as possible

Management of CRBSI

Patients with central venous accesses and new fevers should be evaluated for CRBSI, with the catheter as the source of the infection unless otherwise excluded by patient examination and investigations. The following minimum evaluations should be done.

  • Thorough patient history and examination including the central line insertion sites to assess for superficial thrombophlebitis and insertion site abscess
  • Two sets of blood cultures obtained from two different sites and another drawn from the central venous access site
  • If you suspect bacteremia/sepsis remove catheters and culture the tip to guide antibiotic treatment required.
  • Other investigations as determined from history and physical examination of the patient
  • Empiric antibiotics guided by local microbiology and susceptibility of organisms
  • Vancomycin 1gm IV stat dose and thereafter dosed according to renal function for empiric treatment of Methicillin-Resistant Staphylococcus aureus, Coagulase-Negative Staph, Enterococci species
  • For patients unable to tolerate Vancomycin due to deteriorating renal function, switch to Linezolid for the treatment of MRSA and resistant Enterococcus
  • Fourth Generation Cephalosporins (Cefepime 2gm IV Stat) or Carbapenems (Doripenem or Meropenem) should be initiated for empiric gram-negative bacteremia such as Pseudomonas that may be resistant to routinely used gram-negative antibiotics.
  • If cultures are positive for fungal elements particularly Candida albicans, initiate Caspofungin until sensitivity results are available and switch to Fluconazole if susceptible. Remove the central line immediately in the case of candidemia.