Treatment of Enterobacter cloacae Infection in a Tunneled Dialysis Catheter

Initial Assessment and Management

The American Journal of Kidney Diseases recommends beginning parenteral antibiotic therapy immediately with coverage for both gram-negative bacilli and gram-positive organisms in patients with Enterobacter cloacae infection in a tunneled dialysis catheter 1, 3
Initial empiric antibiotic therapy should include coverage for Enterobacter species and consider adding gram-positive coverage until culture sensitivities are available, as suggested by the American Journal of Kidney Diseases 3
Definitive therapy should be based on culture results and antimicrobial susceptibility testing, according to the American Journal of Kidney Diseases and Clinical Infectious Diseases 1, 2

For clinically stable patients, the American Journal of Kidney Diseases suggests considering catheter exchange over a guidewire plus 3 weeks of systemic antibiotic therapy if the patient becomes afebrile within 48 hours of starting antibiotics and has no tunnel tract involvement 1
The American Journal of Kidney Diseases and Clinical Infectious Diseases recommend removing the catheter if the patient remains symptomatic after 36 hours of appropriate antibiotic therapy, is clinically unstable, or has evidence of tunnel infection or exit site infection that fails to respond to therapy 1, 2, 3
Removal is also recommended if there are complications such as septic thrombosis, endocarditis, or metastatic infection, as stated by Clinical Infectious Diseases and the American Journal of Kidney Diseases 2, 4

The Clinical Infectious Diseases journal suggests considering adding antibiotic lock therapy as an adjunct to systemic antibiotics for stable patients without tunnel infection 2, 4
Antibiotic lock therapy should be continued for 10-14 days in conjunction with systemic antibiotics, according to Clinical Infectious Diseases 2

The American Journal of Kidney Diseases recommends continuing systemic antibiotics for a minimum of 3 weeks 1, 3
Surveillance blood cultures should be obtained periodically during and immediately after treatment to monitor effectiveness, as suggested by the American Journal of Kidney Diseases 1
A new permanent access should not be placed until blood cultures have been negative for at least 48 hours after cessation of antibiotic treatment, according to the American Journal of Kidney Diseases 1, 3