Guidelines for Removal of Permanent Tunneled Dialysis Catheters

Infection‑Related Indications for Immediate Removal

In patients with catheter‑related bacteremia who remain febrile or hemodynamically unstable after 36 hours of appropriate antimicrobial therapy, the catheter should be removed immediately. 1
Any clinically unstable patient with suspected catheter‑related bacteremia warrants prompt catheter removal. 2
Bacteremia involving the tunnel tract always requires catheter removal. 3
Persistent bacteremia lasting ≥ 72 hours despite appropriate antibiotics mandates removal. 4

Staphylococcus aureus bacteremia:
- Nontunneled catheters must be removed immediately.
- Tunneled catheters should be removed if tunnel, pocket, or exit‑site infection is present, or in most cases because of the high risk of metastatic complications (e.g., endocarditis). 5
Candida species bloodstream infection: immediate catheter removal plus a minimum of 14 days of antifungal therapy after the last positive blood culture. 4
Pseudomonas (non‑aeruginosa), Burkholderia cepacia, Stenotrophomonas, Agrobacterium, and Acinetobacter baumannii bacteremia: consider removal, especially when bacteremia persists despite therapy. 6
Bacillus and Corynebacterium species infections: the majority require catheter removal. 5
Mycobacteria (e.g., M. fortuitum, M. chelonae): catheter removal is required. 5
Enterobacter cloacae bacteremia: remove the catheter if the patient remains symptomatic after 36 hours of therapy, is clinically unstable, or has tunnel infection. 7

Isolated exit‑site infection (redness, crusting, exudate without systemic signs) should be managed with topical antibiotics and local care; catheter removal is not indicated. 1
Tunnel drainage accompanied by exit‑site infection: treat with parenteral anti‑staphylococcal/anti‑streptococcal antibiotics; remove the catheter only if the infection fails to respond. 2
Port‑pocket abscess or tunnel infection: immediate catheter removal plus 7–10 days of systemic antibiotics and incision/drainage when indicated. 4

Septic thrombosis – catheter removal plus 4–6 weeks of antimicrobial therapy. 4
Endocarditis – catheter removal plus 4–6 weeks of antimicrobial therapy. 4
Septic emboli – catheter removal is required. 3
Metastatic infection – catheter removal is required. 7

Uncomplicated coagulase‑negative staphylococcal bacteremia in a hemodynamically stable patient without tunnel or pocket infection may be managed without removal. 4
In a stable, asymptomatic patient without exit‑site or tunnel involvement who becomes afebrile within 48 hours of antimicrobial therapy, a guidewire exchange plus 3 weeks of systemic antibiotics can be considered. 1
When salvage is attempted, combine systemic antibiotics with antibiotic lock therapy for 2 weeks. 4
Treatment failure (persistent fever, ongoing positive blood cultures, or relapse after antibiotics) mandates catheter removal. 5

Mechanical malfunction of a non‑infected catheter may be addressed by guidewire exchange if no infection is evident. 8
Routine prophylactic replacement of catheters solely to prevent infection is not recommended; removal should be based on clear clinical indication. 8
Catheter removal should not be performed based on fever alone without evidence of catheter infection. 8

After catheter removal for infection, blood cultures must be negative for ≥ 48 hours following the end of antimicrobial therapy before creating new permanent access. 2
For S. aureus bacteremia with endocarditis: complete 4–6 weeks of antibiotics and wait 5–10 days with negative cultures before new access. 4
For uncomplicated coagulase‑negative staphylococcal bacteremia: wait 5–7 days after catheter removal before new access. 4
For Candida bloodstream infection: wait 14 days after the last positive blood culture before new access. 4

Do not attempt catheter salvage in patients with S. aureus bacteremia who are unstable or have tunnel involvement. 1
Do not delay removal in patients who remain symptomatic beyond 36 hours of appropriate antimicrobial therapy. 2
Do not use guidewire exchange for catheters suspected of being infected; this is contraindicated. 8