Diagnostic Approach

The Infectious Diseases Society of America recommends obtaining paired blood cultures from both the catheter and a peripheral vein before starting antibiotics, and immediately removing short-term non-tunneled central lines if the patient has severe sepsis, erythema/purulence at the insertion site, or if cultures grow S. aureus, Pseudomonas, or Candida species 1, 2.
The American College of Clinical Pharmacy suggests drawing paired blood cultures simultaneously from the catheter hub and a peripheral vein, and disinfecting catheter hubs with alcohol, alcoholic chlorhexidine (>0.5%), or tincture of iodine before drawing 1, 3.
A differential time to positivity (DTP) ≥2 hours is highly sensitive and specific for CRBSI, according to the Clinical Infectious Diseases journal 4, 5.

Immediate Catheter Management Decision

The International Journal of Infectious Diseases recommends removing the catheter immediately in situations such as erythema, purulence, or induration at the exit site, clinical signs of septic shock or severe sepsis, tunnel infection or port pocket infection, or persistent bacteremia/fungemia >72 hours despite appropriate antibiotics 1, 2, 4.
The Clinical Infectious Diseases journal suggests that catheter retention may be considered only for coagulase-negative staphylococci in clinically stable patients with limited venous access, and using systemic antibiotics with or without antibiotic lock therapy 2, 4, 5.

The Praxis Medical Insights guideline recommends starting empirical therapy immediately after obtaining cultures, with vancomycin for gram-positive coverage in settings with elevated MRSA prevalence, and adding gram-negative coverage for severe illness, hemodynamic instability, or septic shock 5, 6, 7.
The Clinical Infectious Diseases journal suggests adding empirical antifungal therapy for total parenteral nutrition use, prolonged broad-spectrum antibiotic exposure, hematologic malignancy or bone marrow/solid organ transplant, or femoral catheterization 7.

The International Journal of Infectious Diseases recommends a minimum of 10-14 days IV antibiotics after catheter removal for S. aureus, and 4-6 weeks of IV antimicrobial therapy for complicated S. aureus infections 2, 4, 7.
The Clinical Infectious Diseases journal suggests 10-14 days IV antibiotics after catheter removal for gram-negative organisms, and mandatory catheter removal plus 14 days of antifungal therapy after first negative blood culture and symptom resolution for Candida species 2, 6, 7.

The Clinical Infectious Diseases journal recommends removing the catheter plus ≥14 days systemic therapy for S. aureus, P. aeruginosa, fungi, or mycobacteria in neutropenic patients with cancer, and catheter may be retained with systemic therapy ± antibiotic lock for coagulase-negative staphylococci 4.
The International Journal of Infectious Diseases suggests that CLABSI rates are 2.6-60 per 1000 catheter-days in resource-limited settings versus 2.9 per 1000 in the US, and mortality related to bloodstream infections is 21% in neonates 8, 2.

The Clinical Infectious Diseases journal recommends hand hygiene and maximal sterile barrier precautions, chlorhexidine >0.5% with alcohol for skin antisepsis, and subclavian site preferred over jugular or femoral for insertion bundle 4, 5, 6.
The International Journal of Infectious Diseases suggests replacing transparent dressings and performing site care with chlorhexidine-based antiseptic every 7 days, and disinfecting catheter hubs before each access for maintenance bundle 9.

Neonatal bloodstream infections carry a 21 % mortality risk. 10
Such infections extend NICU length of stay by an average of 23 days. 10
In very low‑birth‑weight infants, any episode of infection significantly raises the likelihood of permanent neurodevelopmental impairment. 10

Central line‑associated bloodstream infection (CLABSI) rates in NICUs range from 2.6 to 60 per 1,000 catheter‑days in resource‑limited settings, compared with 2.9 per 1,000 catheter‑days in the United States. 10
Staphylococcus aureus bacteremia (including MRSA) is associated with a high risk of metastatic complications such as endocarditis and osteomyelitis, necessitating 4–6 weeks of intravenous antimicrobial therapy when these complications occur. 11

Prolonged hospitalization with repeated invasive procedures increases cumulative exposure to nosocomial pathogens. 10
Frequent caregiver contact elevates colonization pressure, facilitating MRSA transmission. 10
The NICU environment often harbors multidrug‑resistant organisms, including MRSA, contributing to infection risk. 10

Preterm infants may lack a febrile response despite serious infection; clinicians should not rely on temperature alone to rule out sepsis. 11