Management of Tan Drainage Around Dialysis Catheter Site

Immediate Diagnostic Steps

Obtain cultures of the drainage and blood cultures immediately, then initiate empirical systemic antibiotics covering both Gram-positive organisms (including S. aureus) and Gram-negative bacilli while awaiting culture results, as recommended by the Infectious Diseases Society of America 1, 2
Swab the tan drainage for Gram stain and culture to identify the causative organism, following guidelines from the Infectious Diseases Society of America 1
Obtain blood cultures from both a peripheral vein and through the catheter if peripheral access is unavailable, as suggested by the Infectious Diseases Society of America 3, 4
Draw blood cultures before initiating antibiotics to maximize diagnostic yield, according to the Infectious Diseases Society of America 1
Use proper skin preparation with alcoholic chlorhexidine (>0.5%), alcohol, or tincture of iodine rather than povidone-iodine, as recommended by the Infectious Diseases Society of America 1

Evaluate for signs that mandate immediate catheter removal, including purulent drainage at the exit site, erythema or induration extending beyond the immediate exit site, systemic signs of sepsis, and persistent symptoms despite 2-3 days of appropriate antibiotic therapy, as recommended by the Infectious Diseases Society of America 5, 6, 7, 8

Start vancomycin plus coverage for Gram-negative bacilli based on your local antibiogram, as recommended by the Infectious Diseases Society of America 3, 4
Use vancomycin for Gram-positive coverage (including MRSA) and add a third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination for Gram-negative coverage, according to the Infectious Diseases Society of America 3, 8
Switch vancomycin to cefazolin if culture reveals methicillin-susceptible S. aureus, as suggested by the Infectious Diseases Society of America 8

Attempt catheter salvage with systemic antibiotics plus antibiotic lock therapy for uncomplicated exit site infection, as recommended by the Infectious Diseases Society of America 6, 7
Administer antibiotic lock solution after each dialysis session for 10-14 days as adjunctive therapy, according to the Infectious Diseases Society of America 4, 8
Remove the catheter immediately if any of the following are present: infection with S. aureus, Pseudomonas species, or Candida species, purulent drainage at exit site, tunnel infection or port abscess, persistent bacteremia >72 hours despite appropriate antibiotics, or clinical deterioration or hemodynamic instability, as recommended by the Infectious Diseases Society of America 4, 5, 7, 8

Use 10-14 days of systemic antibiotics plus antibiotic lock for uncomplicated infection with catheter salvage, as recommended by the Infectious Diseases Society of America 8
Use 5-7 days for coagulase-negative staphylococci with catheter removal, according to the Infectious Diseases Society of America 1
Use 4-6 weeks for persistent bacteremia >72 hours or complications, endocarditis or suppurative thrombophlebitis, as recommended by the Infectious Diseases Society of America 8
Use 6-8 weeks for osteomyelitis, according to the Infectious Diseases Society of America 8

Always remove catheter for S. aureus bacteremia, as recommended by the Infectious Diseases Society of America 4, 8
Consider transesophageal echocardiography to rule out endocarditis given high rates of this complication, according to the Infectious Diseases Society of America 9
Evaluate for metastatic infections (septic thrombosis, osteomyelitis) if bacteremia persists >72 hours after catheter removal, as suggested by the Infectious Diseases Society of America 9, 2