Management of Central Line-Associated Bloodstream Infections (CLABSI)

Immediate Empirical Antimicrobial Therapy

The American College of Physicians recommends initiating vancomycin 15-20 mg/kg IV every 8-12 hours PLUS an anti-pseudomonal beta-lactam immediately upon suspicion of CLABSI, before culture results are available 1
Obtain at least 2 sets of blood cultures before starting antibiotics: one from the catheter and one from a peripheral vein, as recommended by the Infectious Diseases Society of America 1, 2
A differential time to positivity (DTP) >120 minutes between catheter and peripheral cultures confirms CLABSI, according to the Centers for Disease Control and Prevention 1, 2
Adjust therapy based on culture results and antimicrobial susceptibilities once available, as suggested by the Society for Healthcare Epidemiology of America 1
In countries with low MRSA rates, an anti-staphylococcal beta-lactam may be used instead of vancomycin, as recommended by the European Society of Clinical Microbiology and Infectious Diseases 2

The Infectious Diseases Society of America recommends removing the catheter immediately for CLABSI caused by Staphylococcus aureus, Pseudomonas aeruginosa, Candida species, or mycobacteria 1, 2
Mandatory catheter removal scenarios include S. aureus, P. aeruginosa, fungi, or mycobacteria, as recommended by the American Society of Clinical Oncology 3, 1, 2
Suppurative thrombophlebitis, endocarditis, tunnel infection or port pocket infection, and persistent bacteremia >72 hours despite appropriate antimicrobial therapy are also indications for catheter removal, according to the Society for Healthcare Epidemiology of America 1
Hemodynamic instability or septic shock is another indication for catheter removal, as recommended by the Infectious Diseases Society of America 5

The American College of Physicians recommends a minimum of 14 days of systemic therapy for S. aureus, P. aeruginosa, fungi, or mycobacteria after catheter removal 1
For gram-negative organisms (uncomplicated), 10-14 days of therapy is recommended, though recent evidence supports ≤7 days as equally safe and effective, according to the Infectious Diseases Society of America 1
For coagulase-negative staphylococci, 7-10 days of therapy is recommended if catheter removed, as suggested by the Society for Healthcare Epidemiology of America 1
For complicated CLABSI (endocarditis, osteomyelitis, metastatic infection), 4-6 weeks of therapy is recommended, according to the American Society of Clinical Oncology 3, 1

The Infectious Diseases Society of America recommends always removing the catheter for Staphylococcus aureus and obtaining transesophageal echocardiography to exclude endocarditis 1, 3
Treat S. aureus with isoxazolylpenicillin (methicillin-sensitive) or glycopeptide/linezolid (methicillin-resistant) for ≥2 weeks, as recommended by the European Society of Clinical Microbiology and Infectious Diseases 3
For Pseudomonas aeruginosa, always remove the catheter and treat according to susceptibility pattern for ≥2 weeks, according to the American Society of Clinical Oncology 1, 2, 3
For Candida species, always remove the catheter and treat with echinocandin preferred for initial therapy, as recommended by the Infectious Diseases Society of America 1, 3, 4

The Centers for Disease Control and Prevention recommends hand hygiene as the single most effective intervention to prevent CLABSI 1, 2
Use maximal sterile barrier precautions during catheter insertion, as recommended by the Society for Healthcare Epidemiology of America 1, 2
Apply >0.5% chlorhexidine with alcohol for cutaneous antisepsis, according to the Infectious Diseases Society of America 1, 2
Remove catheters as soon as clinically appropriate, as suggested by the American College of Physicians 1
Implement education and ongoing training for healthcare personnel, as recommended by the European Society of Clinical Microbiology and Infectious Diseases 2
Consider prophylactic antibiotic locks in patients with multiple prior CLABSI or facilities with rates >3.5/1,000 catheter days, according to the American Journal of Kidney Diseases 6

The American Society of Clinical Oncology recommends not adding empiric vancomycin without proof of antibiotic-resistant gram-positive bacteria unless severe sepsis/shock present in neutropenic/hematology-oncology patients 3, 4
Catheter removal is associated with lower mortality specifically in neutropenic patients with candidemia, as suggested by the European Society of Clinical Microbiology and Infectious Diseases 4
Prospective surveillance and intensive training reduce infection rates by up to 68% in neutropenic/hematology-oncology patients, according to the American Society of Clinical Oncology 3
For hemodialysis patients, an individualized approach based on patient health, dialysis circumstances, and vascular access options is recommended, as suggested by the American Journal of Kidney Diseases 6