Management of PICC Line Infections

Diagnostic Approach

The American College of Physicians recommends obtaining paired blood cultures from the catheter and a peripheral vein before starting antibiotics, with the Infectious Diseases Society of America suggesting that if peripheral blood cultures are not possible, draw two blood samples at different times from different catheter lumens 2
The Centers for Disease Control and Prevention guidelines suggest using alcohol, iodine tincture, or alcoholic chlorhexidine (10.5%) for skin preparation before collection, allowing adequate time for the skin to dry to avoid blood contamination 2
If exudate is present at the exit site, obtain a swab for culture and Gram staining, as recommended by the Society for Healthcare Epidemiology of America 2
A positive blood culture from a catheter hub at least 2 hours before microbial growth is detected in a peripheral blood sample best defines catheter-related bloodstream infection (CRBSI), according to the Clinical Infectious Diseases guidelines 3
Quantitative blood cultures and/or differential time to positivity (DTP) should be performed before initiating antimicrobial therapy, as suggested by the Infectious Diseases Society of America 3

The American College of Cardiology recommends starting empirical antibiotic treatment with vancomycin before blood culture results are available, with consideration of daptomycin in cases of higher risk for nephrotoxicity or in settings with high prevalence of MRSA strains with vancomycin MIC ≥2 μg/ml 1, 2
The Infectious Diseases Society of America suggests not using linezolid for empirical therapy, and considering empirical coverage for gram-negative bacilli using fourth-generation cephalosporins, carbapenems, or β-lactam/β-lactamase combinations, with or without an aminoglycoside 2, 4
Remove long-term catheters in patients with CRBSI associated with severe sepsis, suppurative thrombophlebitis, endocarditis, bloodstream infection that continues despite >72 hours of appropriate antimicrobial therapy, or infections due to S. aureus, P. aeruginosa, fungi, or mycobacteria, as recommended by the Society for Healthcare Epidemiology of America 2, 3, 6
The American College of Radiology suggests removing short-term catheters for CRBSI due to gram-negative bacilli, S. aureus, enterococci, fungi, and mycobacteria 3, 7

The American College of Physicians recommends considering empirical therapy for suspected catheter-related candidemia in septic patients with risk factors, using an echinocandin (caspofungin, micafungin, anidulafungin) for empirical treatment, and fluconazole if the patient is clinically stable and has had no exposure to azoles in the previous 3 months 2, 5
Routine flushing with saline after completion of any infusion or blood sampling, weekly flush for tunneled cuffed catheters and PICC lines not in active use, and using chlorhexidine solutions with alcohol for skin preparation during insertion are recommended by the Centers for Disease Control and Prevention to prevent infection 1, 2

Failing to obtain appropriate cultures before initiating antibiotics can complicate diagnosis, according to the Clinical Infectious Diseases guidelines 3
Using linezolid empirically is not recommended by the Infectious Diseases Society of America, and ignoring local resistance patterns can lead to inadequate empiric coverage 2, 4
Monotherapy in high-risk patients is not recommended; combination therapy is preferred, as suggested by the Society for Healthcare Epidemiology of America 4