Management of Vascular Access Infection with Positive Blood Culture for Enterococcus faecalis in a Patient with a Tenckhoff Catheter

Initial Evaluation

For a patient with Enterococcus faecalis bacteremia related to vascular access and a Tenckhoff catheter in place, systemic ampicillin (or vancomycin if resistant) should be initiated, and an attempt can be made to preserve the vascular catheter with systemic antibiotic therapy for 10-14 days, while the Tenckhoff catheter must be carefully evaluated for signs of peritoneal infection 1, 2, 3
To determine the source of bacteremia, blood cultures from the peripheral vein and vascular catheter should be obtained to confirm that the vascular access is the source of infection 1, 2
The American Journal of Kidney Diseases recommends evaluating the exit site and tunnel of the Tenckhoff catheter for signs of infection (redness, drainage, pain) 4

The vascular catheter can be retained if there are no complications (no endocarditis, septic thrombophlebitis, or metastatic infection), the patient stabilizes clinically within 48-72 hours, and there are no signs of exit site or tunnel infection 1, 2, 3, 5
The Infectious Diseases Society of America recommends removing the vascular catheter if blood cultures remain positive after 72 hours of appropriate antibiotic therapy, or if there are signs of endocarditis, tunnel, or exit site infection 2, 6, 7

The American College of Cardiology recommends ampicillin as the first-line antibiotic for susceptible E. faecalis, with vancomycin as an alternative if resistant 1, 2, 3, 6
The duration of treatment is 10-14 days if the catheter is retained, with an additional 10-14 days after catheter removal if there are no complications 2, 3, 5, 6

An transesophageal echocardiogram (TEE) should be performed if there are clinical signs of endocarditis, persistent bacteremia or fever >72 hours despite appropriate therapy, or presence of a prosthetic valve or other endovascular devices 2, 4, 6, 7, 8

If there is no concomitant peritonitis, the Tenckhoff catheter can be preserved if the peritoneal fluid has a white blood cell count <100/mm³, cultures are negative, and there are no signs of exit site or tunnel infection 5
The American Journal of Kidney Diseases recommends daily evaluation of the exit site and tunnel for signs of infection, and monitoring the peritoneal fluid for turbidity and cell count 4