Current strategies for the prevention and management of central line-associated bloodstream infections

Figures & data

Figure 1 Example of a central vascular catheter insertion checklist. Copyright © 2010, reproduced with permission from BJC Infection Prevention and Epidemiology Consortium.

Table 1 Final concentrations of common antibiotic lock solutions

Antibiotic and dosage	Heparin dosage	References
Vancomycin 2 mg/mL	10 units/mL	Robinson et al^Citation88
Daptomycin 5 mg/mL	100–10,000 units/mL	Carpenter and Chambers^Citation90
Gentamicin 1 mg/mL^a	2500 units/mL	Krishnasami et al^Citation76
Ciprofloxacin 0.2 mg/dL	5000 units/mL	Droste et al^Citation85
Ceftazidime 0.5 mg/dL	100 units/mL	Rijnders et al^Citation91
Piperacillin-tazobactam 10 mg/mL	100 units/mL	Del Pozo et al^Citation81
Ethanol 70%	No	Onland et al,^Citation92 Maiefski et al,^Citation93 and Sanders et al^Citation94

Note:

a Heparin partially inhibits the antimicrobial activity of gentamicin, but this inhibition was overcome in vitro by a gentamicin concentration of 1 mg/mL.⁷⁶

Table 2 Preferred antibiotics regimen commonly used in dialysis patients

Antibiotic	Dosing
Vancomycin	20 mg/kg loading dose during the last hour of the dialysis session, then 500 mg during the last 30 min of each subsequent dialysis session
Gentamicin	1 mg/kg, not to exceed 100 mg, after each dialysis session
Ceftazidime	1 g after each dialysis session
Cefazolin	20 mg/kg after each dialysis session
Daptomycin	6 mg/kg after each dialysis session
Echinocandins (caspofungin, micafungin, and anidulafungin), fluconazole, or amphotericin B	Dose and frequency are the same as in nondialysis patients (see Table 3)

Table 3 Intravenous antimicrobial treatment of central line-associated bloodstream infection

Pathogen	Preferred antimicrobial agent with normal renal function and no drug interaction	Alternative antimicrobial agent	Duration	Comments
Gram-positive cocci
MSSA	Nafcillin or oxacillin 2 g q4h	Cefazolin 2 g q8h	4–6 weeks	Remove the infected catheter
MRSA	Vancomycin 15 mg/kg q12h	Daptomycin 6 mg/kg daily or telavancin 10 mg/kg daily
CNS, methicillin sensitive	Nafcillin or oxacillin 2 g q4h	Cefazolin 2 g q8h	1 week if the infected catheter is removed, 2 weeks if the infected catheter is retained + antibiotic lock therapy
CNS, methicillin resistant	Vancomycin 15 mg/kg q12h	Daptomycin 6 mg/kg daily
Enterococcus faecalis/faecium
Ampicillin susceptible	Ampicillin 2 g q4h ± gentamicin 1 mg/kg q8h^a	Vancomycin 15 mg/kg q12h ± gentamicin 1 mg/kg q8h	1–2 weeks Catheter removal is recommended. Treat with IV antibiotics and antibiotic lock therapy if the infected catheter is retained	Quin/Dalf is not effective against E. faecalis
Ampicillin resistant, vancomycin susceptible	Vancomycin 15 mg/kg q12h ± gentamicin 1 mg/kg q8h	Linezolid 600 mg PO/IV bid or daptomycin 6 mg/kg daily
Ampicillin resistant, vancomcyin resistant	Linezolid 600 mg PO/IV bid or daptomycin 6 mg/kg daily	Quin/Dalf 7.5 mg/kg q8h
Gram-negative bacilli
Escherichia coli and Klebsiella spp. ESBL negative	Third-generation cephalosporin such as ceftriaxone 1–2 g daily	Cipro 400 mg IV q12h or Aztreonam 1–2 g IV q8–12h	7–14 days if the infected catheter is removed, 10–14 days of systemic antibiotics and antibiotic lock if the infected catheter is retained
Escherichia coli and Klebsiella spp. ESBL positive	Carbapenems,^Citation114 such as ertapenem 1 g daily or meropenem 1 g q8h or doripenem 500 mg q8h	Cipro 400 mg IV q12h	The same as above
Enterobacter spp. Serratia marcescens	Carbapenems,^Citation114 such as ertapenem 1 g daily or meropenem 1 g q8h or doripenem 500 mg q8h	Cefepime 1 g IV q8h or Cipro 400 mg IV q12h	The same as above
Acinetobacter spp.	Carbapenems (see dose above) ± polymyxins/sulbactam/aminoglycosides^b	Polymyxins, sulbactam, or aminoglycosides if carbapenem resistant	The same as above
Stenotrophomonas maltophilia	TMP-SMZ 3–5 mg/kg q8h ± ticarcillin-clavulanate 3.1 g q6h/ceftazidime 2 g q8h^Citation130	Ticarcillin–clavulanate 3.1 g q6h, ceftazidime 2 g q8h/cefepime 2 g q12h, if TMP-SMZ resistant^c	The same as above	Consider removing the infected catheter^Citation78,Citation131
Pseudomonas aeruginosa	Fourth-generation cephalosporins such as cefepime 2 g q8h, carbapenem such as meropenem 1 g q8h, or piperacillin–tazobactam 4.5 g q6h ± an antipseudomonal aminoglycoside (tobramycin or gentamicin 5–7 mg/kg q24, amikacin 15 mg/kg q24h)^Citation70,Citation132		The same as above	Consider removing the infected catheter^d
Burkholderia cepacia	TMP-SMZ 3–5 mg/kg q8h or carbapenem such as meropenem 1 g q8h		The same as above
Fungi
Candida albicans or other Candida spp.	Echinocandins (such as caspofungin 70 mg loading dose, followed by 50 mg/day; anidulafungin 200 mg loading dose, followed by 100 mg/day; or micafungin 100 mg/day), or fluconazole 800 mg loading dose, followed by 6 mg/kg/day if organism is susceptible	Lipid amphoB preparations	14 days after the first negative blood culture without persistent fungemia or metastatic complications^Citation72	Remove the infected catheter^Citation133
Other Gram-positive microorganisms
Corynbacterium spp., Bacillus spp., Micrococcus	Vancomycin 15 mg/kg q12h	Treat according to in vitro susceptibility	2 weeks	Remove the infected catheter if possible

Notes:

a When catheter is retained, combination therapy with an aminoglycoside is preferred;¹¹¹

b Mortality is significantly higher in patients who are not treated with carbapenems;¹¹⁵

c Combination therapy instead of monotherapy is recommended;^130,134

d Although catheter removal is usually required in Pseudomonas CLABSI,^1,78 systematic antibiotics and antibiotic lock therapy have shown success in selected cases.⁷⁹

Abbreviations: MSSA, methicillin-sensitive S. aureus; MRSA, methicillin-resistant S. aureus; CNS, coagulase-negative Staphylococci; Quin/Dalf, quinupristin/dalfopristin; ESBL, extended-spectrum beta-lactamase; TMP-SMZ, trimethoprim-sulfamethoxazole; cipro, ciprofloxacin; amphoB, amphotericin B.

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