Diagnosis and Management of Central Line Associated Bloodstream Infections (CLI) v.

1
Executive Summary Test Your Knowledge Inclusion Criteria
Inpatients and ED patients with suspected CLI

Initial Blood Culture PHASE

Explanation of Evidence Ratings Summary of Version Changes

Exclusion Criteria

!
Do NOT perform blood cultures if CLI not suspected

Amb. Clinic patients Heme/Onc, BMT patients and those on ECMO

!
Remove/exchange non-tunneled catheters promptly in unstable patients; remove all catheters if tunnel infection suspected

Obtain cultures:
Immunocompetent Patient

Blood cultures peripherally and from all catheter lumens Catheter site cultures if indicated Review clinical status

Immunocompromised Patient

High suspicion of CLI, hemodynamically unstable, toxic, or at risk for complications

Low suspicion of CLI, hemodynamically stable,non-toxic, and low risk for complications (minority of patients)

Hemodynamically stable, and non-toxic

Hemodynamically unstable, toxic, or at risk for complications

antibiotics Empiric Antibiotics:
Piperacillin/tazobactam PLUS Vancomycin AND gentamicin if severely ill AND antifungal antifungal if if AND severely ill ill and and with with risk risk severely factors for for fungal fungal disease disease factors

!
Defer antibiotics
Allergies? Call ID!

Empiric Antibiotics: antibiotics:
Piperacillin/tazobactam PLUS Antifungal if risk factors for fungal disease

Empiric antibiotics: Antibiotics:
Meropenem PLUS Vancomycin PLUS Gentamicin PLUS Antifungal if risk factors for fungal disease

Re-evaluate clinical status: Discontinue Antibiotics
Negative cultures at 48 hours and asymptomatic

Definition for nontunneled or tunneled CLs

To Preliminary Cultures: Non-Tunnelled CVCs

After first antibiotic doses and fluid resuscitation Daily

Positive Cultures

Follow culture results

To Preliminary Cultures: Tunnelled CVCs

For questions concerning this pathway, contact: CLI_Pathway@seattlechildrens.org
© 2012 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

Last Updated: 01/23/2013 Valid until:01/23/2016

Diagnosis and Management of Central Line Associated Bloodstream Infections (CLI) v.1
Executive Summary Test Your Knowledge

Preliminary Culture PHASE, Non-Tunneled CVCs

Explanation of Evidence Ratings Summary of Version Changes

Inclusion Criteria
Inpatients and ED patients with suspected CLI

!
Do NOT perform blood cultures if CLI not suspected

Exclusion Criteria
Amb. Clinic patients Heme/Onc, BMT patients and those on ECMO

!
Remove/exchange non-tunneled catheters promptly in unstable patients; remove all catheters if tunnel infection suspected

Preliminary culture results
Gram-positive organisms Gram-negative organisms

Yeast

Gram-Positive Organisms
Consider removing/exchanging the catheter and culturing the catheter tip Evaluate for other sources of infection Repeat blood cultures (from CL only is acceptable) Then add vancomycin if not currently on Add vancomycin lock therapy if not removing/exchanging immediately

Gram-Negative Organisms Yeast
Remove/exchange the catheter and culture the catheter tip Evaluate for other sources of infection Repeat blood cultures (from CL only is acceptable) Then begin antifungal If CLI, remove/exchange the catheter and culture the catheter tip If not a documented CLI, evaluate for other sources of infection and consider remove/exchange of catheter Repeat blood cultures (from CL only is acceptable) Ensure appropriate gram-negative coverage (e.g., pip/tazo) Add second gram-negative agent if patient unstable

Polymicrobial infections
CLIs can involve more than one organism Do not narrow antimicrobials until all organisms are identified and their susceptibilities known. Call ID with questions.

Documenting clearance of CLI
Repeat blood cultures daily: From CL if retained / possible, otherwise peripherally / arterially Until cultures remain negative for at least 48 hours Assure clearance clearance of of infection infection prior prior to to Assure replacing the the catheter, catheter, if if needed needed replacing
Final culture results available

To Definitive Treatment: NonTunnelled CVCs

For questions concerning this pathway, contact: CLI_Pathway@seattlechildrens.org
© 2012 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

Last Updated: 01/23/2013 Valid until:01/23/2016

Diagnosis and Management of Central Line Associated Bloodstream Infections (CLI) v.1
Executive Summary Test Your Knowledge

Preliminary Culture PHASE, Tunneled CVCs

Explanation of Evidence Ratings Summary of Version Changes

Inclusion Criteria
Inpatients and ED patients with suspected CLI

!
Do NOT perform blood cultures if CLI not suspected

Exclusion Criteria
Amb. Clinic patients Heme/Onc, BMT patients and those on ECMO

!
Remove/exchange non-tunneled catheters promptly in unstable patients; remove all catheters if tunnel infection suspected

Preliminary culture results
Gram-positive organisms Gram-negative organisms

Gram-Negative Organisms Gram-Positive Organisms
If CLI, consider catheter salvage if patient stable If CLI, remove/exchange the catheter if patient unstable If not a documented CLI, evaluate for other sources of infection and consider remove/exchange of catheter Repeat blood cultures (from CL only is acceptable) Then add vancomycin if not currently on Add vancomycin lock therapy if catheter retained
Yeast

Yeast
Remove/exchange the catheter Repeat blood cultures (from CL only is acceptable) Then begin antifungal

If CLI, consider catheter salvage if patient stable If CLI, remove/exchange the catheter if patient unstable If not a documented CLI, evaluate for other sources of infection and consider remove/exchange of catheter Repeat blood cultures (from CL only is acceptable) Ensure appropriate gram-negative coverage (e.g., pip/tazo) Add second gram-negative agent if patient unstable Add lock therapy if catheter retained

Polymicrobial infections
CLIs can involve more than one organism Do not narrow antimicrobials until all organisms are identified and their susceptibilities known. Call ID with questions.

Documenting clearance of CLI
Repeat blood cultures daily: From CL if retained / possible, otherwise peripherally / arterially Until cultures remain negative for at least 48 hours Assure Assure clearance clearance of of infection infection prior prior to to replacing the catheter, if needed replacing the catheter, if needed
For questions concerning this pathway, contact: CLI_Pathway@seattlechildrens.org
© 2012 Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

Final culture results available

To Definitive Treatment: Tunnelled CVCs

Last Updated: 01/23/2013 Valid until:01/23/2016

4. 5.org © 2012 Seattle Children’s Hospital.Diagnosis and Management of Central Line Associated Bloodstream Infections (CLI) v. BMT patients and those on ECMO Repeat blood blood cultures daily: Repeat cultures daily: From CL if retained / possible. aureus antibiotic selection Treat uncomplicated CLI for 14 days. Medical Disclaimer Last Updated: 01/23/2013 Valid until:01/23/2016 . Enterococci: Use vancomycin lock therapy in addition to systemic therapy if the catheter is retained. otherwise peripherally / arterially Until cultures remain negative for at least 48 hours Assure Assure clearance clearance of of infection infection prior prior to to replacing replacing the the catheter. all rights reserved. remove/exchange catheter and evaluate for metastatic infection Exclusion Criteria Amb. contact: CLI_Pathway@seattlechildrens.1 Executive Summary Test Your Knowledge Definitive Results PHASE. Treat complicated CLI for 4-6 weeks. Gram-negative bacilli: ! Other situations. Remove/exchange the catheter 2.lugdunensis) If CLI. Perform echocardiography if >1 positive culture Consult Infectious Diseases for all patients with high illness severity or multiple comorbidities. Clinic patients Heme/Onc. Enterococcal antibiotic selection Treat for 7-14 days. can consider catheter salvage if patient stable Add vancomycin lock therapy if not currently on Treat for 5-10 days if CL salvaged. For questions concerning this pathway. or 3-5 days if removed Manage CLI due to S. or >4-6 weeks for complicated infections. or >4-6 weeks for complicated infections. Staphylococcus aureus: S. aureus CLI Day 1 of treatment is the first day of negative cultures without subsequent positives All Other Organisms 1. 3.lugdunensis) All other organisms Coagulase-Negative Staphylococcus (other than S. lugdunensis similarly to recommendations for S. Candida species: Candida antifungal selection Treat for 14 days for uncomplicated CLI. if if needed needed Definitive culture results (identification and susceptibilities of all organisms finalized) Coagulase-negative Staphylococcus (other than S. Non-Tunneled CVCs Explanation of Evidence Ratings Summary of Version Changes Inclusion Criteria Inpatients and ED patients with suspected CLI ! If >3 days of positive cultures on appropriate antibiotics. Call ID! Gram-negative Gram-negative antibiotic antibiotic selection selection Treat for 7-14 days for uncomplicated CLI. catheter.

consult Infectious Diseases ! Other situations. P. lugdunensis similarly to recommendations for S.Diagnosis and Management of Central Line Associated Bloodstream Infections (CLI) v. aeruginosa. aureus.lugdunensis) S. consult Infectious Diseases All Other Organisms Attempt catheter catheter salvage salvage in in stable stable Attempt patients patients Employ the narrowest possible antibiotic therapy Employ Employ lock lock therapy therapy Enterococcus Gram Negative Bacilli For other scenarios. remove/exchange catheter and evaluate for metastatic infection Inpatients and ED patients with suspected CLI Exclusion Criteria Amb. Yeast.1 Executive Summary Test Your Knowledge Definitive Results PHASE. aureus. if needed Definitive culture results (identification and susceptibilities of all organisms finalized) Coagulase-negative Staphylococcus (other than S. Yeast. P. contact: CLI_Pathway@seattlechildrens. AFB.lugdunensis) If CLI.org © 2012 Seattle Children’s Hospital. Call ID! How to define treatment duration For questions concerning this pathway. AFB. Medical Disclaimer Last Updated: 01/23/2013 Valid until: 01/23/2016 . other difficult to eradicate pathogens Remove / exchange the catheter Employ the narrowest possible antibiotic therapy Staphylococcus aureus recommendations Pseudomonas aeruginosa recommendations Yeast recommendations AFB recommendations For other scenarios or if unable to discontinue CL. aeruginosa. consider catheter salvage if patient stable Add vancomycin lock therapy if not currently on Treat for 5-10 days if CL salvaged. BMT patients and those on ECMO Repeat blood cultures daily: From CL if retained / possible. Tunneled CVCs Explanation of Evidence Ratings Summary of Version Changes Inclusion Criteria ! If >3 days of positive cultures on appropriate antibiotics. other difficult to eradicate pathogens All other organisms Coagulase-Negative Staphylococcus (other than S. Clinic patients Heme/Onc. otherwise peripherally / arterially Until cultures remain negative for at least 48 hours Assure clearance of infection prior to replacing the catheter. aureus CLI S. or 3-5 days if removed Manage CLI due to S. all rights reserved.

non-tunneled CVC Preliminary cultures.Background Millions of indwelling vascular devices are placed annually for administering medications. non-tunneled CVC Definitive treatment. which can cause significant morbidity and mortality. fluids. Furthermore. tunneled CVC . This pathway’s intent is to standardize – to the extent possible – the diagnosis and management of such central venous catheter infections at Seattle Children’s. These catheters can become infected. the variety both of vascular devices available and organisms that can cause catheter-related infections makes providing simple and easy-to-follow recommendations for the management of such infections difficult. tunneled CVC Definitive treatment. and nutrition. To Initial Culture Phase To Preliminary cultures.

non-tunneled CVC Preliminary cultures. The inclusion and exclusion criteria as are follows: • Inclusion criteria: o o Presence of a central venous catheter Suspected CLI among inpatients and Emergency Department patients Patients without central venous catheters Ambulatory clinic patients Patients on ECMO Hematology / Oncology patients • Exclusion criteria: o o o o To Initial Culture Phase To Preliminary cultures. tunneled CVC Definitive treatment.Introduction – Central Line Infections This clinical standard work pathway is meant to entail the diagnosis and management of patients with Central Line Infections (CLI). non-tunneled CVC Definitive treatment. tunneled CVC .

tunneled CVC . non-tunneled CVC Definitive treatment. non-tunneled CVC Preliminary cultures.Definition: Suspected CLI CLI should be suspected in those with a central catheter in place for >24 hours and a new-onset fever or other systemic or local signs of infection such as hypotension or redness. consider using this pathway for those >7 days of post-natal age and who have central catheters in place for >24 hours. tenderness. or discharge from their central catheter site. In NICU patients. To Initial Culture Phase To Preliminary cultures. tunneled CVC Definitive treatment.

femoral lines. non-tunneled CVC Preliminary cultures. and ports. IJ lines. To Initial Culture Phase To Preliminary cultures. such as Hickman catheters. tunneled CVC . and other central lines not tunneled under the skin. non-tunneled CVC Definitive treatment. Broviacs. tunneled CVC Definitive treatment. • Tunneled catheters include those tunneled under the skin and placed surgically.Definition: Non-Tunneled and Tunneled Catheters • Non-tunneled catheters include peripherally inserted central catheters (PICCs).

non-tunneled CVC Definitive treatment. To Initial Culture Phase To Preliminary cultures. HIV). • Higher risk: o Patients who are immunocompromised* (receiving immunosuppressive medications. with indwelling hardware other than the central line (e. mental status changes. or otherwise of tenuous clinical status / critically ill. * If in doubt. or indwelling hardware other than their central line (e. with a single fever or sustained low-grade fever. prosthetic heart valves). tunneled CVC . tunneled CVC Definitive treatment. assume a patient to be immunocompromised and / or call Infectious Diseases.g. non-tunneled CVC Preliminary cultures.Definition: Risk of Complications • Low risk: o Patients who are immunocompetent.. primary immunodeficiency. and without hemodynamic instability. prosthetic heart valves).. transplant recipients.g. a right-to-left cardiac shunt of any kind. toxic appearance.

• Linezolid should not typically be used for empirical therapy (i. tunneled CVC .. ). non-tunneled CVC Preliminary cultures. When an organism has been identified and susceptibilities are available. • Do NOT routinely use urokinase and other thrombolytic agents as adjunctive therapy for patients with CLI (Mermel. Likewise use micafungin if initial culture results suggest candidal infection (e. ongoing use of parenteral nutrition (Mermel. Mermel..g. ).Definition: Risk Factors for Fungal Disease • No clear guidelines for when to begin empiric antifungal therapy exist. tailor the antibiotics to the narrowest effective agent (see subsequent slides). femoral line in place. Amphotericin B rather than micafungin is typically used for empiric antifungal treatment of neonates. • Administer antibiotics through the colonized catheter (Mermel. Mermel. ). ). but typically empiric antifungal therapy should be begun only in the presence of known risk factors. tunneled CVC Definitive treatment. • Some services (e. Empiric Therapy for CLI (cont’d) • Use micafungin in addition to antibiotics above for septic patients with any fungal infection risk factors (see risk factors definition slide. • Known risk factors for fungemia include extreme prematurity.. ). in patients suspected but not proven to have CRBSI.e. non-tunneled CVC Definitive treatment. yeast identified on culture).g. ICU) have specific protocols for empiric antimicrobial therapy that may supersede these recommendations. SCCA. prolonged broad-spectrum antibiotics. To Initial Culture Phase To Preliminary cultures. bone marrow or solid organ transplantation or other abdominal surgery entering a viscus.

3% of all CLI would be missed if not all lumens are sampled (Guembe. tunneled CVC Definitive treatment.. Some central catheters (e.8% and 37. To Initial Culture Phase To Preliminary cultures. ) • If a patient with a CVC has a single positive blood culture that grows coagulase-negative Staphylococcus species. Studies estimate that between 15. ) • Prepare skin and the catheter hub for peripheral culture using either alcohol or tincture of iodine or alcoholic chlorhexidine (10.3% of CLI would be missed had peripheral cultures not been drawn (Scheinemann et al.e. (Mermel.. obtain blood cultures daily until cultures remain negative for at least 48 hours to document sterilization. and Shah ) Culture All Lumens and Peripherally • Catheter-drawn cultures alone are significantly less specific than when peripheral cultures are also performed (Falagas. (Mermel. (Mermel. • Culture the catheter skin exit site if signs of local infection (i. tunneled CVC .Blood Culture Recommendations • Do NOT routinely obtain catheter cultures in the absence of suspected CLI. ) and that 12. ) and result in higher rates of false-positive CLI diagnoses. (Mermel. ) • Once bacteremia or fungemia has been identified. (Local consensus. ) Blood Culture Recommendations (cont’d) • Do NOT routinely obtain catheter cultures as test-of-cure after treatment for CLI. redness) and discharge are present. and allow adequate skin contact and drying time. by which time 96% of cultures from central catheters are predicted to be positive. • Similarly. culturing all lumens and obtaining peripheral cultures add sensitivity to making the diagnosis of CLI. non-tunneled CVC Preliminary cultures. • Arterial samples are an acceptable alternative to peripheral samples. . (Mermel.. in neonates) cannot be sampled directly.g. non-tunneled CVC Definitive treatment. ) • Obtain blood cultures prior to initiation of antibiotic therapy. rather than povidone-iodine. ).5%). obtain additional cultures through the suspected catheter and peripherally before the initiation of antimicrobial therapy and/or catheter removal.

tunneled CVC . non-tunneled CVC Preliminary cultures. ) To Initial Culture Phase To Preliminary cultures. ) • Growth of microbes from blood drawn through a catheter hub at least 2 hours before microbial growth is detected in blood samples obtained peripherally. non-tunneled CVC Definitive treatment. (Mermel. SCH does not currently employ the quantitative blood culture technique. However.  • A quantitative blood culture obtained through the catheter with a colony count of microbes at least 3-fold greater than that from peripheral culture. (Mermel. Diagnosis of CLI (cont’d) Diagnosis of possible CLI includes the following: • 2 quantitative blood cultures obtained through 2 catheter lumens in which the colony count for the sample drawn through one lumen is at least 3-fold greater than that from the second lumen.Diagnosis of CLI Definitive diagnosis of CLI includes any of the following: • The same organism growing peripherally and from the catheter tip. Again. SCH does not currently employ the quantitative blood culture technique. tunneled CVC Definitive treatment. The SCH laboratory does report time to positivity for blood cultures. (Mermel. with the same volume of blood obtained in each bottle.

e. for selected immunocompetent patients who are stable and at low risk for complications. in patients suspected but not proven to have CRBSI.. tailor the antibiotics to the narrowest effective agent (see subsequent slides). • Use piperacillin/tazobactam for empirical CLI therapy in stable immunocompetent and immunocompromised hosts (Mermel. ). • Alternatively. ICU) have specific protocols for empiric antimicrobial therapy that may supersede these recommendations. SCCA. ) Use empirical antibiotics as follows: • Instill antibiotics through the infected catheter when possible. Empiric Therapy for CLI (cont’d) • Use micafungin in addition to antibiotics above for septic patients with any fungal infection risk factors (see risk factors definition slide. use vancomycin and gentamicin (Mermel. To Empiric Therapy Pg 2 To Initial Culture Phase To Preliminary cultures. Likewise use micafungin if initial culture results suggest candidal infection (e. When an organism has been identified and susceptibilities are available. non-tunneled CVC Definitive treatment.g. • Administer antibiotics through the colonized catheter (Mermel. • Do NOT routinely use urokinase and other thrombolytic agents as adjunctive therapy for patients with CLI (Mermel. ). ). • Some services (e.g. Mermel. tunneled CVC . non-tunneled CVC Preliminary cultures. (Mermel. ).Empiric Therapy for CLI Use the first day on which negative blood culture results are obtained as day 1 of therapy. Mermel. antibiotics may be withheld pending culture results (Local consensus. tunneled CVC Definitive treatment.. ). Amphotericin B rather than micafungin is typically used for empiric antifungal treatment of neonates. • Use piperacillin/tazobactam and vancomycin with or without gentamicin for empirical CLI therapy in unstable immunocompetent and immunocompromised hosts (Mermel. yeast identified on culture). • Linezolid should not typically be used for empirical therapy (i. ).. ). ). • For empirical CLI therapy in patients with hemodialysis catheters.

bone marrow or solid organ transplantation or other abdominal surgery entering a viscus. prolonged broad-spectrum antibiotics. femoral line in place. tunneled CVC Definitive treatment. low risk for complications Unstable. non-toxic. low risk for complications. non-toxic. severely ill Antibiotic selection Piperacillin/ tazobactam [AND micafungin if risks for fungal disease] Meropenem AND vancomycin AND gentamicin [AND micafungin if risks for fungal disease] Meropenem if penicillin allergic Discuss with Infectious Diseases Alternatives Meropenem if penicillin allergic Discuss with Infectious Diseases Alternatives *See Febrile neutropenia pathway for management of those patients **Known risk factors for fungemia include extreme prematurity.Empiric Antibiotic Selection by Clinical Scenario Immunocompetent patients Stable. non-toxic. severely ill Antibiotic selection Can defer antibiotics Piperacillin/ tazobactam Piperacillin/ tazobactam AND vancomycin AND gentamicin [AND micafungin if risks for fungal disease**] Immunocompromised* patients Stable. ongoing monitoring assured Stable. ). To Initial Culture Phase To Preliminary cultures. toxic. low risk for complications (most patients) Unstable. non-tunneled CVC Definitive treatment. ongoing use of parenteral nutrition (Mermel. tunneled CVC . toxic. non-tunneled CVC Preliminary cultures.

tunneled CVC Definitive treatment. non-tunneled CVC Preliminary cultures. Do NOT routinely allow antibiotic lock solution dwell times to exceed 48 hours before re-instillation of lock solution. Lock Therapy for CLI Treatment with Catheter Salvage (cont’d) • Do NOT routinely use antibiotic lock therapy for CLI due to S. ). ethanol lock therapy is limited to use in patients with CLI meeting criteria specified in the SCH ethanol lock policy (Local consensus. ). ). Re-instill lock solution with each dialysis session for patients undergoing hemodialysis (Mermel. ). tunneled CVC . non-tunneled CVC Definitive treatment. unless there are significant extenuating circumstances (Mermel. ). • Do NOT routinely use ethanol lock therapy (Mermel. use antibiotic lock therapy in conjunction with systemic antimicrobial therapy. the vancomycin concentration should be at least 1000 times higher than the minimum inhibitory concentration of the microorganism involved (Mermel.Lock Therapy with Catheter Salvage • Use lock therapy for all patients with CLI of a long-term catheter without signs of exit site or tunnel infection and for whom catheter salvage is the goal (Mermel. ). • Do NOT routinely use antibiotic lock therapy ALONE for CLI. • When vancomycin lock therapy is used. with both regimens administered for 7-14 days (Mermel. ). and the lock solution should be administered 1-2 times daily to each lumen (Local consensus. aureus or Candida species and instead remove the catheter. Re-instill lock solution every 24 hours for ambulatory patients with femoral catheters (Mermel. To Initial Culture Phase To Preliminary cultures. ). • Dwell times for antibiotic locks should be 8-12 hours per day or >2 hours per day for ethanol locks. ).

Questions regarding risk or management of possible MDR infection should be directed to Infectious Diseases. tunneled CVC Definitive treatment. tunneled CVC . such as ciprofloxacin) in addition to piperacillin/tazobactam and vancomycin as initial therapy. To Initial Culture Phase To Preliminary cultures. non-tunneled CVC Preliminary cultures. non-tunneled CVC Definitive treatment. deescalation of the initial regimen to a single appropriate antibiotic is recommended once culture and susceptibility results are available (Mermel.Additional Gram-Negative Agent Selection Patients who are critically ill with suspected CLI and who have recent colonization or infection with a multi-drug resistant (MDR) gramnegative pathogen should receive gentamicin (or another agent with broad gram-negative activity from an antimicrobial class different than that of the primary antibiotic. ).

kidneys.Other Evaluation After Fungemia Identified Additional evaluation for patients with fungemia should include an ophthalmologic exam. Pappas et al. non-tunneled CVC Definitive treatment. . and echocardiogram. tunneled CVC . non-tunneled CVC Preliminary cultures. 2009 To Initial Culture Phase To Preliminary cultures. ). and spleen. Based on IDSA guidelines for management of Candidemia. to rule out other disseminated sites of infection (Mermel. tunneled CVC Definitive treatment. Pappas. and if persistent/prolonged fungemia should also include abdominal ultrasound of liver.

gramnegative bacilli. or mycobacteria. exit site infections that are severe or fail to resolve with antibiotic therapy. or Propionibacteria). ). or any bloodstream infection that continues despite 72 h of antimicrobial therapy to which the infecting microbes are susceptible.. )). Freifeld.Catheter Removal • Remove and culture non-tunneled catheters if the patient is hemodynamically unstable or has erythema overlying the catheter insertion site or purulence at the catheter insertion site (Mermel. To Initial Culture Phase To Preliminary cultures.g. . endocarditis. ). tunneled CVC .g. Catheter Removal (cont’d) • Remove catheters after blood culture contamination is ruled out on the basis of multiple positive culture results. . • Remove tunneled catheters from patients with CLI associated with any one of the following complications (Mermel. aureus. with at least 1 blood culture sample drawn from a peripheral vein. ): severe sepsis. • In any situation when salvage of the catheter is attempted. remove the catheter if blood cultures obtained 72 hours after the initiation of appropriate therapy remain positive (Mermel. tunneled CVC Definitive treatment. (Mermel. aeruginosa. P. suppurative thrombophlebitis. and mycobacteria (Mermel. for non-tunneled and tunneled CLI due to less virulent microbes that are difficult to eradicate (e. fungi. ). aureus. S. Freifeld. enterococci.. non-tunneled CVC Definitive treatment. tunnel infection. fungi. port abscess. • Remove non-tunneled catheters from patients with CLI due to any pathogens other than coagulase-negative staphylococci (e. non-tunneled CVC Preliminary cultures. CLI due to S. Micrococcus species. Bacillus species.

).  for S. to patients with infective endocarditis or suppurative thrombophlebitis. remove the catheter if blood cultures obtained 72 hours after the initiation of appropriate therapy remain positive (Mermel. . Consider Infectious Diseases consultation. ). tunneled CVC Definitive treatment. To Initial Culture Phase To Preliminary cultures. ophthalmologic exam and CT scan of chest/abdomen/pelvis. obtain blood cultures daily until cultures remain negative for at least 48 hours to document sterilization (Local consensus. suppurative thrombophlebitis. aureus infection. non-tunneled CVC Definitive treatment. Shah ). and to pediatric patients with osteomyelitis (Mermel. bone scan.  for infection due to other pathogens). tunneled CVC . extremity Doppler ultrasound. Recommendations for Persistently Positive Cultures (cont’d) • Evaluate patients with persistently positive blood cultures (bacterial or fungal) and/or ongoing fevers for >72 hours after line removal aggressively for evidence of complicated or metastatic disease. such as endocarditis. echocardiogram. • Whenever salvage of the catheter is attempted in a patient with CLI due to any pathogen.Recommendations for Persistently Positive Cultures • Once bacteremia or fungemia has been identified. • Administer antibiotics for 4 to 6 weeks to patients with persistent fungemia or bacteremia occurring >72 hours after catheter removal (Mermel. non-tunneled CVC Preliminary cultures. occult abscess or osteomyelitis.

aureus Recommendations (cont’d) • Treat patients for 4-6 weeks if S.S. non-tunneled CVC Definitive treatment. or quality of life issues take priority over the need for reinsertion of a new catheter at another site. treat with nafcillin (cefazolin is an acceptable alternative). aureus CLI is complicated by persistent bacteremia. aureus. endocarditis. • Consider Infectious Diseases consultation for all patients with S. ). an ID consultation is recommended. tunneled CVC . ). aureus and any one of the following criteria: underlying structural heart disease. aureus CLI (Mermel. ). peripheral stigmata of endocarditis. aureus (MRSA) with a vancomycin MIC >2 μg/mL. septic thrombophlebitis. • Treat patients with uncomplicated CLI due to S. For methicillin-resistant S. aureus Recommendations • Remove short-term catheters immediately for patients with S. use vancomycin. • Perform echocardiography in all patients with >1 positive blood culture with S. S. aureus CLI involving long-term catheters. aureus bacteremia and a high illness severity of multiple comorbidities (Honda. tunneled CVC Definitive treatment. OR metastatic infection (Mermel. To Initial Culture Phase To Preliminary cultures. • For methicillin-susceptible S. Mermel.g. ). • If an echocardiogram is performed. non-tunneled CVC Preliminary cultures. murmur. ). the patient has significant bleeding diathesis. ). • For methicillin-resistant S. • For S. remove the catheter unless there are major contraindications (e. aureus (MRSA) with a vancomycin MIC <2 μg/mL. aureus for a minimum of 14 days (Mermel. or persistently positive cultures. there is no alternative venous access.. perform it at least 5-7 days following onset of bacteremia to minimize the likelihood of a false-negative result (Mermel.

). ). ). immunocompetent patients: o Treat with ampicillin if the isolate is susceptible (Mermel. tunneled CVC . ). o o To Initial Culture Phase To Preliminary cultures. Treat for 7-14 days from first negative culture in cases of uncomplicated enterococcal CLI (Mermel. or in patients who are immunocompromised: o Add gentamicin to ampicillin or vancomycin if the isolate is susceptible to gentamicin or shows gentamicin synergy (Mermel. suppurative thrombophlebitis. sepsis. non-tunneled CVC Definitive treatment. Enterococcus Species Recommendations (cont’d) o Use vancomycin if the isolate is resistant to ampicillin but susceptible to vancomycin (Mermel. tunneled CVC Definitive treatment. non-tunneled CVC Preliminary cultures. or metastatic infection (Mermel. ). Mermel.  Gentamicin may be added if the isolate is susceptible to gentamicin or shows gentamicin synergy (Mermel. persistent bacteremia. • For severe or complicated CLI due to Enterococcus species. • Use lock therapy in addition to systemic therapy if the catheter is retained (Mermel. Consult Infectious Diseases if there is high-level gentamicin resistance or for VRE. Infectious Disease approval required.  Gentamicin may be added if the isolate is susceptible to gentamicin or shows gentamicin synergy (Mermel. ). ). ). • Remove long-term catheters infected with enterococci in cases of insertion site or pocket infection. endocarditis. ). o Use linezolid if the isolate is resistant to ampicillin and vancomycin (VRE. ).Enterococcus Species Recommendations • Remove short-term intravascular catheters infected with enterococci (Mermel. • For treatment of uncomplicated CLI due to Enterocccus species in stable.

in combination with lock therapy. lugdunensis similarly to recommendations above for S. • If the isolate is methicillin-resistant. Treatment for neonates can be as short as 3 days for uncomplicated CLI when the catheter has been removed (Hemels. non-tunneled CVC Preliminary cultures. ). if the catheter is retained (Mermel. use nafcillin. ). non-tunneled CVC Definitive treatment. • For uncomplicated CLI. treat with antibiotics for 5-7 days if the catheter is removed and for 10-14 days. To Initial Culture Phase To Preliminary cultures. • Manage CLI due to S. o o Cefazolin is an acceptable alternative. aureus CLI (Mermel. Use vancomycin for patients with anaphylactic allergies to beta-lactam antibiotics. • If the isolate is methicillin-susceptible. tunneled CVC . discontinue antibiotics (Mermel. tunneled CVC Definitive treatment. ).Coagulase-Negative Staphylococci Recommendations • If only one culture was positive and the repeat culture drawn prior to the initiation of empirical antibiotics is negative at 48 hours. ). use vancomycin.

non-tunneled CVC Preliminary cultures.. or >4-6 weeks for complicated infections. To Initial Culture Phase To Preliminary cultures. • Treat for 7-14 days from first negative blood culture for uncomplicated gram-negative CLI. piperacillin/tazobactam and gentamicin). tunneled CVC Definitive treatment. non-tunneled CVC Definitive treatment. ).Gram-Negative Bacilli Recommendations • For patients who received combination empiric therapy (e. de-escalate the initial regimen to a single appropriate antibiotic once culture and susceptibility results are available (Mermel. tunneled CVC .g.

• Treat for 14 days from first negative blood culture for uncomplicated Candida CLI. tunneled CVC Definitive treatment. or >4-6 weeks for complicated infections. • Depending on antifungal sensitivity of the isolate. ). To Initial Culture Phase To Preliminary cultures. use micafungin or fluconazole for treatment.Candida Species Recommendations • Remove catheters in cases of CLI due to Candida species (Mermel. non-tunneled CVC Preliminary cultures. tunneled CVC . non-tunneled CVC Definitive treatment.

and for patients with an infected longterm catheter or implanted port. non-tunneled CVC Preliminary cultures. ). remove the catheter for patients with a short-term CVC. These organisms can be difficult to eradicate with antimicrobial therapy alone.Other Gram-Positive Organism Recommendations • Diagnosis of CLI due to Corynebacterium. • For the management of these infections. unless there are no alternative intravascular access sites (Mermel. tunneled CVC Definitive treatment. non-tunneled CVC Definitive treatment. ). To Initial Culture Phase To Preliminary cultures. tunneled CVC . Bacillus and Micrococcus species requires at least 2 positive results of blood cultures performed on samples obtained from different sites (Mermel.

In such situations. tunneled CVC Definitive treatment. non-tunneled CVC Definitive treatment. If other vascular sites are unavailable and/or the patient is at increased risk for bleeding diathesis in the setting of CLI not complicated by an exit site or tunnel infection. but some slow growing organisms may require longer. Documenting clearance typically requires a minimum of 48 hours of negative cultures. ). then attempt exchange of the infected catheter over a guidewire (Mermel. • Ideally. non-tunneled CVC Preliminary cultures. ).Replacing the Catheter (if needed) • The preferred method when a catheter must be replaced is to place the new catheter in a different location. consider an antimicrobialimpregnated catheter with an anti-infective intraluminal surface for catheter exchange (Mermel. tunneled CVC . Questions regarding the risks of replacing the catheter during treatment of a CLI may best be addressed by an Infectious Diseases consultation. To Initial Culture Phase To Preliminary cultures. clearance of the CLI should be documented before replacing the catheter.

Average charges per case 5. standardizing the diagnosis and treatment of Central Line Infections. and Inpatient PowerPlans through multiple phases to: 1) Diagnose a central-line associated bloodstream infection 2) Select appropriate empiric and definitive antibiotic treatment of CLI 3) Know when to remove a catheter to manage a CLI 4) Use lock therapy for catheter salvage during selected CLI. services.Executive Summary Objective Create an evidence-based guideline that standardizes the diagnosis and management of Central Line Infections (CLI). Delivery of care will be improved by defining eligible patient populations. Costs will be monitored as CSW Core Metric. Rationale Safety the CLI standard Pathway offers specific recommendation to diagnose and treat CLI. from 2008 (the year prior to a major IDSA guideline on the topic) to date Search done only from 2008 forward because of IDSA guideline published in 2009. CSW Pathway Owner sought broad input for creation of this Pathway as it impacts patients from multiple specialties. Neonatal. Engagement: the pathway has been developed with by MDs. and. % of patients with any of the specified CLI Powerplan 4. Quality of care will improve as result of administering empiric antibiotics as recommended by the best available evidence. Median Length of Stay 3. Count of Inpatient/obs discharges 2. PhDs. RNs. Patient/Family Satisfaction will be improved through implementing clinical standard work that will assure the highest quality of care. Recommendations Providers can revisit and update ED. and departments. Readmission PDCA Plan Revision History Date Approved: January 2013 Next Review Date: January 2016 Return to Home . Implementation Items • • CLI Algorithm CLI Training Slides Metrics Plan 1. Evidence Searches were performed in July 2012. We believe that this pathway represents “state of the art” care. highlighting the rationale behind various decision points.

ceftriaxone. In an unstable immunocompetent patient with concern for CLI being admitted to the PICU. what empiric antibiotic regimen should be used? a) b) c) d) Vancomycin and gentamicin Linezolid and gentamicin Vancomycin. immunocompetent patients? a) Piperacillin/tazobactam b) c) Ceftazidime Vancomycin 5. and gentamicin Vancomycin and piperacillin/tazobactam e) Vancomycin. PICC infection with Staphylococcus aureus 4 month old. When evaluating a patient for CLI. Broviac infection with Staphylococcus aureus None of the above 4.Self-Assessment Completion qualifies you for 1 hour of Category II CME credit. piperacillin/tazobactam. If you are taking this self-assessment as a part of required departmental training at Seattle Children’s Hospital. Which of the following is typical empiric therapy for CLI in hemodynamically stable. blood cultures should be drawn: a) Peripherally only b) c) d) From one lumen of the central line only From all lumens of the central line only From both the periphery and all central line lumens 2. Broviac infection with coagulase-negative staphylococcus 3 year old. In which of the following circumstances would antibiotic lock therapy be indicated in standard CLI management? a) b) 4 month old. you MUST logon to Learning Center. and metronidazole Return to Home View Answers . CLI of a tunneled line caused by which of these pathogens can be managed with catheter retention? a) b) c) d) Staphylococcus aureus Pseudomonas aeruginosa Coagulase-negative staphylococci Candida albicans 3. PICC infection with Candida albicans c) d) e) 4 month old. 1.

Answer Key 1) d 2) c 3) c 4) a 5) c Return to Home .

Evidence is first assessed as to whether it is from randomized trial. or observational studies. The rating is then adjusted in the following manner: Quality ratings are downgraded if studies: • Have serious limitations • Have inconsistent results • If evidence does not directly address clinical questions • If estimates are imprecise OR • If it is felt that there is substantial publication bias Quality ratings can be upgraded if it is felt that: • The effect size is large • If studies are designed in a way that confounding would likely underreport the magnitude of the effect OR • If a dose-response gradient is evident Quality of Evidence:  High quality  Moderate quality  Low quality  Very low quality Expert Opinion (E) Reference: Guyatt G et al.Evidence Ratings We used the GRADE method of rating evidence quality. J Clin Epi 2011: 383-394 To Bibliography Return to Home .

Summary of Version Changes Version 1 (01/23/2013): Go live Return to Home .

As new research and clinical experience broaden our knowledge. The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However. Readers should confirm the information contained herein with other sources and are encouraged to consult with their health care provider before making any health care decision. and they are not responsible for any errors or omissions or for the results obtained from the use of such information. Return to Home . neither the authors nor Seattle Children’s Healthcare System nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete.Medical Disclaimer Medicine is an ever-changing science. in view of the possibility of human error or changes in medical sciences. changes in treatment and drug therapy are required.

2013 To Bibliography. device removal. Clinical Queries. Clinical Standard Work Studies were identified by searching electronic databases using search strategies developed and executed by a medical librarian. National Guideline Clearinghouse and TRIP. Cochrane Central Register of Controlled Trials. microbial sensitivity tests. Susan Klawansky. such as relevant publication types. index terms for study types and other similar limits. and terms for diagnosis and management. Cochrane Database of Systematic Reviews. including dozens of alternative phrases. from 2008 (the year prior to a major IDSA guideline on the topic) to date. including specific agents. AHIP January 3. All retrieval was further limited to certain evidence categories. appropriate Medical Subject Headings (MeSH) and Emtree headings were used respectively. diagnostic techniques and procedures. along with text words. where available. Pg 1 Return to Home . elsewhere – Embase. Clinical Evidence. In Medline and Embase. MLS. Susan Klawansky. including specific bacterial infections. Searches were performed in July 2012. catheter-related infections. ethanol. and the search strategy was adapted for other databases using their controlled vocabularies. The following databases were searched – on the Ovid platform: Medline. and subheadings for diagnosis. along with text words. such as anti-infective agents. Retrieval was limited to humans and English language.Bibliography Search Methods. Central Line Infection. therapy and drug therapy. Concepts searched were central venous catheters.

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