Management approach for suspected bloodstream infection associated with a central venous catheter or peripherally inserted central catheter (PICC) line
Central venous catheters (CVCs) and peripherally inserted central catheter (PICC) lines should always be suspected to be the source of infection if the patient has:
- sepsis or septic shock without another clear source
- tunnel infection
- thromboembolism
- a pathogen shown to be a Candida species or S. aureus.
For suspected bloodstream infection associated with a PICC line or CVC, obtain at least 2 sets of blood samples for culture – one set from the suspected intravenous catheter and one set from a separate peripheral site (to determine if systemic bacteraemia is present).
A key aspect of management is removing the catheter suspected to be the source of infection; however, the ease of removal depends on the type of catheter. If removed, send the catheter tip for culture. Remove a PICC line immediately if it is inflamed or suspected of being the source of infection. Because CVCs are generally more complicated to remove and replace, consult the treating team before removal; if the patient has signs of sepsis or septic shock, urgent consultation and removal is required.
In addition to removing the PICC line or CVC, start empirical antibiotic therapy.
Modify therapy based on culture results.
If the blood culture results from the PICC line or CVC are positive, but the peripherally obtained blood culture results are negative, removal of the catheter and short-term empirical intravenous antibiotic therapy (eg 5 days) may be sufficient. However, for infections associated with a PICC line, it is important to exclude extensive septic vein thrombosis, which frequently requires a longer duration of therapy.
If the blood culture results from the PICC line or CVC are positive, and the peripherally obtained blood culture results are positive, systemic bacteraemia is present. Treat the bacteraemia with empirical intravenous antibiotic therapy and investigate for potential complications (eg bacterial endocarditis).
For patients in whom it is unclear whether the PICC line or CVC is the source of infection, or if the potential harms of removal outweigh potential benefits, catheter salvage can sometimes be attempted, but success is uncommon. Salvage involves administration of intravenous antibiotics via the infected lumen(s), or an antibiotic or ethanol lock – seek expert advice.