🩸 Chapter 101: CVC Infections (CRBSI / CLABSI)

Catheter-related bloodstream infection · CLABSI surveillance · Prevention bundle · Empiric antibiotics · Line removal · Antibiotic lock · Diagnosis & management

🔍 Core Concepts: Central Line Infections

📌 Definitions
CLABSI (surveillance): primary BSI with line within 48h. CRBSI (clinical): definitive catheter source (quantitative culture, differential time to positivity).
🦠 Common Pathogens
CoNS, S. aureus (MRSA/MSSA), Enterococcus, Gram-negatives (E. coli, Klebsiella, Pseudomonas), Candida.
⚡ Diagnosis
≥2 blood cultures (1 peripheral, 1 from CVC). Differential time to positivity >2h or quantitative ratio ≥5:1 suggests CRBSI.
💊 Empiric Therapy
Vancomycin (MRSA) + antipseudomonal beta-lactam (cefepime, meropenem). Add echinocandin if candidemia risk.
🔧 Line Management
Remove CVC if S. aureus, Candida, Pseudomonas, severe sepsis, or persistent bacteremia >72h. Antibiotic lock for salvage attempts (long-term catheters, CoNS).
🛡️ Prevention Bundle
Hand hygiene, maximal sterile barrier, chlorhexidine skin prep, avoid femoral site, daily line necessity review.
⏱️ Duration
Uncomplicated CoNS: 5-7d. Enterococcus/Gram-neg: 7-14d. S. aureus/Candida: 14d after first negative culture (often remove line).

🩺 Stepwise Management of Suspected CRBSI

1
Obtain appropriate cultures
Draw peripheral blood culture and at least one culture from each CVC lumen before starting antibiotics. Also culture catheter tip if removed.
2
Start empiric antibiotics
Vancomycin (MRSA coverage) + antipseudomonal beta-lactam (cefepime/meropenem). Add echinocandin if Candida risk (TPN, prolonged ICU, broad-spectrum antibiotics, femoral line).
3
Decide on catheter removal
Remove if: severe sepsis, S. aureus bacteremia, Candida, Pseudomonas, or persistent bacteremia >72h despite appropriate therapy. For long-term catheters with CoNS, consider salvage + antibiotic lock.
4
Tailor therapy based on susceptibilities & de-escalate
Once culture/sensitivities back, narrow regimen. For uncomplicated CRBSI (CoNS, enterococci, Gram-neg) treat 7-14 days. For S. aureus or Candida: 14 days after first negative blood culture (often requires line removal).
5
Prevent recurrence & use bundles
Implement CVC insertion bundle (maximal barriers, chlorhexidine). Daily review of line necessity. Use antibiotic lock for long-term catheters (if salvage attempted).