Algorithm for diagnosis and management of line sepsis with long-term intravenous devices (IVDs).
| * Per 1000 days a central line was used. |
| • Examine the patient thoroughly to identify unrelated sources of infection. |
| • Carefully examine all catheter insertion sites; gram stain and culture any expressible purulence. |
| • Obtain two 10-15 mL cultures: |
| • If standard (nonquantitative) blood cultures, draw one by percutaneous peripheral venipuncture and one through the suspect IVD. |
| If quantitative blood culture techniques are available (e.g., the Isolator® system), catheter-drawn cultures can enhance the diagnostic specificity of blood culturing in diagnosis of line sepsis. However, a peripheral percutaneous quantitative blood culture must be drawn concomitantly. |
| • Option regarding a peripheral IV or arterial catheter: remove and culture catheter. |
| • Options regarding a short-term central venous catheter: |
| •Purulence at insertion site |
| or |
| No purulence, but patient floridly septic, without obvious source: |
| Remove and culture catheter. |
| Gram stain purulence. |
| Re-establish access at new site. |
| •No purulence, patient not floridly septic: |
| • Leave catheter in place, pending results of blood cultures. |
| or |
| •Remove and culture catheter, re-establish needed access at new site. |
| • Options regarding surgically-implanted, cuffed Hickman-type catheters. |
| •Remove at outset if: |
| • Infecting organism known to be S. aureus, Bacillus spp., JK Diptheroid, Mycobacterium species or filamentous fungus. |
| • Refractory or progressive exit site infection, despite antimicrobial therapy, especially with Pseudomonas aeruginosa. |
| • Tunnel infected. |
| • Evidence of septic thrombosis of cannulated central vein or septic pulmonary emboli. |
| • Evidence of endocarditis. |
| •Remove later on if: |
| • Any of the above become manifest. |
| • BSI persists ≥ 3 days, despite IV antimicrobial therapy through catheter. |
| • Options regarding surgically implanted subcutaneous ports (e.g., Portacath): |
| • Cellulitis without documented bacteremia: begin antimicrobial therapy, withhold removing port. |
| • Aspirate from port shows organisms on gram-stain or heavy growth in quantitative culture, or documented port-related bacteremia: remove port. |
| • Decision on whether to begin antimicrobial therapy, before culture results available, based on clinical assessment and/or gram stain of exit site or the blood drawn from a long-term IVD. |
| • With no microbiologic data to guide antimicrobial selection in a septic patient with suspected line sepsis, consider: IV vancomycin and ciprofloxacin, cefepime, or imipenem. |
| * Per 1000 days a central line was used. |
| • Examine the patient thoroughly to identify unrelated sources of infection. |
| • Carefully examine all catheter insertion sites; gram stain and culture any expressible purulence. |
| • Obtain two 10-15 mL cultures: |
| • If standard (nonquantitative) blood cultures, draw one by percutaneous peripheral venipuncture and one through the suspect IVD. |
| If quantitative blood culture techniques are available (e.g., the Isolator® system), catheter-drawn cultures can enhance the diagnostic specificity of blood culturing in diagnosis of line sepsis. However, a peripheral percutaneous quantitative blood culture must be drawn concomitantly. |
| • Option regarding a peripheral IV or arterial catheter: remove and culture catheter. |
| • Options regarding a short-term central venous catheter: |
| •Purulence at insertion site |
| or |
| No purulence, but patient floridly septic, without obvious source: |
| Remove and culture catheter. |
| Gram stain purulence. |
| Re-establish access at new site. |
| •No purulence, patient not floridly septic: |
| • Leave catheter in place, pending results of blood cultures. |
| or |
| •Remove and culture catheter, re-establish needed access at new site. |
| • Options regarding surgically-implanted, cuffed Hickman-type catheters. |
| •Remove at outset if: |
| • Infecting organism known to be S. aureus, Bacillus spp., JK Diptheroid, Mycobacterium species or filamentous fungus. |
| • Refractory or progressive exit site infection, despite antimicrobial therapy, especially with Pseudomonas aeruginosa. |
| • Tunnel infected. |
| • Evidence of septic thrombosis of cannulated central vein or septic pulmonary emboli. |
| • Evidence of endocarditis. |
| •Remove later on if: |
| • Any of the above become manifest. |
| • BSI persists ≥ 3 days, despite IV antimicrobial therapy through catheter. |
| • Options regarding surgically implanted subcutaneous ports (e.g., Portacath): |
| • Cellulitis without documented bacteremia: begin antimicrobial therapy, withhold removing port. |
| • Aspirate from port shows organisms on gram-stain or heavy growth in quantitative culture, or documented port-related bacteremia: remove port. |
| • Decision on whether to begin antimicrobial therapy, before culture results available, based on clinical assessment and/or gram stain of exit site or the blood drawn from a long-term IVD. |
| • With no microbiologic data to guide antimicrobial selection in a septic patient with suspected line sepsis, consider: IV vancomycin and ciprofloxacin, cefepime, or imipenem. |