Selection of empiric therapy in patients with catheter-related infections

Catheter-related infections (CRI) are frequent and manifest in a wide range of clinical situations. A rational approach is necessary for the adequate management of these infections. Whenever a CRI is suspected, two main questions have to be addressed: whether to remove the catheter and whether to initiate empiric antimicrobial treatment. As the clinical diagnosis of CRI has a low specificity, the catheter should be removed only in circumstances such as severe or ongoing sepsis, persistent bacteremia, pulmonary or peripheral embolization, endocarditis, signs of tunnel infection, when the catheters or when the CRI is caused by fungi, Staphylococcus aureus or Pseudomonas aeruginosa are easy to replace among others. Exchanging the catheter through a guidewire is a frequent practice but is not recommended by some authors. Empiric antimicrobial treatment should be administered in any of the following situations: when the catheter is not removed, in the case of central venous or surgically implanted catheters and prosthetic implants, in the presence of severe sepsis, neutropenia or other immunodepressed status, suppurative phlebitis, embolization and acute endocarditis. Empriic antimicrobial treatment should include a glycopeptide (vancomycin or teicoplanin) as staphylococci are the most frequent cause of CRI. Adding an antipseudomonal agent, such as amikacin, aztreonam, ceftazidime, cefepime, piperacillin/tazobactam, or a carbapenem (depending on the local antimicrobial susceptibility data or antibiotic policy) is necessary in cases of neutropenia, burn patients, severe sepsis, or suspicion of contaminated infusate. Empiric treatment against Candida is not initially necessary in most cases. Empiric treatment should be replaced by specific therapy whenever possible.