Management of Cathether-Related Bacteremia in HD
1. Catheter-related bacteremia (CRB) suspected
Fever >38°C, chills+/-hypotension, increased WBC count; no apparent source of bacteremia other than the catheter.
2. Perform clinical assessment
- Identify if source of infection is a location other than catheter (lung, GIT, bladder, skin (feet), abdomen, or AVF/AVG).
- Identify if metastatic infection in bones/joints or heart valves.
- Perform echocardiogram1 if organism is Staph aureus, viridans Strep, or Enterococcus.
- Perform echocardiogram regardless of organism if clinical suspicion of endocarditis or if an artificial valve is present.
- Perform x-ray and/or MRI if clinical suspicion of bone/joint involvement. Bone scan and/or WBC scan may be considered if patient is not a candidate for MRI.
1Transthoracic echocardiogram (TTE) should be performed first. If negative, a TEE is required to exclude the possibility of endocarditis.
3. Obtain cultures
- If possible, obtain paired blood cultures (1 set from the catheter & 1 from the periphery drawn at the same time); if not possible (e.g., limited access to veins), obtain 2 sets of 2 blood cultures from catheter at least 5 min apart (10 mL each bottle).
- Culture from the most purulent aspect of the exit site if discharge present or suspicious.
- Other cultures as indicated (e.g., sputum, wound, urine).
4. Start empiric antibiotics
- If patient is acutely ill or hemodynamically unstable, give antibiotics, remove catheter and admit.
- If patient looks well, give antibiotics, leave catheter in situ, and follow-up with results of culture.
5. Consider Infectious Diseases consultation
- In all cases of bacteremia.
- If patient remains febrile or has continued signs and symptoms of infection, despite being on antibiotics.
6. Indications to Remove CVC
If clinical assessment reveals any of the following, remove the catheter & insert a new one at a different site (If possible, leave out x 48 hours).
- Clinical signs & symptoms of sepsis (acutely ill or hemodynamically unstable)
- Temp remains >38°C in 48 hrs
- Recent catheter related infection (with same catheter)
- Patient on immunosuppressants
- Uncuffed catheter
- Presence of prosthetic heart valve
- Exit site or tunnel infection present
7. Follow Culture & Sensitivity Results
- If culture negative @ 72 hrs, consider stopping antibiotics. If ongoing fever, investigate other sources.
- If culture positive, adjust antibiotics based on sensitivity results.
8. Complete antibiotic course
9. Repeat blood culture 1 week after completion of antibiotic therapy
Protocol used in Fraser Health Renal Program.
Adapted with permission from the BC Renal Agency
Vascular Access Guideline: Prevention, Treatment, and Monitoring of VA Related Infection in HD Patients (rev. March 13, 2008)
Revised September 2013
See Empiric Antimicrobial Guide for Adult Outpatient Hemodialysis Patients
This resource only serves as a reference. Clinical judgment is warranted in all cases.