Pathogen specific therapy for intravascular catheter related infections

The mainstay of the management of intravascular catheter related infections is line removal (source control), however on occasion where venous access is difficult, managing infection conservatively may be indicated. See pathogen-specific guidance below.

Line lock therapy is only indicated for intravascular catheter related infections involving long term catheters or catheters that are difficult to remove where the goal is line salvage. Line lock therapy involves filling the catheter for a defined period with a concentrated antimicrobial solution. Discuss all cases with Micro/ID.

When an intravascular catheter related infection is suspected clinically, empirical treatment should be started (see under Empirical management of intravascular catheter related infections) and once culture results are known, the choice of therapy should be adjusted according to sensitivities.

Use the table below to identify possible treatment options for intravascular catheter related infections caused by specific pathogens.

Pathogen	Possible Options for Line Management	Line Lock Agent	Systemic Antimicrobial Therapy
Coagulase Negative Staphylococci (CoNS)	Remove line and take surveillance cultures at 72 hours. Remove the line and give short course antibiotics (3-5 days). Retain the line and treat with systemic antibiotics and line lock therapy for 10-14 days. Remove the line if deterioration or bacteraemia after 72 hours.	Vancomycin 5mg/mL	Treat according to sensitivity. Discuss with Micro/ID, options include: teicoplanin iv, or, linezolid 600mg po bd, or, co-trimoxazole 960mg po/iv bd, or, vancomycin iv
Enterococcus (Vancomycin susceptible)	Remove the line and give short course antibiotics (3-5 days). Retain the line and treat with systemic antibiotics for 10-14 days and line lock therapy. Remove the line if deterioration, bacteraemia or fever after 72 hours.	Vancomycin 5mg/mL	Treat according to sensitivity. Discuss with Micro/ID, options include: teicoplanin iv, or, linezolid 600mg po bd, or, vancomycin iv
Vancomycin-resistant Enterococcus	Remove the line and give short course antibiotics (3-5 days). Retain the line and treat with systemic antibiotics for 10-14 days and line lock therapy. Remove the line if deterioration, bacteraemia or fever after 72 hours.	Discuss with Micro/ID	Treat according to sensitivity. Discuss with Micro/ID, options include: daptomycin 8-12mg/kg iv od, or, linezolid 600mg po bd, or, oritavancin 1.2g iv stat
Gram negative bacilli (excluding pseudomonas)	Remove the line and treat with systemic antibiotics for 7 days. Retain the line and treat with systemic antibiotics and line lock therapy for no more than 14 days.	Gentamicin 1mg/mL	Treat according to sensitivity. Discuss with Micro/ID, options include: co-trimoxazole 960mg po/iv bd, or, cefalexin 1g po tds , or, cefazolin 2g iv tds, or, gentamicin 5mg/kg iv for maximum of 3 days*
Staphylococcus aureus	Remove the line. Give systemic antibiotics for 14 days from the date of the first negative set of surveillance cultures. Contact Micro/ID if line removal is not feasible or if the patient has intravascular prosthetic material, immunosuppression or persistent signs/symptoms.	Not advised	Treat according to sensitivity. Discuss with Micro/ID, options include: MSSA: flucloxacillin 2g iv qds, or, cefazolin 2g iv tds, MRSA: according to sensitivity. Options include: linezolid 600mg po bd, or, co-trimoxazole 960mg po/iv bd, or, teicoplanin iv, or, vancomycin iv
Pseudomonas	Remove the line and give systemic antibiotics for 7-14 days from the date of the first negative set of surveillance cultures.	Not advised	Treat according to sensitivity. Discuss with Micro/ID, options include: ceftazidime 2g iv tds, or, piperacillin-tazobactam 4.5g iv tds-qds If severe infection: ADD gentamicin iv 5mg/kg for maximum of 3 days*
Candida	Remove the line. Give systemic antifungal therapy for 14 days from the date of the first negative set of surveillance cultures. Contact Micro/ID if line removal is not feasible or if the patient has intravascular prosthetic material, immunosuppression or persistent signs/symptoms. A catheter exchange over a guidewire may be considered if there is limited vascular access.	Not advised	Treat according to sensitivity. Discuss with Micro/ID, options include: caspofungin iv, see drug monograph for dosing If sensitive to fluconazole and clinically improving: fluconazole 800mg iv bd for day 1 then 800mg iv od (once the line remove consider oral switch if no complicating factors)

*Take a gentamicin level at 6-14 hours after first dose to calculate dosing interval, usually 24 hourly, 36 hourly or 48 hourly. See gentamicin monograph for dosing (including renal dosing) and monitoring.

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