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 and lines have been in for 14 days or more, managing infection conservatively may be indicated.
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.
Line lock therapy is only indicated for intravascular catheter related infections involving long term catheters (14 days or more indwelling) 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 Paediatric ID.
- The antibiotic volume required for line lock should be made up to a volume of 5mL.
- Use fluids which are compatible with the antibiotic for dilution/flushing purposes.
- The dwell time for antibiotic lock therapy is ideally 24 hours and should not exceed 48 hours in between reinstallations.
- Withdraw the antibiotic lock from the line once complete and flush the line afterwards. Do not instil the antibiotic line lock into the patient.
- If there is on-going bacteraemia or no sign of clinical improvement within 72 hours; remove the line.
- All durations given below are from the first negative culture or line removal.
Prescribe line locks using the 'paediatric antimicrobial line lock' powerplan on EPR.
Coagulase Negative Staphylococci (CoNS)
Possible options for line management:
- Remove/exchange the line and give short course antibiotics (3-5 days).
- Retain the line and treat with systemic iv or oral antibiotics and line lock therapy for 7-10 days.
Line lock agent: vancomycin 5mg/mL.
Systemic Antimicrobial Therapy for children one month or over:
teicoplanin iv ADD vancomycin 5mg/mL line lock if line is retained
OR
linezolid po (see dosing table below) ADD vancomycin 5mg/mL line lock if line is retained
|
Age |
linezolid po dose |
|
1 month – 11 years |
10mg/kg TDS (Max 600mg TDS) |
|
12 years – 17 years |
600mg BD |
Enterococcus
Possible options for line management:
- Remove/exchange the line and give short course antibiotics (7 days).
- Retain the line and treat with systemic iv or oral antibiotics and line lock therapy for 10 days.
Line lock agent: vancomycin 5mg/mL.
Systemic Antimicrobial Therapy for children one month or over
amoxicillin 60mg/kg (Max 1g) iv TDS (if organism sensitive) ADD vancomycin 5mg/mL line lock if line is retained
OR
teicoplanin iv ADD vancomycin 5mg/mL line lock if line is retained
OR
linezolid po (see dosing table below) ADD vancomycin 5mg/mL line lock if line is retained
|
Age |
linezolid po dose |
|
1 month – 11 years |
10mg/kg TDS (Max 600mg TDS) |
|
12 years – 17 years |
600mg BD |
Gram negative bacilli (Excluding pseudomonas)
Possible options for line management:
- If CVC removal and good clinical response with rapid clearance of bacteraemia, treat with systemic antibiotics for 7 days.
- For CVC salvage, treat with systemic antibiotics and line lock therapy for 10-14 days.
Line lock agent: gentamicin 1mg/mL.
Systemic Antimicrobial Therapy for children one month or over
ceftriaxone 80mg/kg (Max 4g) iv OD. Do not use if patient has a history of severe penicillin allergy or resistance to ceftriaxone ADD gentamicin 1mg/mL line lock if line is retained
OR
co-trimoxazole po (see dosing table below) ADD gentamicin 1mg/mL line lock if line is retained
|
Age |
co-trimoxazole oral dose |
|
6 Weeks to 5 Months |
120mg BD |
|
6 Months to 5 Years |
240mg BD |
|
6 Years to 11 years |
480mg BD |
|
12 years to 17 years |
960mg BD |
Alternative:
ciprofloxacin* 10mg/kg (Max 400mg) iv TDS OR ciprofloxacin* 20mg/kg (Max 750mg) po BD
ADD gentamicin 1mg/mL line lock if line is retained
*ciprofloxacin may induce convulsions in patients with or without a history of convulsions – use with caution
Pseudomonas
Possible options for line management:
- If CVC removal and good clinical response with rapid clearance of bacteraemia, treat with systemic antibiotics for 7 days.
- For CVC salvage, treat with systemic antibiotics and line lock therapy for 10-14 days.
Line lock agent: gentamicin 1mg/mL.
Systemic Antimicrobial Therapy for children one month or over
ceftazidime 50mg/kg (Max 2g) iv TDS ADD gentamicin 1mg/mL line lock if line is retained
OR
ciprofloxacin* 10mg/kg (Max 400mg) iv TDS OR ciprofloxacin* 20mg/kg (Max 750mg) po BD
ADD gentamicin 1mg/mL line lock if line is retained
*ciprofloxacin may induce convulsions in patients with or without a history of convulsions – use with caution
Staphylococcus aureus
Possible options for line management:
- If CVC removal and good clinical response treat with systemic antibiotics for 7-10 days.
- For CVC salvage, treat with systemic antibiotics and line lock therapy for 14 days.
Line lock agent: vancomycin 5mg/mL.
Systemic Antimicrobial Therapy for children one month or over:
MSSA:
flucloxacillin 50mg/kg (Max 2g) iv QDS ADD vancomycin 5mg/mL line lock if line is retained
OR
cefalexin see dosing table below ADD vancomycin 5mg/mL line lock if line is retained
|
Weight |
cefalexin oral dosing |
|
Less than 15 kg |
33 mg/kg po TDS |
|
15 to 20 kg |
500mg po TDS |
|
21 to 30 kg |
750mg po TDS |
|
31 to 40 kg |
1g po TDS |
|
Over 40 kg |
1g po QDS |
MRSA:
teicoplanin iv ADD vancomycin 5mg/mL line lock if line is retained
OR
linezolid po (see dosing table below) ADD vancomycin 5mg/mL line lock if line is retained
|
Age |
linezolid po dose |
|
1 month – 11 years |
10mg/kg TDS (Max 600mg TDS) |
|
12 years – 17 years |
600mg BD |
Candida
Possible options for line management:
- Remove the line and give systemic antifungal therapy for 14 days from the date of the first negative culture.
Line lock agent: Not advised
Systemic Antimicrobial Therapy for children one month or over
Caspofungin iv (see dosing table below)
|
Age |
Caspofungin IV dose |
|
Less than 3 months |
25mg/m2 iv OD |
|
3 -11 months |
50mg/m2 iv OD |
|
1-17 years |
Loading dose: 70mg/m2 iv OD (max per dose 70mg) for 1 day Maintenance dose: 50mg/m2 iv OD (max per dose 70mg). Can be increased to 70mg/m2 iv OD (max per dose 70mg) if tolerated but inadequate clinical response |
|
1-17 years and concurrent use of enzyme inducer* |
Loading dose: 70mg/m2 iv OD (max per dose 70mg) for 1 day Maintenance dose:70mg/m2 iv OD (max per dose 70mg) |
|
Moderate hepatic impairment all ages |
Loading dose: Usual initial dose for age Maintenance dose: Use 70% of normal maintenance dose (consider age and if on enzyme inducers) |
*Phenytoin, Carbamazepine, Dexamethasone and Rifampicin.This list is not exhaustive, see BNFC and SPC for drug interactions.
If sensitive to fluconazole and clinically improving: Switch to fluconazole 12mg/kg (Max 400mg) iv OD