Infectious Diseases I
Clinical signs and symptoms of infection have poor sensitivity and specificity. Fever is the most sensitive
clinical finding, whereas inflammation or purulence at the insertion site is the most specific.
from a peripheral vein should be obtained. The individual bottles should be appropriately marked
through the culture-reporting period.
If a blood culture cannot be drawn from a peripheral vein, it is recommended that at least two blood
cultures be obtained through different catheter hubs/ports.
Blood cultures positive for S. aureus, coagulase-negative staphylococci, or Candida spp. that are
not attributable to another source should increase the suggestion of CLABSI.
Blood cultures should be obtained before initiation of antimicrobial therapy, as appropriate.
A definitive diagnosis of CLABSI requires positive percutaneous blood culture results with positive
culture of same pathogen from the catheter tip or catheter-drawn cultures. Please see the Infections
Diseases II chapter for further discussion on the pathway for regulatory reporting of CLABSI.
Catheter removal should be considered in all patients with a confirmed CLABSI. If a CVC is still
necessary, a different anatomic site should be used. Changing to a new catheter at the same site using a
guidewire or catheter introducer should be avoided.
Inappropriate empiric antimicrobial therapy is associated with increased mortality, including bacterial
and fungal etiologies.
Empiric antimicrobial therapy should minimally include an agent active against methicillin-
resistant coagulase-negative (e.g., methicillin-resistant S. epidermidis [MRSE]) or coagulase-
positive (e.g., MRSA) staphylococci. Vancomycin or daptomycin are preferred; linezolid should
not be used for empiric management of CLABSI.
Pathogen-specific risk factors, documented colonization, and previous antimicrobial exposure
should be considered when choosing empiric antimicrobial therapy.
Patients at risk of MDROs should receive combination therapy against gram-negative bacilli
using agents from separate antibiotic classes.
ii.
Patients at high risk of candidemia include those receiving TPN, those with prolonged use
of broad-spectrum antibiotics, those with hematologic malignancy, those who have received
a bone marrow or solid-organ transplant, those with femoral catheterization, and those with
colonization because of Candida spp at multiple sites. A Candida score may be used to help
predict risk, but it is primarily validated in surgical ICU patients.
| (a) | Use of an echinocandin (eg, anidulafungin, caspofungin, or micafungin) should be |
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considered for patients at risk of candidemia.
| (b) | Fluconazole is reasonable in patients without recent exposure to an -azole in the previous 6 |
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months and in health care settings with a low prevalence of non-susceptible species.
Local antimicrobial activity should be considered to increase the probability of appropriate therapy.
| d. | Empiric antimicrobial therapy should be de-escalated, depending on the identified pathogen(s) and |
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related antimicrobial susceptibility. Antimicrobial therapy should be discontinued if a CLABSI is
not evident and there are no other sources of infection.
Definitive management and antimicrobial therapy should be based on whether the CLABSI is complicated
or uncomplicated (more common than complicated) and the identified pathogen(s). Ongoing clinical
trials may provide guidance to the optimal duration of antibiotic therapy for CLABSI and non–central
line-associated bacteremia (BMJ Open 2020;10:e038300).
The duration of antimicrobial therapy should be based on the first day of negative blood culture.