ICU · Antimicrobial Stewardship
Catheter-related bloodstream infection (CRBSI)
Also known as Central line-associated bloodstream infection (CLABSI) · CRBSI · Catheter-related sepsis · Line sepsis
CRBSI is bloodstream infection originating from an intravascular catheter. The 1 preventable ICU-acquired infection. Common organisms: coagulase-negative staphylococci (1 — Staph epidermidis), S. aureus, Enterococcus, Gram-negative bacilli, Candida. Diagnosis: positive blood cultures from peripheral vein AND catheter (same organism, differential time to positivity 2h, or semi-quantitative culture 15 CFU). Management: REMOVE the catheter + targeted antibiotics (7-14 days). Prevention: full barrier precautions during insertion, chlorhexidine skin antisepsis, optimal site selection (subclavian jugular femoral), daily review of line necessity, removal when no longer needed. Bundle approach can reduce CRBSI to near-zero.
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Target exams
Red flags
- REMOVE the catheter when CRBSI confirmed — source control is essential
- Femoral lines have highest infection rate — avoid unless emergency or severe coagulopathy
- Subclavian lines have lowest infection rate — preferred site for non-tunneled CVCs
- Daily review: does this patient still need this line? Remove as soon as no longer necessary
- S. aureus, Pseudomonas or Candida CRBSI = ALWAYS remove the catheter (no salvage attempt)
- S. aureus CRBSI: minimum 14 days therapy + echocardiography to exclude endocarditis (25% have valvular involvement)
- Persistent bacteraemia >72 h despite catheter removal and appropriate antibiotics: search for metastatic foci (endocarditis, septic thrombophlebitis, vertebral osteomyelitis, epidural abscess, septic pulmonary emboli)
- Candida CRBSI: ophthalmology review for endophthalmitis (chorioretinitis) — occurs in up to 16%
- Differential time to positivity (DTP) >2 h (catheter positive first) is highly specific for catheter as the source
- Do NOT guidewire exchange a suspected infected line — the new catheter becomes contaminated from the same tract
- Paired quantitative blood cultures with a catheter:peripheral ratio ≥3:1 supports CRBSI
- Tip culture (Maki roll-plate) >15 CFU demonstrates colonisation — NOT by itself bacteraemia; CRBSI requires positive blood cultures
Meet the patient
A 64-year-old man, day 9 of severe pancreatitis, has a right internal jugular triple-lumen CVC sited on admission and a femoral arterial line. He spikes a fever to 39.1°C with rigors and a lactate climbing from 1.2 to 3.4 mmol/L, and no other source is obvious.[4]
The exit site looks quiet — the recurring trap. Most CRBSIs have a normal-looking exit site, because the biofilm lives on the intravascular segment, not the skin. Before you chase an intra-abdominal collection, draw paired cultures from a peripheral vein and from every lumen, and ask the one question that prevents the next case: does this line still need to be in today?[5]
References18ShowHide
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- [2]Simon A, Bode U, Beutel K. Diagnosis and treatment of catheter-related infections in paediatric oncology: an update Clin Microbiol Infect, 2006.PMID 16774556
- [3]Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU N Engl J Med, 2006.PMID 17192537
- [4]Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America Clin Infect Dis, 2009.PMID 19489710
- [5]O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections Am J Infect Control, 2011.PMID 21511081
- [6]Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial JAMA, 2009.PMID 19318651
- [7]Darouiche RO, Raad II, Heard SO, et al. A comparison of two antimicrobial-impregnated central venous catheters. Catheter Study Group N Engl J Med, 1999.PMID 9878638
- [8]Hanna H, Benjamin R, Chatzinikolaou I, et al. Long-term silicone central venous catheters impregnated with minocycline and rifampin decrease rates of catheter-related bloodstream infection in cancer patients: a prospective randomized clinical trial J Clin Oncol, 2004.PMID 15284269
- [9]Parienti JJ, Mongardon N, Mégarbane B, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site N Engl J Med, 2015.PMID 26398070
- [10]Climo MW, Yokoe DS, Warren DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection N Engl J Med, 2013.PMID 23388005
- [11]Ziegler MJ, Pellegrini DC, Safdar N Attributable mortality of central line associated bloodstream infection: systematic review and meta-analysis Infection, 2015.PMID 25331552
- [12]Minter DJ, Appa A, Chambers HF, Doernberg SB. Contemporary Management of Staphylococcus aureus Bacteremia-Controversies in Clinical Practice Clin Infect Dis, 2023.PMID 37950887
- [13]Kim EY, Saunders P, Yousefzadeh N. Usefulness of anti-infective lock solutions for catheter-related bloodstream infections Mt Sinai J Med, 2010.PMID 20960556
- [14]Tzalis S, Ioannou P, Billiari E, et al. Daptomycin as an option for lock therapy: a systematic literature review Future Microbiol, 2023.PMID 37622290
- [15]Del Pozo JL, Rodil R, Aguinaga A, et al. Daptomycin lock therapy for grampositive long-term catheter-related bloodstream infections Int J Clin Pract, 2012.PMID 22340450
- [16]Rybak MJ, Le J, Lodise TP, et al. Executive Summary: Therapeutic Monitoring of Vancomycin for Serious Methicillin-resistant Staphylococcus aureus Infections: A Revised Consensus Guideline and Review of the American Society of Health-system Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists Pharmacotherapy, 2020.PMID 32227354
- [17]Catton JA, Dobbins BM, Kite P, et al. In situ diagnosis of intravascular catheter-related bloodstream infection: a comparison of quantitative culture, differential time to positivity, and endoluminal brushing Crit Care Med, 2005.PMID 15818106
- [18]Bisanti A, Giammatteo V, Bello G, et al. Usefulness of differential time to positivity between catheter and peripheral blood cultures for diagnosing catheter-related bloodstream infection: Data analysis from routine clinical practice in the intensive care unit J Crit Care, 2023.PMID 36706553