A 49-year-old man with end-stage renal disease is hospitalized because of fever and malaise for the past 2 days. His other medical problems include hypertension and type 2 diabetes mellitus. His renal failure is attributed to uncontrolled hypertension and progressive diabetic nephropathy. He has had several hemodialysis access failures due to infection and thrombosis issues.
His temperature is 38.9 C (102 F), blood pressure is 124/60 mm Hg, pulse is 88/min, and respirations are 18/min. Examination shows a tunneled hemodialysis catheter in the right chest which was placed four weeks ago. There is no drainage, erythema, or tenderness over the catheter entry or tunnel site. Lungs are clear to auscultation and there are no cardiac murmurs. The remainder of the examination shows no abnormalities.
His chest x-ray shows no infiltrates. Blood cultures are sent and he is started on broad-spectrum antibiotics.
Which of the following positive culture results would necessitate immediate catheter removal?

Question

A 49-year-old man with end-stage renal disease is hospitalized because of fever and malaise for the past 2 days.  His other medical problems include hypertension and type 2 diabetes mellitus.  His renal failure is attributed to uncontrolled hypertension and progressive diabetic nephropathy.  He has had several hemodialysis access failures due to infection and thrombosis issues.
His temperature is 38.9 C (102 F), blood pressure is 124/60 mm Hg, pulse is 88/min, and respirations are 18/min.  Examination shows a tunneled hemodialysis catheter in the right chest which was placed four weeks ago.  There is no drainage, erythema, or tenderness over the catheter entry or tunnel site.  Lungs are clear to auscultation and there are no cardiac murmurs.  The remainder of the examination shows no abnormalities.
His chest x-ray shows no infiltrates.  Blood cultures are sent and he is started on broad-spectrum antibiotics.
Which of the following positive culture results would necessitate immediate catheter removal?

Quizplus · Accepted Answer

11ec193a_96f7_4ddb_853d_c9b5ffd21e5e_MD0002_00 This patient's clinical history and presentation are consistent with tunneled catheter-related bloodstream infection (CRBSI). Systemic antibiotics are usually not required for CRBSI patients with positive catheter tip culture, phlebitis without signs of infection (e.g., fever), or those with positive blood cultures through the catheter but negative cultures from the peripheral vein. All other cases (such as with this patient) usually require systemic antibiotics in addition to catheter removal. If catheter removal carries a high risk for reinsertion, then guidewire exchange may also be attempted. In patients with uncomplicated CRBSI, catheter salvage with close monitoring may be attempted. Certain organisms (e.g., coagulase-negative Staphylococcus) can form biofilms on central venous catheter surfaces, making it very difficult to eradicate these organisms without catheter removal. Antimicrobial "lock" therapy involves placing a supratherapeutic antibiotic amount (100-1000 times higher than the normal dose) in the catheter lumen for hours to days to attempt catheter salvage in these cases. However, Pseudomonas aeruginosa CRBSI usually has poor outcomes with catheter salvage, thus long-term catheters should be removed. Afterwards, surveillance blood cultures should be drawn to document bacteremia clearance. (Choice A) Catheter-related bloodstream infections due to E. coli susceptible to cephalosporins can be treated with systemic antibiotics and catheter salvage as long as there are no acute indications for catheter removal. However, catheter removal should be strongly considered for CRBSI due to multidrug resistant E. coli. (Choices B and D) Catheter salvage may be considered for stable CRBSI due to E. faecalis and Streptococcus species as long as the patient has no acute indications for catheter removal. (Choice E) Unless the patient has indications for catheter removal, current guidelines allow catheter salvage for infections from coagulase-negative Staphylococcus sensitive to vancomycin. However, catheter salvage should be avoided in catheter associated infections caused by Staphylococcus aureus. Educational objective: Catheter-related bloodstream infection (CRBSI) usually requires systemic antibiotics and catheter removal in patients with suppurative thrombophlebitis, endocarditis, sepsis, or persistent bacteremia. Catheter removal is usually indicated In CRBSI due to Pseudomonas aeruginosa, Staphylococcus aureus, or fungi. __________ References: Successful prevention of tunneled, central catheter infection by antibiotic lock therapy using cefotaxime. (http://www.ncbi.nlm.nih.gov/pubmed/22091249) Factors associated with improved outcome of Pseudomonas aeruginosa bacteremia in a Finnish university hospital. (http://www.ncbi.nlm.nih.gov/pubmed/9865983) Role of culturing from the tip and the tunneled segment of the catheters in tunneled catheter infection. (http://www.ncbi.nlm.nih.gov/pubmed/19061170)

A 49-Year-Old Man with End-Stage Renal Disease Is Hospitalized Because