A 74-year-old male with end-stage renal disease (ESRD) and recent pulmonary embolism on apixaban presents to the intensive care unit from dialysis clinic with a 6-day history of fevers and chills. He received hemodialysis through a tunneled central venous catheter. Blood cultures drawn in the emergency room are all positive for gram-positive cocci that are later identified as coagulase-negative Staphylcoccus (CNS). The patient is hemodynamically stable with significant thrombocytopenia to 15 and is methicillin-resistant Staphylococcus aureus (MRSA) negative.
What is the next best step in this patient’s management?A. Tunneled dialysis catheter exchange over a guidewire
Correct Answer: A
This patient likely has CNS CRBSI. Central line removal is often advocated but is controversial in the setting of CNS CRBSI especially in hemodynamically stable and immunocompetent patients without signs of infection and foreign bodies. Salvage therapy using antibiotic lock therapy or a guidewire exchange of his tunneled dialysis catheter can be considered as an alternative treatment for catheter removal especially given this patient’s significant coagulopathy and risk for complications related to removing and placing a new central line. For organisms other than Staphylococcus aureus and candida, repeat blood cultures are not necessary unless salvage therapy has been used to ensure resolution of bacteremia. Antibiotic course is typically 7 days if the catheter is removed and 14 days if salvage therapy is used. CNS CRBSI should be initially treated with vancomycin until sensitivities return because of the high incidence of resistance to methicillin, cephalosporins, and many other antibiotics. Echocardiogram is not necessary in the setting of CNS CRBSI unless there is persistent bacteremia.