Suspected central line bloodstream infection (adult)
Fever, rigors or sepsis in an adult with a central venous catheter (CVC) and no other clear source.
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Infectious DiseaseManagement
Central Line-Associated Bloodstream Infection Management
Central Line-Associated Bloodstream Infection Management: Suspected central line bloodstream infection (adult) → Other pathway first: neutropenia, child...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Warning Other pathway first: neutropenia, child, haemodialysis line
This pathway is for adults with a non-dialysis central line.
- Neutropenic fever: use the febrile neutropenia pathway
- Child or neonate: use paediatric guidance; doses here are for adults
- Haemodialysis catheter: use haemodialysis-specific guidance (antibiotics dosed after dialysis)
03Action Paired blood cultures before antibiotics
One set from a peripheral vein and one through the catheter hub, labelled by site. In septic shock, do not delay antibiotics to get cultures.
- Clean skin and hub with alcoholic chlorhexidine (>0.5%) and let it dry
- No peripheral vein: take 2 or more sets through different lumens
- Catheter set positive 2 h or more before the peripheral set (differential time to positivity) supports line infection
- Look for exit-site pus, tunnel redness or port-pocket infection
- If the line is removed for suspected infection, send the tip for culture
04Action Start empiric IV antibiotics (adult doses)
Vancomycin for all; add gram-negative and antifungal cover by risk. Adjust doses for renal function. Beta-lactam allergy: check the history first; severe reaction: ask infectious diseases or pharmacy.
- Vancomycin (adult): loading dose 20-35 mg/kg actual body weight IV, max 3 g; then dose by renal function, AUC-guided (target AUC 400-600 mg.h/L)
- Add gram-negative cover if septic, critically ill, neutropenic, femoral line or known gram-negative focus: cefepime 2 g IV 8-hourly or piperacillin-tazobactam 4.5 g IV 6-hourly (adult, normal renal function; choose by local antibiogram)
- Septic or critically ill, or known colonisation with a multidrug-resistant gram-negative (for example P. aeruginosa): 2 agents of different classes until susceptibilities are known
- Add an echinocandin if septic AND any of: TPN, prolonged broad-spectrum antibiotics, haematological malignancy, bone marrow or organ transplant, femoral line, Candida at several sites
- Echinocandin (adult): caspofungin 70 mg IV once, then 50 mg IV daily (35 mg daily in moderate hepatic impairment); or micafungin 100 mg IV daily; or anidulafungin 200 mg IV once, then 100 mg IV daily
- Do not use linezolid for empiric therapy
- Narrow therapy when the organism and susceptibilities are known
05Action Remove the line now if any red flag (any line type)
Red flags: severe sepsis or septic shock, tunnel or port-pocket infection, suppurative thrombophlebitis, endocarditis, or bacteraemia after 72 h of active therapy.
- Also remove if the line is no longer needed
- Send the catheter tip for culture
- Place any new line at a different site when possible
- The organism decides removal in all other cases (next step)
06Decision Which organism grew?
Line removal and duration depend on the organism and on whether the line is short-term or long-term (tunnelled line or port).
- S. aureus / S. lugdunensis
07Action S. aureus or S. lugdunensis: remove the line, consult ID
Short-term line: remove at once. Long-term line: remove unless there is no other venous access. Consult infectious diseases. S. lugdunensis is managed like S. aureus.
- Follow-up blood cultures (2 sets) 48 h after the first positive set, then every 24-48 h until negative
- MSSA: cefazolin 2 g IV 8-hourly or flucloxacillin 2 g IV 6-hourly (adult, normal renal function); endocarditis: ID-led dosing
- MRSA: vancomycin (AUC-guided) or daptomycin (dose: see eTG Antibiotic)
- No deep or metastatic focus after full work-up: 14 days from the first negative blood culture
- Positive culture 48 h or more after the first, or incomplete work-up: consider more than 14 days
- Retained intracardiac device, recent endovascular graft or thrombus at the line site: consider more than 14 days, ID-led
- Endocarditis, septic thrombosis or other deep focus: 4-6 weeks or longer, ID-led
- Line kept (rare, no other access): systemic plus antibiotic lock therapy for 4 weeks
08Action S. aureus: echocardiography for all adults
Transthoracic echo (TTE) for every adult with S. aureus bacteraemia. A negative TTE does not exclude endocarditis in high-risk patients.
- TEE if TTE negative and any of: intracardiac device (prosthetic valve, pacemaker, ICD, LVAD), valve disease or prior endocarditis, positive culture 48 h or more after the first, embolic events, more than one separate focus
- Consider TEE if community-onset S. aureus or injection drug use
- Image symptomatic sites (spine, joints, abscess) for a deep focus
09Decision All organisms: still bacteraemic >72 h, or a deep focus?
Blood cultures positive more than 72 h after line removal on active therapy, or signs of endocarditis, septic thrombosis or metastatic infection.
- If Yes
10Action Persistent bacteraemia or deep focus: 4-6 weeks, ID-led
Consult infectious diseases. Remove any retained line.
- TEE, duplex ultrasound of the catheter vein, and imaging of symptomatic sites
- 4-6 weeks of therapy; osteomyelitis 6-8 weeks
- Suppurative thrombophlebitis: surgery only for a purulent superficial vein, spread beyond the vein wall, or failed antibiotic therapy
- S. aureus, earlier TEE negative, and fever or bacteraemia 3 days or more after line removal: repeat TEE
11Outcome Complete the extended course with ID follow-up
Count the duration from the first negative blood culture, or from source control if that comes later.
If No12Outcome Cleared: complete the course
Count the duration from the first negative blood culture. A new line can go in at a new site once blood cultures are negative.
- CoNS
13Action Coagulase-negative staphylococci (not S. lugdunensis)
Often a contaminant. Confirm true infection before treating or removing the line.
- Single positive set: repeat catheter and peripheral cultures before treating
- Line removed: 5-7 days of antibiotics
- Line kept: 10-14 days of systemic antibiotics plus antibiotic lock
- Line removed, uncomplicated, no intravascular or orthopaedic hardware, and repeat cultures taken off antibiotics are negative: observation without antibiotics is an option
14Action Long-term line that must be kept: salvage rules
Only for uncomplicated infection with CoNS, enterococcus or a gram-negative other than P. aeruginosa, when the line is hard to replace.
- Not for S. aureus, P. aeruginosa, Candida or other fungi, Bacillus, Micrococcus, Cutibacterium or mycobacteria
- Not with tunnel or pocket infection, sepsis, septic thrombosis or endocarditis
- Systemic antibiotics plus antibiotic lock for 10-14 days; renew the lock at least every 48 h
- Repeat blood cultures; remove the line if still positive 72 h after starting active therapy
- Path rejoins step 09Shared downstream outcome
- Enterococcus
15Action Enterococcus: remove a short-term line
Long-term line: remove if tunnel or pocket infection, septic thrombosis, sepsis, endocarditis, persistent bacteraemia or metastatic infection.
- Ampicillin-susceptible: ampicillin 2 g IV 4- to 6-hourly (adult)
- Ampicillin-resistant: vancomycin. Vancomycin-resistant: linezolid or daptomycin by susceptibility
- TEE if signs of endocarditis, bacteraemia or fever >72 h on active therapy, septic emboli, or prosthetic valve or other endovascular device
- Uncomplicated: 7-14 days
- Path rejoins step 14Shared downstream outcome
- Gram-negative
16Action Gram-negative bacilli: remove a short-term line
Long-term line: remove if P. aeruginosa. Other gram-negatives: salvage is possible only if uncomplicated (see salvage rules).
- Target therapy by susceptibilities; step down to one agent
- Line removed and prompt response: 7 days is usually enough (not tested in neutropenia or transplant)
- Otherwise 7-14 days
- Bacteraemia or sepsis persisting despite therapy: remove the line, look for endovascular and metastatic infection, and extend therapy
- Path rejoins step 14Shared downstream outcome
- Candida
17Action Candida: remove the line, echinocandin, eye exam
Remove any line type. Give antifungal therapy even if candidaemia clears after line removal. Pregnancy: avoid fluconazole; amphotericin B is preferred; get ID and obstetric advice.
- Echinocandin first (adult): caspofungin 70 mg IV once, then 50 mg IV daily (35 mg daily in moderate hepatic impairment); or micafungin 100 mg IV daily; or anidulafungin 200 mg IV once, then 100 mg IV daily
- Infectious diseases consultation
- Blood cultures daily or every second day until negative
- Dilated eye exam, ideally by an ophthalmologist, within the first week
- Stable, susceptible isolate and cultures negative: step down to fluconazole, usually after 5-7 days; not in pregnancy (dose: see IDSA 2016 candidiasis guideline or eTG)
- No metastatic focus: 14 days after the first negative blood culture and resolution of symptoms
- Path rejoins step 09Shared downstream outcome
- Other
18Action Other: Bacillus, Corynebacterium, Micrococcus, mycobacteria, non-Candida fungi
Bacillus, Corynebacterium, Micrococcus or Cutibacterium: confirm with 2 or more positive sets from different sites, then remove the line. Mycobacteria or non-Candida fungi: remove the line. Seek infectious diseases advice.
- Path rejoins step 09Shared downstream outcome
Guideline Source
IDSA Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update (Mermel et al.), with IDSA/ESCMID 2026 S. aureus bacteraemia consensus and IDSA 2016 candidiasis guideline
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Not for neutropenic fever, children or neonates, or haemodialysis catheters.
- Based on IDSA 2009 (archived by IDSA, no replacement), updated with the IDSA/ESCMID 2026 S. aureus bacteraemia consensus and IDSA 2016 candidiasis guideline. Choose agents by local susceptibilities and eTG Antibiotic.
- Prevention, peripheral cannula infection and exit-site-only infection are not covered.
- Does not replace infectious diseases advice.
Contraindicated Populations
Neonates and children (adult doses; use paediatric guidance)Neutropenic fever (use the febrile neutropenia pathway)Haemodialysis catheter infection (use haemodialysis-specific guidance)
Applicable Regions
AUUSEU
AU: Choose agents and doses with eTG Antibiotic and the local antibiogram. Nafcillin is not marketed in Australia; use cefazolin or flucloxacillin for MSSA.
EU: Follow national susceptibility data for empiric gram-negative cover.
US: Nafcillin or oxacillin are alternatives to cefazolin for MSSA.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Central Line-Associated Bloodstream Infection Management?
The Central Line-Associated Bloodstream Infection Management is a management clinical algorithm for Infectious Disease. It provides a structured decision tree to guide clinical decision-making, based on IDSA Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update (Mermel et al.), with IDSA/ESCMID 2026 S. aureus bacteraemia consensus and IDSA 2016 candidiasis guideline.
What guideline is the Central Line-Associated Bloodstream Infection Management based on?
This algorithm is based on IDSA Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update (Mermel et al.), with IDSA/ESCMID 2026 S. aureus bacteraemia consensus and IDSA 2016 candidiasis guideline (DOI: 10.1086/599376).
What are the limitations of the Central Line-Associated Bloodstream Infection Management?
Known limitations include: Adults only. Not for neutropenic fever, children or neonates, or haemodialysis catheters.; Based on IDSA 2009 (archived by IDSA, no replacement), updated with the IDSA/ESCMID 2026 S. aureus bacteraemia consensus and IDSA 2016 candidiasis guideline. Choose agents by local susceptibilities and eTG Antibiotic.; Prevention, peripheral cannula infection and exit-site-only infection are not covered.; Does not replace infectious diseases advice.. Individual patient factors may require deviation from these recommendations.
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