Intravascular catheter-related bloodstream infection (CRBSI) is a that is attributable to the presence of an intravascular catheter, typically a central venous catheter or an arterial catheter. Peripheral intravenous catheters (with or without ) are rarely responsible for bloodstream infections. Coagulase-negative staphylococci and Staphylococcus aureus are the most common causative pathogens; however, gram-negative bacilli and Candida spp. are also frequently responsible, especially in critically ill patients and those with femoral intravascular catheters. CRBSI can manifest with fever with or without and evidence of infection at the catheter insertion site (e.g., localized erythema, induration, exudate). Isolation of the same pathogen on cultures obtained from at least 2 different sites (e.g., blood cultures from a peripheral venipuncture and the suspected infected catheter) confirms the diagnosis. Empiric antibiotic therapy should be initiated as soon as appropriate cultures are obtained. Inadequate response to empiric antibiotic therapy should prompt evaluation for complications of CRBSI (e.g., infective endocarditis, suppurative thrombophlebitis) and typically necessitates removal of the catheter and prolonged antibiotic therapy.
- Intravascular catheter-related bloodstream infection (CRBSI): in a patient with an intravascular catheter accessed > 48 hours prior or within 48 hours of catheter removal that can be attributed to the presence of an intravascular catheter (see also “”)
- Central line-associated bloodstream infection (CLABSI) : in patients with a central line accessed > 48 hours prior or within 48 hours of central line removal
Common pathogens 
- Gram-positive: coagulase-negative staphylococci and S. aureus (most common)
- Fungal: Candida spp.
- Gram-negative: Pseudomonas aeruginosa
Risk factors for CRBSI 
- Patient-related factors
- Catheter-related factors
Mechanism of infection 
- Pathogens (e.g., bacterial or fungal) at the percutaneous exit site migrate along the outer surface of the catheter to the bloodstream.
- Tends to occur in short-term catheters (placed for < 14 days)
- Pathogens (e.g., bacterial or fungal) infect the catheter hub and migrate within the lumen of the catheter into the bloodstream.
- Can occur in both long-term catheters (placed for ≥ 14 days) and short-term catheters
- Infusion contamination (e.g., infected blood transfusion, )
- Hematogenous seeding (from other sites)
The following recommendations relate primarily to CRBSI secondary to central lines and arterial catheters. Peripheral intravenous catheters (with or without ) are rarely responsible for bloodstream infections. However, exudates from any intravascular line (including peripheral lines) should be submitted for Gram stain and culture.
Routine initial diagnostics 
- CBC, inflammatory markers, BMP, liver chemistries (similar to the )
- Consider additional tests (e.g., urinalysis, chest x-ray) as needed to rule out other potential primary sources of infection.
- Should be obtained preferably prior to starting antibiotics from two different sites simultaneously
- One of the cultures should be either a blood culture from the catheter lumen or, if the catheter has been removed, the catheter tip.
- Any exudate at the catheter insertion site should also be cultured.
- The same organism should be isolated from the different sites to confirm CRBSI.
|Diagnostic criteria for intravascular catheter-related bloodstream infection |
|Peripheral venipuncture AND intravascular catheter lumen|
|Peripheral venipuncture AND intravascular catheter tip |
|≥ 2 samples from different catheter lumens |
A diagnosis of CRBSI requires the same organism to be grown in at least two cultures obtained from different sites. 
If the diagnostic criteria for CRBSI are not fulfilled, investigate for alternative sources of infection. If another primary source cannot be found and signs and symptoms persist, remove the catheter and culture the catheter tip. 
- Indications: to evaluate for infective endocarditis in patients who have any of the following 
- Important consideration: TEE should ideally be performed 5–7 days after the onset of BSI to minimize the likelihood of false negatives.
- septic shock: Initiate hemodynamic support (see “Acute management checklist for sepsis”). or
- Obtain appropriate cultures before administering antibiotics.
- Initiate .
- Remove the catheter if are met.
- Start supportive care and monitor response to treatment.
- Should be administered as soon as appropriate cultures have been obtained
- Coverage required:
|Empiric antibiotic therapy for CRBSI|
|Coverage||Indications ||Example regimens for adult patients |
|Gram-negative bacilli (including Pseudomonas aeruginosa)|| |
Empiric antibiotics for CRBSI should always provide gram-positive coverage. Empiric antibiotics for CRBSI in patients with femoral catheters should include coverage for gram-positive pathogens, gram-negative bacilli, and Candida spp. 
In patients with fungemia, obtain an ophthalmologic examination to rule out fungal retinitis. 
Indications for intravascular catheter removal 
- Any peripheral venous catheter with signs of local infection
- Long-term (≥ 14 days) central lines or arterial catheters: if any of the following are present
- Severe sepsis or septic shock
- Suppurative thrombophlebitis
- Infective endocarditis
- Evidence of persistent BSI (symptoms or positive cultures) despite 72 hours of appropriate therapy
- Obvious signs of infection at the catheter site
- Confirmed infection with S. aureus, P. aeruginosa, enterococci, fungi, or mycobacteria
- Catheter dysfunction (e.g., cracked and/or clotted lumen)
- Short-term (< 14 days) central access and confirmed infection with S. aureus, Enterococci, fungi, mycobacteria, or gram-negative bacilli
- Consider removal of long-term or short-term catheters with CRBSI due to less virulent pathogens that are difficult to eradicate (e.g., Bacillus spp., Micrococcus spp., propionibacteria, coagulase-negative Staphylococci)
Hemodynamically instability or end-organ damage likely due to CRBSI necessitates immediate catheter removal. 
In patients who require continued vascular access, establish intravascular access at a new site or consider catheter salvage in patients with limited venous access. 
Catheter salvage 
- Consider in patients with long-term catheters who do not have any indications for intravascular catheter removal
- Consider in patients who fulfill indications for removal but require long-term vascular access (e.g., for hemodialysis) and have limited vascular access
- Consider under specialist guidance.
- Appropriate , , , (see “Supportive therapy” in “ ”)
- Monitor patients in an appropriate care setting with repeat clinical assessments and laboratory studies.
Uncomplicated CRBSI 
- Resolution of symptoms and negative blood cultures within 72 hours of appropriate antibiotic therapy in a patient without any of the features of complicated CRBSI
- Continue antibiotics for 7–14 days after the first negative blood culture, depending on the cultured organism.
- There is insufficient evidence to recommend repeat cultures following the completion of antimicrobial therapy. 
Complicated CRBSI 
- Defined as CRBSI in a patient with any of the following:
Specialists (e.g., in infectious disease) should be actively involved in the management of all patients with complicated CRBSIs.
Acute management checklist
See also the “.”
- ABCDE approach
- Immediate hemodynamic support (e.g., IV fluids, vasopressors) and respiratory support as needed.
- Order at least 2 blood cultures from different sites (e.g., peripheral venipuncture and catheter lumen).
- Consult an infectious disease specialist early.
- Start empiric antibiotic therapy for CRBSI.
- If indications for intravascular catheter removal are met:
- Remove the intravascular catheter and send the tip for culture.
- Establish a new IV access site at a different site.
- Consider catheter salvage in patients with limited vascular access.
- Admit to appropriate care setting (e.g., ICU for critically ill patients).
- Ensure appropriate supportive care (e.g., IV, fluids, antipyretic therapy, VTE prophylaxis).
- One-Minute Telegram 49-2022-3/3: A care bundle to reduce bloodstream infections in hemodialysis
- One-Minute Telegram 36-2021-3/3: Replacement of peripheral IV catheters and incidence of bloodstream infections
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