Tunneled catheters are subject to several types of infection: exit site cellulitis, bacteremia with or without external signs, tunnel infection, and septic thrombophlebitis. The most common causative organisms are coagulase-negative staphylococci, but Staphylococcus aureus, Enterococcus, Gram-negative bacilli, other skin flora, yeast, and occasionally nontuberculous mycobac-teria also may be causative organisms. Decisions regarding catheter removal often must be made in the face of fever, neutropenia, and need for multilumen access. In general, tunnel infections require catheter removal regardless of the organism, and pain over the tunnel may be the only sign in a neutropenic patient. In Candida, VRE, or Bacillus infection, it is particularly important to remove the catheter, and it is often desirable to do so for Staphylococcus aureus and Gram-negative bacilli. On the other hand, in the absence of tunnel infection, coagulase-negative staphylococcal infection can often be cleared without catheter removal. If the catheter is to be left in place, repeat blood cultures on therapy should be obtained to document initial clearing, then again after therapy is completed, to document cure. Many clinicians recommend alternating catheter lumens for administration of the i.v. antibiotic.
Persistent positive blood cultures on therapy may reflect septic thrombophlebitis, or less commonly endocarditis, and indicates a need to remove the catheter.
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