Catheter-related bloodstream infection
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Jason Le, B.S.[2]
Overview of catheter-related bloodstream infection
- Catheter-related bloodstream infection (CRBSI) is a bloodstream infection in which an intravascular catheter is demonstrated to be the source of infection. CRBSI should be distinguished from central line-associated bloodstream infection (CLABSI), which is a standardized healthcare-associated infection surveillance definition and does not necessarily establish that the catheter caused the bacteremia or fungemia.[1][2][3]
- CRBSI is clinically important because delayed recognition or inappropriate catheter management can result in persistent bacteremia or fungemia, sepsis, metastatic infection, and other catheter-related complications.[1]
- Management requires assessment of clinical stability, catheter necessity, suspected or identified pathogen, evidence of complications, and whether catheter removal or attempted salvage is appropriate.[4][5]
Historical Perspective
- The semiquantitative roll-plate catheter-tip culture described by Maki and colleagues established an early reproducible microbiologic method for implicating the catheter as the source of bloodstream infection, and it remains the comparator for later attribution techniques.[6]
- The Infectious Diseases Society of America (IDSA) codified clinical diagnostic and management criteria in the 2009 Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection, which formalized the differential-time-to-positivity and quantitative paired-culture criteria still in use.[6]
- In parallel, the CDC National Healthcare Safety Network (NHSN) operationalized central line-associated bloodstream infection (CLABSI) as a surveillance definition—laboratory-confirmed bloodstream infection in a patient with a central line in place for more than 2 calendar days and no other identified source—deliberately distinct from the clinical CRBSI definition so that it could be applied consistently for institutional benchmarking.[2]
- In 2013 the CDC introduced mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) criteria to distinguish translocation-related bacteremia in neutropenic and transplant patients from true catheter-attributable infection, addressing systematic overestimation of catheter infection in oncology populations.[7]
- The conceptual trajectory has thus moved from catheter-tip culture, to paired clinical attribution criteria, to standardized surveillance definitions—explaining why CRBSI and CLABSI, though related, are not interchangeable.[6][2]
Clinical distinction from CLABSI
| Feature | CRBSI | CLABSI |
|---|---|---|
| Purpose | Clinical diagnosis of catheter-attributable bloodstream infection | Standardized surveillance definition for healthcare-associated infection |
| Catheter causality | Requires evidence that the catheter is the source | Does not necessarily establish catheter causality |
| Clinical use | Guides diagnostic evaluation and catheter management | Primarily supports infection surveillance and prevention programs |
- The distinction is clinically consequential: CLABSI surveillance events may not represent true CRBSI, whereas CRBSI requires evaluation for catheter-source infection.[1][2][3]
Etiology and clinical context
- CRBSI can occur with short- or long-term intravascular catheters and is particularly important in patients who require prolonged vascular access, including patients receiving hemodialysis, oncology therapy, or other long-term intravenous treatment.[4][8]
- The causative organism should be established whenever possible because catheter-management decisions and antimicrobial treatment depend on the pathogen and clinical course.[9]
Epidemiology and Demographics
- With modern insertion and maintenance bundles, CVC-associated bloodstream infection occurs in roughly 0.5–1.5% of catheterized ICU patients, with a reported median of approximately 0.5–2.5 episodes per 1000 catheter-days.[5]
Risk Factors
- Risk factors for CRBSI are conventionally grouped into patient (host), provider (process), and device characteristics; provider and device factors are the most modifiable.[10][11]
Host factors
- Immunocompromise from hematologic malignancy, neutropenia, malnutrition, prolonged pre-insertion hospitalization, severe burns, body-mass index >40, and prematurity in infants increase risk.[1]
- Neutropenia is a major independent risk factor and is associated with higher mortality from catheter-related bloodstream infection.[7]
- In a 2023 systematic review/meta-analysis of ICU patients, independently associated host factors included immunosuppression (OR 2.87, 95% CI 2.08–3.95), age ≥60 years (OR 2.19, 95% CI 1.76–2.73), and higher APACHE II score (OR 1.84, 95% CI 1.54–2.20).[10]
- Malnutrition/hypoalbuminemia has been associated with CLABSI (OR 3.13, 95% CI 1.38–5.24).[11]
Device and insertion-site factors
- Multilumen catheters carry higher risk than single-lumen catheters (OR 3.41, 95% CI 2.27–5.11); conversely, single-lumen devices are protective (OR 0.45, 95% CI 0.37–0.55). Bilumen catheters were not independently associated with infection in pooled analysis (OR 0.78, 95% CI 0.51–1.19).[10][11]
- The subclavian site is preferred in the ICU to minimize infectious risk. In a pairwise/network meta-analysis, catheter-related bloodstream infection risk was higher for femoral than subclavian (RR 2.44, 95% CI 1.25–4.75) and lower for internal jugular than femoral (RR 0.55, 95% CI 0.34–0.89), while internal jugular and subclavian were comparable; colonization was higher for both internal jugular (RR 2.25) and femoral (RR 2.92) versus subclavian.[12]
- The subclavian advantage must be weighed against higher mechanical-complication risk (e.g., pneumothorax) and should be avoided when hemodialysis access may be needed, because of subclavian stenosis risk.[4]
- Subclavian-site preference is not uniform across all data: a 2024 systematic review found CLABSI rates broadly comparable across subclavian (2.5), femoral (2.7), and internal jugular (3.8 per 1000 catheter-days) with overlapping credible intervals, and the American Society of Anesthesiologists graded bloodstream-infection evidence between sites as equivocal.[13][14]
- Device type also matters beyond conventional CVCs: short peripheral catheters, PICCs, midline catheters, and peripheral arterial catheters all carry infectious risk; pulmonary-artery catheters and catheter introducers are associated with substantial risk.[3]
Process and dwell-time factors
- Risk rises with catheter dwell time in a dose-dependent manner: ≥5 days (OR 2.07, 95% CI 1.41–3.03), ≥7 days (OR 3.62, 95% CI 2.65–4.97), and ≥14 days (OR 4.85, 95% CI 3.35–7.01).[10]
- Total parenteral nutrition (OR 2.27, 95% CI 1.56–3.29), multiple insertion attempts/re-cannulation (OR 3.50, 95% CI 2.93–4.17), prolonged ICU stay (OR 4.05, 95% CI 2.41–6.80), and extensive antibiotic exposure (OR 3.54, 95% CI 1.65–7.61) are additional modifiable associations.[10]
- Heavy microbial colonization at the insertion site or catheter hub, concurrent catheters, emergency insertion, breaches in sterile technique, excessive catheter manipulation, reduced nurse-to-patient ratio, and failure to remove unnecessary catheters are established process-related risk factors.[1][11][3]
Areas of inconsistency
- Diabetes mellitus is reported as a risk factor in some analyses (OR 3.06, 95% CI 2.56–3.66) but showed no association in others (OR 1.08, 95% CI 0.94–1.25); kidney disease similarly showed no consistent independent association (OR 0.63, 95% CI 0.35–1.12). These should be presented as uncertain rather than established.[10][11]
Diagnosis
- Diagnosis requires microbiologic evaluation together with assessment of the catheter as a potential source of bloodstream infection.[9]
- When CRBSI is suspected, obtain appropriate blood cultures and evaluate whether cultures obtained from the catheter and a peripheral site support catheter attribution. Differential time to positivity (DTP) and quantitative or semiquantitative culture methods may assist in establishing catheter source when applicable.[9][8]
- Supportive microbiologic criteria include a DTP of ≥2 hours, defined as the catheter-drawn culture turning positive at least 2 hours before the paired peripheral culture when the same organism is recovered, and a quantitative catheter-to-peripheral colony-count ratio of approximately 3:1 to 10:1.[9][8][15]
- In meta-analysis, DTP had a summary sensitivity of approximately 81% and specificity of approximately 92%. DTP performs poorly for Staphylococcus aureus because of low sensitivity and for Candida because of low specificity; these organisms generally warrant catheter removal based on the clinical context regardless of attribution testing.[15][4]
- The quantitative culture ratio criterion is supported by the IDSA clinical CRBSI guideline and AGIHO/DGHO guidance; reported thresholds vary within the broader range of approximately 3:1 to 10:1.[6][8]
- Imaging is not required to establish uncomplicated CRBSI but may be indicated when complications or metastatic infection are suspected.
- The diagnostic approach should distinguish uncomplicated bloodstream infection from persistent infection, endovascular infection, or metastatic complications because these findings affect catheter management and treatment duration.[1]
Management principles
- Initial management includes appropriate antimicrobial therapy, assessment of hemodynamic stability, evaluation for complications, and a decision regarding catheter removal, replacement, or attempted salvage.[4][5]
- Catheter removal is generally required when CRBSI is associated with Staphylococcus aureus, Pseudomonas species, Candida/fungi, mycobacteria, clinical or hemodynamic instability, persistent fever or bacteremia 48–72 hours after appropriate antimicrobial therapy, tunnel-tract or port-pocket infection, or metastatic complications (eg, suppurative thrombophlebitis, endocarditis). Any non-tunneled (temporary) catheter with CRBSI generally warrants removal.[4][6]
- Catheter salvage may be considered in selected clinically stable patients when vascular access is difficult or preservation of the catheter is important and the pathogen and clinical circumstances are appropriate.[4][5]
- Antibiotic lock therapy may be used as part of a catheter-salvage strategy in selected patients, generally in conjunction with systemic antimicrobial therapy rather than as a substitute for systemic treatment.[4][16]
- The principal trade-off with catheter salvage is preservation of vascular access versus a higher risk of persistent or recurrent infection in some settings. Although observational studies have associated catheter removal with lower mortality, the certainty of evidence supporting an optimal removal-versus-retention strategy is low or very low, and the 2026 Cochrane review concluded that the optimal strategy remains uncertain.[5][17][18]
- Guidance is not uniform: the French intensive-care society advises catheter removal whenever CRBSI is confirmed or suspected, whereas earlier IDSA guidance permitted retention for selected tunneled-catheter infections (eg, non-Pseudomonas Gram-negative bacilli or coagulase-negative staphylococci); the optimal strategy remains uncertain.[5]
- Organism-specific antimicrobial regimens, doses, durations, and detailed indications for catheter salvage or removal should be addressed in the Medical Therapy microchapter rather than duplicated here.
Prevention
- Prevention depends on evidence-based central-line insertion and maintenance practices, including standardized care bundles, appropriate catheter selection, aseptic technique, and ongoing surveillance and quality-improvement measures.[19][1]
Prognosis and complications
- Potential complications include persistent bloodstream infection, sepsis, metastatic infection, and other endovascular or organ-specific complications.[1]
- Persistent or recurrent bacteremia or fungemia should prompt reassessment of catheter source control and evaluation for complications.[1][4]
- Prognosis depends on the causative organism, host factors, clinical severity, adequacy of antimicrobial therapy, source control, and development of metastatic or other complications.
- Reported 30-day mortality is approximately 13.8% in a multicenter cohort of predominantly non-ICU/general-ward patients and has declined over the past decade; this figure should not be interpreted as a universal mortality estimate because ICU-acquired CRBSI carries substantially higher mortality. Higher mortality has been reported with ICU or medical-ward acquisition and with S. aureus or Candida.[20][21][22]
- Bloodstream infection in this setting is associated with increased mortality: a meta-analysis of 18 studies found a pooled odds ratio of death of 2.75 (95% CI 1.86–4.07) for CLABSI versus no CLABSI, with substantial heterogeneity (I²=80%). A 2024 meta-analysis that separated the two definitions reported mortality odds ratios of 3.19 (95% CI 2.44–4.16) for CLABSI and 2.47 (95% CI 1.51–4.02) for CRBSI compared with uninfected patients.[23][24]
- Metastatic complications occur in an estimated 3–22% of episodes, most commonly infective endocarditis, suppurative thrombophlebitis, and osteomyelitis/spondylodiscitis.[22]
Differentiating CRBSI from other Diseases
- For further information about the differential diagnosis, click here.
- The CRBSI-versus-CLABSI distinction is summarized in the Clinical distinction from CLABSI section above.
Key clinical points
- CRBSI and CLABSI are not synonymous: CRBSI establishes catheter attribution clinically; CLABSI is a surveillance construct.
- Obtain microbiologic evidence and assess catheter attribution whenever CRBSI is suspected.
- DTP ≥2 hours supports catheter attribution when paired catheter and peripheral cultures grow the same organism, but DTP has important organism-specific limitations.
- Source control is central to management. Catheter removal is particularly important for S. aureus, Pseudomonas, Candida/fungi, mycobacteria, temporary non-tunneled catheters, persistent infection, tunnel or pocket infection, instability, and metastatic complications.
- Catheter salvage is selective, not routine. When salvage is attempted, antibiotic lock therapy may be used with systemic therapy in appropriately selected patients.
- Persistent or recurrent bloodstream infection requires reassessment for inadequate source control or metastatic infection.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 O'Grady NP (2023). "Prevention of Central Line–Associated Bloodstream Infections". The New England Journal of Medicine. 389 (12): 1121–1131. doi:10.1056/NEJMra2213296.
- ↑ 2.0 2.1 2.2 2.3 United States Centers for Disease Control and Prevention. 2026 National Healthcare Safety Network (NHSN) Patient Safety Component Manual. 2026 NHSN Patient Safety Component Manual
- ↑ 3.0 3.1 3.2 3.3 O'Grady NP, Alexander M, Burns LA; et al. (2011). "Guidelines for the Prevention of Intravascular Catheter-Related Infections". Clinical Infectious Diseases. 52 (9): e162–e193. doi:10.1093/cid/cir257.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Lok CE, Huber TS, Lee T; et al. (2020). "KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update". American Journal of Kidney Diseases. 75 (4 Suppl 2): S1–S164. doi:10.1053/j.ajkd.2019.12.001.
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Izawa J, Daneman N, Adhikari NKJ, et al. Retention versus replacement or removal of catheters for people with confirmed or suspected intravascular catheter-related infections. Cochrane Database of Systematic Reviews. 2026. doi:10.1002/14651858.CD016329.
- ↑ 6.0 6.1 6.2 6.3 6.4 Mermel LA, Allon M, Bouza E, et al. Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2009;49(1):1-45. doi:10.1086/599376.
- ↑ 7.0 7.1 Zakhour R, Chaftari AM, Raad II (2016). "Catheter-Related Infections in Patients With Haematological Malignancies: Novel Preventive and Therapeutic Strategies". The Lancet Infectious Diseases. 16 (11): e241–e250. doi:10.1016/S1473-3099(16)30213-4.
- ↑ 8.0 8.1 8.2 8.3 Böll B, Schalk E, Buchheidt D, et al. Central venous catheter-related infections in hematology and oncology: 2020 updated guidelines on diagnosis, management, and prevention by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Annals of Hematology. 2021;100(1):239-259. doi:10.1007/s00277-020-04286-x.
- ↑ 9.0 9.1 9.2 9.3 Miller JM, Binnicker MJ, Campbell S, et al. Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2024 Update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Clinical Infectious Diseases. 2024. doi:10.1093/cid/ciae104.
- ↑ 10.0 10.1 10.2 10.3 10.4 10.5 Huang H, Chang Q, Zhou Y, Liao L (2023). "Risk factors of central catheter bloodstream infections in intensive care units: A systematic review and meta-analysis". PLoS One. 18 (9): e0282003. doi:10.1371/journal.pone.0282003.
- ↑ 11.0 11.1 11.2 11.3 11.4 Lafuente Cabrero E, Terradas Robledo R, Civit Cuñado A; et al. (2021). "Risk factors of catheter-associated bloodstream infection: Systematic review and meta-analysis". PLoS One. 16 (11): e0256547. doi:10.1371/journal.pone.0256547.
- ↑ Arvaniti K, Lathyris D, Blot S; et al. (2017). "Cumulative Evidence of Randomized Controlled and Observational Studies on Catheter-Related Infection Risk of Central Venous Catheter Insertion Site in ICU Patients: A Pairwise and Network Meta-Analysis". Critical Care Medicine. 45 (4): e437–e448. doi:10.1097/CCM.0000000000002092. PMID 27632678.
- ↑ Teja B, Bosch NA, Diep C; et al. (2024). "Complication Rates of Central Venous Catheters: A Systematic Review and Meta-Analysis". JAMA Internal Medicine. 184 (5): 474–482. doi:10.1001/jamainternmed.2023.8232.
- ↑ No authors listed. Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2020;132(1):8-43. doi:10.1097/ALN.0000000000002864.
- ↑ 15.0 15.1 Dhaliwal M, Daneman N (2023). "Utility of Differential Time to Positivity in Diagnosing Central Line-Associated Bloodstream Infections: A Systematic Review and Meta-Analysis". Clinical Infectious Diseases. 77 (3): 428–437. doi:10.1093/cid/ciad225. PMID 37062596 Check
|pmid=value (help). - ↑ Almeida BM, Moreno DH, Vasconcelos V, et al. Interventions for treating catheter-related bloodstream infections in people receiving maintenance haemodialysis. Cochrane Database of Systematic Reviews. 2022. doi:10.1002/14651858.CD013554.pub2.
- ↑ Calò F, Retamar P, Martínez Pérez-Crespo PM; et al. (2020). "Catheter-Related Bloodstream Infections: Predictive Factors for Gram-Negative Bacteria Aetiology and 30 day Mortality in a Multicentre Prospective Cohort". The Journal of Antimicrobial Chemotherapy. 75 (10): 3056–3061. doi:10.1093/jac/dkaa262. PMID 32688386 Check
|pmid=value (help). - ↑ Evans L, Rhodes A, Alhazzani W; et al. (2021). "Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021". Critical Care Medicine. 49 (11): e1063–e1143. doi:10.1097/CCM.0000000000005337.
- ↑ Buetti N, Marschall J, Drees M; et al. (2022). "Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute-Care Hospitals: 2022 Update". Infection Control and Hospital Epidemiology. 43 (5): 553–569. doi:10.1017/ice.2022.87.
- ↑ Badia-Cebada L, Peñafiel J, López-Contreras J, et al. Decreased Mortality Among Patients With Catheter-Related Bloodstream Infections at Catalan Hospitals (2010-2019). The Journal of Hospital Infection. 2022;126:70-77. doi:10.1016/j.jhin.2022.05.009. PMID:35594988.
- ↑ Saliba P, Hornero A, Cuervo G, et al. Mortality Risk Factors Among Non-Icu Patients With Nosocomial Vascular Catheter-Related Bloodstream Infections: A Prospective Cohort Study. The Journal of Hospital Infection. 2018;99(1):48-54. doi:10.1016/j.jhin.2017.11.002. PMID:29128346.
- ↑ 22.0 22.1 Şibar EG, Şencan İC. Catheter-related bloodstream infections in hemodialysis: microbiology, antimicrobial resistance, complications and predictors of mortality. BMC Infectious Diseases. 2026;26(1):948. doi:10.1186/s12879-026-13225-6.
- ↑ Ziegler MJ, Pellegrini DC, Safdar N (2015). "Attributable mortality of central line associated bloodstream infection: systematic review and meta-analysis". Infection. 43 (1): 29–36. doi:10.1007/s15010-014-0689-y. PMID 25331552.
- ↑ Elangovan S, Lo JJ, Xie Y; et al. (2024). "Impact of Central-Line-Associated Bloodstream Infections and Catheter-Related Bloodstream Infections: A Systematic Review and Meta-Analysis". The Journal of Hospital Infection. 152: 126–137. doi:10.1016/j.jhin.2024.08.002. PMID 39151801 Check
|pmid=value (help).