Antibiotic lock therapy (ALT) involves instillation of a concentrated antibiotic solution into the catheter lumen with the intention of achieving a drug level high enough to kill sessile bacteria within the biofilm of the catheter. Anticoagulants are often included in the solution and are thought to facilitate antibiotic penetration into microbial biofilm.
For clinically stable children and adults with infections of long-term tunneled central venous catheters and ports due to coagulase-negative staphylococci, gram-negative rods, and vancomycin -sensitive enterococci in whom a decision is made to salvage the catheter, we suggest ALT in conjunction with systemic antibiotics rather than systemic antibiotics alone ( Grade 2B ).
Catheter management options for catheter-related bloodstream infections (CRBSI) include removal, salvage, and exchange over a guidewire. Catheter salvage should not be attempted in the following circuminfections
-Severe sepsis or hemodynamic instability
-Persistent bacteremia despite 72 hours of appropriate antibiotic therapy
-Infections caused by S. aureus, P. aeruginosa, fungi, mycobacteria, Bacillus species, Micrococcus species, or Propionibacteria
-Tunnel infections, port abscesses, or exit site infections
Cefazolin , vancomycin , ceftazidime , and gentamicin are commonly used in ALT and are stable in solution with heparin over a prolonged period of time ( see table ). Specific antibiotic selection for ALT should be guided by culture and susceptibility results when available. We favor a dose in which the final antibiotic concentration exceeds the minimum inhibitory concentration (MIC) of the organism by at least 10administered
For patients receiving ALT, we typically include heparin in the antibiotic lock solution unless there is a contraindication to heparin (eg, heparin-induced thrombocytopenia). For patients with contraindications to heparin, only antibiotics that have been shown be stable and effective when used alone should be administered
Fungal superinfection, systemic toxicities of antibiotics or anticoagulants included in lock solutions, and emergence of antibiotic resistance with failure are potential but not frequently reported adverse effects.
Antibiotic lock solutions should be administered in an amount sufficient to fill and dwell in the catheter lumen when the catheter is not in use. Depending on the need for access, dwell times can range from four to six hours to three days, after which the solution should be withdrawn and discarded.
Infected catheters should be removed in patients who remain febrile 48 to 72 hours after initiating ALT, who have persistently positive blood cultures 72 hours after initiating ALT, or who have signs of sepsis, hemodynamic instability, or metastatic infection.
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