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This document aims to provide assistance with clinical management of probable or confirmed paediatric line-related sepsis in GG&C, including diagnosis, decisions regarding line salvage if necessary, and use of antimicrobial agents. The prevention of line related infections, and the use of line locks to prevent line infections, is outwith the scope of this guideline.
From the perspective of managing infections as well as to conserve valuable antibiotics and prevent resistance from developing, it is always ideal to remove infected lines or other prosthetic material. Line salvage therapy should only be considered when it is thought to be in the best interests of the patient and the benefits associated with this are thought to outweigh the risks. For example, in patients with multiple previous lines, limited ongoing options for vascular access, or a significant bleeding risk, one might have a lower threshold for considering line salvage. In all cases, the best decisions regarding line removal or salvage are made in the context of the wider multi-disciplinary team which should include a member of the vascular access team. These discussions may be informed by up to date imaging to assess available options for subsequent replacement of central venous access. Risks of line salvage therapy include ongoing or worsening sepsis due to continuing indwelling source of infection, and failure of salvage therapy or recurrence of infection.
It is always good practice to ensure individualised management plans tailored to each patient’s unique needs and circumstances. These guidelines are purely to facilitate this process and are not a substitute for senior clinical review and discussion with an infection specialist where appropriate. Local departmental guidelines may already be in use to facilitate management of line related infections; these should be referred to and if in any doubt the most appropriate course of action should be discussed with an infection specialist.
This document does not provide a comprehensive account of the pathophysiology, potential sources or metastatic complications associated with individual organisms. Organisms not covered in this document, or line sepsis with mixed organisms, should also be discussed with an infection specialist.
“Infection specialist” refers to a specialist in clinical microbiology or infectious diseases.
It is recognised that each patient and situation is unique. The following initial actions are recommended in patients with possible or probable line related sepsis:
Line rest and rechallenge a few days later may allow more bacteria to grow within the line and risk severe septic showers on rechallenge. This might reduce the efficacy of salvage therapy. Removal of an infected line is always ideal when managing line infections, but if this is not possible then a decision to salvage should be made early and salvage therapy that includes line locks, instituted as soon as practicable, guided by senior clinical input. Line removal is indicated in patients who are severely unwell, haemodynamically unstable, or with signs of insertion site infection, severe exit site infection or tunnel infection. If line removal is still not possible then discuss the case urgently with senior clinicians, intensive care and infection specialists.
Line tips should only be sent to microbiology for culture when there is a clinical suspicion of line sepsis. When these are sent, the results should be chased up by the responsible clinical team.
There is evidence that the following organisms, when cultured from a line tip but not blood cultures, MAY warrant clinical review, further investigations, consideration of a period of intravenous antimicrobial treatment, due to the association with deep sources or metastatic septic complications:
If in doubt, discuss with an infection specialist.
Paediatric patients weighing less than 3kg should be discussed with the paediatric infectious diseases team prior to using locks.
Antimicrobial line locks deliver a high concentration of antimicrobial agent direct to the lumen of the line and remain in situ for a period of time before being aspirated and replaced. Line locks should be replaced at least every 24 hours. The line lock should be removed before infusion of the next dose of systemic antibiotic down the line, or, where applicable, other intravenous solution, or medication.
Line locks are an adjunct and not a replacement for systemic antimicrobials and are used as a final attempt at line salvage. For suspected bacterial line related infection, the initial choice of lock therapy suggested is taurolock. Lock therapy can then be guided by culture results and antimicrobial sensitivities. When using antibiotic locks, the choice of lock should ideally be a different class of antimicrobial from the agent used systemically. A number of different antibiotics can be used as a lock. Antibiotic locks not mentioned in this guideline may be considered under the guidance of microbiology and pharmacy based on the organism and antibiotic sensitivities.
For fungal/candidal infection and Staphylococcus aureus/lugdunensis infection, line removal is strongly recommended. Line salvage with antibacterial or antifungal locks should not be attempted unless in exceptional circumstances and should be discussed with an infection specialist first.
There may be instances where it is not possible to use antibiotic lock therapy, or locks cannot be instilled or changed with regularity, and these cases should be discussed with an infection specialist.
Lastly, the volume of lock instilled will vary according to the length and type of line: this cannot be defined in a protocol and must be individualised for the patient.
See Quick Reference Guideline section below for suggested antibiotic lock formulations and clinical management flowchart.
Urokinase administration may be required if a line cannot be aspirated or is considered to be blocked. Further information on troubleshooting and general line-related care can be found at the vascular access device practice website on Staffnet [NOTE: you must be connected to the NHSGGC network to view]:
If a line has been removed due to line sepsis and another line is required, this should ideally be placed in a different location. Guidewire exchange in insertion site infections is not appropriate as it can lead to bacteraemia and septic emboli.
Ideally, clearance of bacteraemia should be documented prior to replacing a line. This usually means a minimum of 48 hours of negative cultures.
This should be discussed with an infection specialist and may vary according to the organism and clinical circumstances. In patients with suspected deep foci of infection, such as endocarditis, septic thrombophlebitis, bony infection, or another deep or potentially infected nidus of infection or prosthesis, a more prolonged course of antibiotics may be required on discussion with the infection specialist
As a general guide:
Vancomycin (5mg/mL) and sodium chloride 0.9% antibiotic lock:
Method for preparation and administration
Gentamicin (5mg/mL) and sodium chloride 0.9% antibiotic lock:
Method of preparation and administration
Method for preparation and administration
Instructions for use can be found at: https://www.taurolock.com/en/download/instructions-use
However, always check the actual instructions supplied with the product on the ward.
Prescription of locks and labelling of lumens:
Line locks should be prescribed on the Kardex as illustrated below.
When salvaging a line, it is ideal to reserve the line purely for antimicrobial therapy (locks and systemic antibiotics) for the duration of salvage treatment. Peripheral access should be cited for any other IV therapies.
For multilumen lines where peripheral access is not available and the patient requires IV therapy of any description in addition to IV antibiotics, it may be necessary to lock different lumens on rotation.
For single lumen lines where peripheral access is not available, the lumen must be locked with antibiotic solution when not in use. Prior to using the line, the lock should be removed and discarded, and the line flushed. After using the line, fresh lock should be instilled until the next use, or 24 hours, whichever is first.
Lumens that are locked should be clearly labelled.
Line removal is strongly recommended in specific problem situations or in infections with problem organisms (Tables 1 and 2). If line removal is not deemed possible or is deemed unsafe, discuss with an infection specialist for individualised advice as a prolonged course of targeted antibiotic therapy along with specific line locks may be required. Unstable patients should be discussed early with an intensive care specialist.
Table 1: Problem Situations where line removal strongly recommended
Infectious Endocarditis or evidence of metastatic complications
Erythema or exudate due to suppurative thrombophlebitis
Persistent bacteraemia after 72 hours of antimicrobial therapy to which an organism is susceptible
Evidence of tunnel infection
Evidence of insertion site infection or severe exit site infection
Table 2: Problem organisms
Highly virulent organisms:
Organisms that may be less virulent but can be difficult to eradicate:
Environmental and multidrug resistant organisms:
Up to Date: Intravascular catheter-related infection: treatment.
Mermel et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infec Dis 2009 49 (1): 1-45
Last reviewed: 01 February 2021
Next review: 28 February 2023
Author(s): Dr Ash Deshpande, Consultant Microbiologist, QEUH; Dr Louisa Pollock, Consultant Paediatrician, RHC
Approved By: Antibiotic Users Committee
Reviewer Name(s): Mr T Bradnock & Dr G Bell