• Fever in a patient with a tunneled catheter is due to catheter related bacteremia unless proven otherwise.
• Separate (but simultaneous) blood cultures from a peripheral vein and each catheter lumen (3 sets of blood cultures).
• If peripheral veins are difficult to access-take blood cultures from the HD circuit.
• IDSA criteria for diagnosing catheter related bacteremia:

o Culture of the same organism from at least two blood samples (one from a catheter lumen and the other from a peripheral vein)

o Culture of the same organism from both the catheter tip and at least one percutaneous blood culture

o Bacteremia in the absence of another source.

• To treat catheter with infection:

o If patient is on dialysis-STOP dialysis if there is hypotension or patient is ‘looking sick’

o Empirical antibiotics after stopping/end of dialysis and after drawing blood cultures: based on local microbiology and sensitivity patterns

o IV gentamicin 3 mg/kg stat + IV cephazolin 2 g stat.

• Catheter removal:

o Severe sepsis: if the patient is clinically deteriorating i.e., persisting/worsening hypotension-URGENT

o Blood culture: Staphylococcus aureus, Pseudomonas or fungi species

o Other indications; endocarditis, other metastatic infections, concomitant tunnel infection, persistent bacteremia after 72 hours of antibiotic treatment.

• In selected patients, aim to exchange catheter within 72 hours in most patients can be done without waiting for a negative blood culture.