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Antibiotic lock therapy for treatment of catheter-related bloodstream infections

Heather L Girand, PharmD
Section Editor
Daniel J Sexton, MD
Deputy Editor
Elinor L Baron, MD, DTMH


Central venous catheter (CVC) use has increased substantially, and associated infections have become a frequent complication of catheter use. An estimated 250,000 catheter-related bloodstream infections (CRBSIs) occurred annually in the United States [1-4]. Rates are declining in some reports as a result of initiatives designed to prevent these infections; nonetheless, CRBSIs remain a significant cause of morbidity and mortality among patients receiving chemotherapy, parenteral nutrition, and hemodialysis. Infection rates are dependent on the type of CVC used and are reported as the number of bloodstream infections per 1000 intravascular device days. CVC infection rates are highest with short-term noncuffed, nontunneled hemodialysis and multilumen catheters, and lowest with subcutaneous central venous ports [1].

Management of CRBSI depends on the decision to salvage, exchange, or remove the catheter. Antibiotic lock therapy has been used in conjunction with systemic antibiotics in attempts to salvage infected long-term catheters (tunneled catheters and subcutaneous central ports), and its use will be reviewed here.

Diagnosis, general management, and prevention of CRBSI are reviewed elsewhere. (See "Diagnosis of intravascular catheter-related infections" and "Treatment of intravascular catheter-related infections" and "Tunneled, cuffed hemodialysis catheter-related bacteremia" and "Prevention of intravascular catheter-related infections".)


Antibiotic lock therapy (ALT) involves instillation of a highly concentrated antibiotic solution into an intravascular catheter lumen for the purpose of sterilization in order to treat catheter-related bloodstream infections (CRBSIs), minimize associated complications, and avoid catheter removal [5,6]. (See "Treatment of intravascular catheter-related infections", section on 'Salvage' and "Tunneled, cuffed hemodialysis catheter-related bacteremia", section on 'Catheter management'.)

Intraluminal colonization and infection of central venous catheters (CVCs) are associated with the development of microbial biofilm on catheter surfaces. Bacteria in a biofilm can be difficult to eradicate with traditional systemic antibiotic administration and can lead to recurrent CRBSI [7-10]. Antibiotic concentrations must be 100- to 1000-fold greater to kill sessile bacteria within a biofilm as compared with planktonic bacteria [9,11]. The antibiotic lock is a highly concentrated antibiotic solution, often combined with an anticoagulant such as heparin, administered in an amount sufficient to fill and dwell in the catheter lumen when the catheter is not in use. Anticoagulants are thought to be beneficial in ALT for treatment of CRBSI by interfering with fibrin formation and allowing increased antibiotic penetration into microbial biofilm. Dwell times may range from four hours to three days, depending on solution stability and amount of time available when the catheter is not in use. Antibiotic lock solutions should be withdrawn from the catheter when it is needed for intravenous access to avoid systemic exposure to high concentrations of antibiotics and/or anticoagulants that can result in toxic effects, particularly with prolonged use or when used in low-weight neonates [12,13].


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Literature review current through: Sep 2016. | This topic last updated: Oct 11, 2016.
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  1. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006; 81:1159.
  2. O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011; 52:e162.
  3. Berenholtz SM, Lubomski LH, Weeks K, et al. Eliminating central line-associated bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidemiol 2014; 35:56.
  4. Centers for Disease Control and Prevention. Healthcare-associated Infections (HAI) Progress Report. http://www.cdc.gov/hai/progress-report/index.html (Accessed on October 23, 2015).
  5. Messing B, Peitra-Cohen S, Debure A, et al. Antibiotic-lock technique: a new approach to optimal therapy for catheter-related sepsis in home-parenteral nutrition patients. JPEN J Parenter Enteral Nutr 1988; 12:185.
  6. Messing B. Catheter-sepsis during home parenteral nutrition: use of the antibiotic-lock technique. Nutrition 1998; 14:466.
  7. Raad I, Davis S, Khan A, et al. Impact of central venous catheter removal on the recurrence of catheter-related coagulase-negative staphylococcal bacteremia. Infect Control Hosp Epidemiol 1992; 13:215.
  8. Gaillard JL, Merlino R, Pajot N, et al. Conventional and nonconventional modes of vancomycin administration to decontaminate the internal surface of catheters colonized with coagulase-negative staphylococci. JPEN J Parenter Enteral Nutr 1990; 14:593.
  9. Pascual A, Ramirez de Arellano E, Martínez Martínez L, Perea EJ. Effect of polyurethane catheters and bacterial biofilms on the in-vitro activity of antimicrobials against Staphylococcus epidermidis. J Hosp Infect 1993; 24:211.
  10. Raad I, Costerton W, Sabharwal U, et al. Ultrastructural analysis of indwelling vascular catheters: a quantitative relationship between luminal colonization and duration of placement. J Infect Dis 1993; 168:400.
  11. Carratalà J. The antibiotic-lock technique for therapy of 'highly needed' infected catheters. Clin Microbiol Infect 2002; 8:282.
  12. Saxena AK, Panhotra BR, Naguib M. Sudden irreversible sensory-neural hearing loss in a patient with diabetes receiving amikacin as an antibiotic-heparin lock. Pharmacotherapy 2002; 22:105.
  13. Karaaslan H, Peyronnet P, Benevent D, et al. Risk of heparin lock-related bleeding when using indwelling venous catheter in haemodialysis. Nephrol Dial Transplant 2001; 16:2072.
  14. 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. Clin Infect Dis 2009; 49:1.
  15. Fowler VG Jr, Justice A, Moore C, et al. Risk factors for hematogenous complications of intravascular catheter-associated Staphylococcus aureus bacteremia. Clin Infect Dis 2005; 40:695.
  16. Kassar R, Hachem R, Jiang Y, et al. Management of Bacillus bacteremia: the need for catheter removal. Medicine (Baltimore) 2009; 88:279.
  17. Ramos ER, Hachem R, Youssef S, et al. The crucial role of catheters in micrococcal bloodstream infections in cancer patients. Infect Control Hosp Epidemiol 2009; 30:83.
  18. Krishnasami Z, Carlton D, Bimbo L, et al. Management of hemodialysis catheter-related bacteremia with an adjunctive antibiotic lock solution. Kidney Int 2002; 61:1136.
  19. Capdevila JA, Segarra A, Planes AM, et al. Successful treatment of haemodialysis catheter-related sepsis without catheter removal. Nephrol Dial Transplant 1993; 8:231.
  20. Boorgu R, Dubrow AJ, Levin NW, et al. Adjunctive antibiotic/anticoagulant lock therapy in the treatment of bacteremia associated with the use of a subcutaneously implanted hemodialysis access device. ASAIO J 2000; 46:767.
  21. Poole CV, Carlton D, Bimbo L, Allon M. Treatment of catheter-related bacteraemia with an antibiotic lock protocol: effect of bacterial pathogen. Nephrol Dial Transplant 2004; 19:1237.
  22. Maya ID, Carlton D, Estrada E, Allon M. Treatment of dialysis catheter-related Staphylococcus aureus bacteremia with an antibiotic lock: a quality improvement report. Am J Kidney Dis 2007; 50:289.
  23. Aslam S, Trautner BW, Ramanathan V, Darouiche RO. Pilot trial of N-acetylcysteine and tigecycline as a catheter-lock solution for treatment of hemodialysis catheter-associated bacteremia. Infect Control Hosp Epidemiol 2008; 29:894.
  24. Peterson WJ, Maya ID, Carlton D, et al. Treatment of dialysis catheter-related Enterococcus bacteremia with an antibiotic lock: a quality improvement report. Am J Kidney Dis 2009; 53:107.
  25. Messing B, Man F, Colimon R, et al. Antibiotic-lock technique is an effective treatment of bacterial catheter-related sepsis during parenteral nutrition. Clin Nutr 1990; 9:220.
  26. Williams N, Carlson GL, Scott NA, Irving MH. Incidence and management of catheter-related sepsis in patients receiving home parenteral nutrition. Br J Surg 1994; 81:392.
  27. Krzywda EA, Andris DA, Edmiston CE Jr, Quebbeman EJ. Treatment of Hickman catheter sepsis using antibiotic lock technique. Infect Control Hosp Epidemiol 1995; 16:596.
  28. Benoit JL, Carandang G, Sitrin M, Arnow PM. Intraluminal antibiotic treatment of central venous catheter infections in patients receiving parenteral nutrition at home. Clin Infect Dis 1995; 21:1286.
  29. Reimund JM, Arondel Y, Finck G, et al. Catheter-related infection in patients on home parenteral nutrition: results of a prospective survey. Clin Nutr 2002; 21:33.
  30. Viale P, Pagani L, Petrosillo N, et al. Antibiotic lock-technique for the treatment of catheter-related bloodstream infections. J Chemother 2003; 15:152.
  31. Sánchez-Muñoz A, Aguado JM, López-Martín A, et al. Usefulness of antibiotic-lock technique in management of oncology patients with uncomplicated bacteremia related to tunneled catheters. Eur J Clin Microbiol Infect Dis 2005; 24:291.
  32. Rijnders BJ, Van Wijngaerden E, Vandecasteele SJ, et al. Treatment of long-term intravascular catheter-related bacteraemia with antibiotic lock: randomized, placebo-controlled trial. J Antimicrob Chemother 2005; 55:90.
  33. Fernandez-Hidalgo N, Almirante B, Calleja R, et al. Antibiotic-lock therapy for long-term intravascular catheter-related bacteraemia: results of an open, non-comparative study. J Antimicrob Chemother 2006; 57:1172.
  34. Fortún J, Grill F, Martín-Dávila P, et al. Treatment of long-term intravascular catheter-related bacteraemia with antibiotic-lock therapy. J Antimicrob Chemother 2006; 58:816.
  35. Rao JS, O'Meara A, Harvey T, Breatnach F. A new approach to the management of Broviac catheter infection. J Hosp Infect 1992; 22:109.
  36. Johnson DC, Johnson FL, Goldman S. Preliminary results treating persistent central venous catheter infections with the antibiotic lock technique in pediatric patients. Pediatr Infect Dis J 1994; 13:930.
  37. Megged O, Shalit I, Yaniv I, et al. Outcome of antibiotic lock technique for persistent central venous catheter-associated coagulase-negative Staphylococcus bacteremia in children. Eur J Clin Microbiol Infect Dis 2010; 29:157.
  38. Longuet P, Douard MC, Arlet G, et al. Venous access port--related bacteremia in patients with acquired immunodeficiency syndrome or cancer: the reservoir as a diagnostic and therapeutic tool. Clin Infect Dis 2001; 32:1776.
  39. Del Pozo JL, Alonso M, Serrera A, et al. Effectiveness of the antibiotic lock therapy for the treatment of port-related enterococci, Gram-negative, or Gram-positive bacilli bloodstream infections. Diagn Microbiol Infect Dis 2009; 63:208.
  40. Del Pozo JL, García Cenoz M, Hernáez S, et al. Effectiveness of teicoplanin versus vancomycin lock therapy in the treatment of port-related coagulase-negative staphylococci bacteraemia: a prospective case-series analysis. Int J Antimicrob Agents 2009; 34:482.
  41. Funalleras G, Fernández-Hidalgo N, Borrego A, et al. Effectiveness of antibiotic-lock therapy for long-term catheter-related bacteremia due to Gram-negative bacilli: a prospective observational study. Clin Infect Dis 2011; 53:e129.
  42. O'Horo JC, Silva GL, Safdar N. Anti-infective locks for treatment of central line-associated bloodstream infection: a systematic review and meta-analysis. Am J Nephrol 2011; 34:415.
  43. Wolf J, Allison KJ, Tang L, et al. No evidence of benefit from antibiotic lock therapy in pediatric oncology patients with central line-related bloodstream infection: results of a retrospective matched cohort study and review of the literature. Pediatr Blood Cancer 2014; 61:1811.
  44. Viale P, Stefani S. Vascular catheter-associated infections: a microbiological and therapeutic update. J Chemother 2006; 18:235.
  45. Henrickson KJ, Powell KR, Schwartz CL. A dilute solution of vancomycin and heparin retains antibacterial and anticoagulant activities. J Infect Dis 1988; 157:600.
  46. Henrickson KJ, Dunne WM Jr. Modification of central venous catheter flush solution improves in vitro antimicrobial activity. J Infect Dis 1992; 166:944.
  47. Bookstaver PB, Williamson JC, Tucker BK, et al. Activity of novel antibiotic lock solutions in a model against isolates of catheter-related bloodstream infections. Ann Pharmacother 2009; 43:210.
  48. Vercaigne LM, Sitar DS, Penner SB, et al. Antibiotic-heparin lock: in vitro antibiotic stability combined with heparin in a central venous catheter. Pharmacotherapy 2000; 20:394.
  49. Vercaigne LM, Zelenitsky SA, Findlay I, et al. An in vitro evaluation of the antibiotic/heparin lock to sterilize central venous haemodialysis catheters. J Antimicrob Chemother 2002; 49:693.
  50. LaPlante KL, Mermel LA. In vitro activity of daptomycin and vancomycin lock solutions on staphylococcal biofilms in a central venous catheter model. Nephrol Dial Transplant 2007; 22:2239.
  51. Andris DA, Krzywda EA, Edmiston CE, et al. Elimination of intraluminal colonization by antibiotic lock in silicone vascular catheters. Nutrition 1998; 14:427.
  52. Lee JY, Ko KS, Peck KR, et al. In vitro evaluation of the antibiotic lock technique (ALT) for the treatment of catheter-related infections caused by staphylococci. J Antimicrob Chemother 2006; 57:1110.
  53. Lee MY, Ko KS, Song JH, Peck KR. In vitro effectiveness of the antibiotic lock technique (ALT) for the treatment of catheter-related infections by Pseudomonas aeruginosa and Klebsiella pneumoniae. J Antimicrob Chemother 2007; 60:782.
  54. Raad I, Hanna H, Jiang Y, et al. Comparative activities of daptomycin, linezolid, and tigecycline against catheter-related methicillin-resistant Staphylococcus bacteremic isolates embedded in biofilm. Antimicrob Agents Chemother 2007; 51:1656.
  55. Aslam S, Trautner BW, Ramanathan V, Darouiche RO. Combination of tigecycline and N-acetylcysteine reduces biofilm-embedded bacteria on vascular catheters. Antimicrob Agents Chemother 2007; 51:1556.
  56. von Eiff C, Jansen B, Kohnen W, Becker K. Infections associated with medical devices: pathogenesis, management and prophylaxis. Drugs 2005; 65:179.
  57. Kim EY, Saunders P, Yousefzadeh N. Usefulness of anti-infective lock solutions for catheter-related bloodstream infections. Mt Sinai J Med 2010; 77:549.
  58. Anthony TU, Rubin LG. Stability of antibiotics used for antibiotic-lock treatment of infections of implantable venous devices (ports). Antimicrob Agents Chemother 1999; 43:2074.
  59. Droste JC, Jeraj HA, MacDonald A, Farrington K. Stability and in vitro efficacy of antibiotic-heparin lock solutions potentially useful for treatment of central venous catheter-related sepsis. J Antimicrob Chemother 2003; 51:849.
  60. Robinson JL, Tawfik G, Saxinger L, et al. Stability of heparin and physical compatibility of heparin/antibiotic solutions in concentrations appropriate for antibiotic lock therapy. J Antimicrob Chemother 2005; 56:951.
  61. Shanks RM, Donegan NP, Graber ML, et al. Heparin stimulates Staphylococcus aureus biofilm formation. Infect Immun 2005; 73:4596.
  62. Shanks RM, Sargent JL, Martinez RM, et al. Catheter lock solutions influence staphylococcal biofilm formation on abiotic surfaces. Nephrol Dial Transplant 2006; 21:2247.
  63. Sauer K, Steczko J, Ash SR. Effect of a solution containing citrate/Methylene Blue/parabens on Staphylococcus aureus bacteria and biofilm, and comparison with various heparin solutions. J Antimicrob Chemother 2009; 63:937.
  64. Justo JA, Bookstaver PB. Antibiotic lock therapy: review of technique and logistical challenges. Infect Drug Resist 2014; 7:343.
  65. Onland W, Shin CE, Fustar S, et al. Ethanol-lock technique for persistent bacteremia of long-term intravascular devices in pediatric patients. Arch Pediatr Adolesc Med 2006; 160:1049.
  66. Broom J, Woods M, Allworth A, et al. Ethanol lock therapy to treat tunnelled central venous catheter-associated blood stream infections: results from a prospective trial. Scand J Infect Dis 2008; 40:399.
  67. Dannenberg C, Bierbach U, Rothe A, et al. Ethanol-lock technique in the treatment of bloodstream infections in pediatric oncology patients with broviac catheter. J Pediatr Hematol Oncol 2003; 25:616.
  68. Valentine KM. Ethanol lock therapy for catheter-associated blood stream infections in a pediatric intensive care unit. Pediatr Crit Care Med 2011; 12:e292.
  69. Raad I, Chaftari AM, Zakhour R, et al. Successful Salvage of Central Venous Catheters in Patients with Catheter-Related or Central Line-Associated Bloodstream Infections by Using a Catheter Lock Solution Consisting of Minocycline, EDTA, and 25% Ethanol. Antimicrob Agents Chemother 2016; 60:3426.
  70. Soriano A, Bregada E, Marqués JM, et al. Decreasing gradient of antibiotic concentration in the lumen of catheters locked with vancomycin. Eur J Clin Microbiol Infect Dis 2007; 26:659.