Pedemy All toolsFever with a central line in a child: empiric antibiotics, when the line must come out, and how long to treat.
This tool supports clinicians caring for a child with a central venous catheter and fever or a positive blood culture. It covers how to draw cultures so a line infection can be proven, and empiric antibiotics by neutropenia status, stability and Candida risk. For neutropenic children it follows the 2023 pediatric fever and neutropenia guideline, with anti-pseudomonal beta-lactam monotherapy and vancomycin added for instability or signs of line infection.
Once an organism is known, the tool says whether the line must come out or can be kept with systemic antibiotics plus an antibiotic lock, and how long to treat. It covers coagulase-negative staphylococci, S. aureus, enterococci, gram-negative bacilli and Candida. S. aureus guidance follows the 2026 IDSA/ESCMID consensus, and Candida guidance follows the 2016 IDSA candidiasis guideline, including line removal, the eye exam and 14 days after clearance.
A third branch handles exit-site, tunnel and port-pocket infections. Each result gives pediatric mg/kg doses with maximums, the team to involve, and brief prevention points such as chlorhexidine bathing and daily review of whether the line is still needed. The IDSA 2009 catheter guideline is archived but has not been replaced, and the tool labels it that way.
Draw paired blood cultures from the catheter and a peripheral vein before antibiotics. Infection is line-related if the catheter culture turns positive at least 2 hours before the peripheral culture, or grows at least 3 times more colonies on quantitative culture.
Remove it for sepsis with shock, tunnel or port-pocket infection, septic thrombophlebitis, endocarditis, bacteremia lasting more than 72 hours on active therapy, and for S. aureus, Pseudomonas, Candida or mycobacteria. In children, weigh this against how hard new access will be.
A concentrated antibiotic solution, such as vancomycin 5 mg/mL, fills the catheter lumen and is replaced at least every 48 hours, together with systemic antibiotics, to try to save a long-term line infected with coagulase-negative staphylococci, enterococci or some gram-negative bacilli.
Remove the line. The 2026 IDSA/ESCMID consensus suggests 14 days from the first negative blood culture if there is no deep focus after evaluation, and longer for endocarditis, septic thrombosis or persistent bacteremia.
Remove the line, start an echinocandin (amphotericin B or fluconazole in neonates), get a dilated eye exam, repeat blood cultures until negative, and treat for 14 days after the first negative culture.
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