Prevention measures such as hand hygiene and the use of fully sterile barriers should be implemented during catheter insertion; application of chlorhexidine gluconate for skin antisepsis, maintenance of the sterile technique, and removal of catheters when they are not necessary are effective in preventing infections. In our case, the blood and catheter cultures revealed that
Klebsiella pneumoniae, a gram-negative rod bacterium that is part of the enteric flora and produces endotoxins, caused a severe infection. The central line had been inserted through the left femoral vein in a sterile fashion and was placed for 2 weeks (Fig.
3). Stools could have possibly contaminated the catheter and thus enabled the inhabiting
Klebsiella pneumoniae to infect the blood stream. This situation could have been managed using two strategies: an early empirical and over-indicative administration of antibiotics or a strict application of CRBSI preventive measures. The single most important prognostic factor in sepsis is timing of antibiotic administration. In our case, there was a delay of nearly 24 h before antibiotic administration was started. Although the differential diagnosis was challenging and the laboratory results were seemingly normal, infection should always be considered a reason for fever, especially when further signs of systemic inflammatory response syndrome are observed (in this case, hemodynamic compromise and disseminated intravascular coagulation). Moreover, preventive guidelines for CRBSI recommend that CVC lines should be inserted through subclavian or jugular veins; this is not currently obligatory in general practice [
19,
20]. We routinely try not to place the catheter at the femoral site. In this case, we had initially inserted the catheter through the right neck and then reinserted it through the left femoral vein because the left neck was infected and not hygienic. Currently, we do not understand whether removal and replacement of CVCs through the left femoral vein is useful in avoiding CRBSI, though it is not recommended to routinely switch the position of or to replace CVCs [
19,
21]. Recent randomized control studies also showed no differences in outcome between early CVC removal and watchful waiting [
22]. When CRBSI was suspected, fever was mildly high (37.5 °C) (Fig.
2a) and other infections, such as pneumonia or UTI, were also suspected. In this case, watchful waiting instead of a daily CVC removal could be another option. We cannot conclude that long-term CVC insertion causes CRBSI and death, and whether early replacement or watchful waiting is better to prevent CRBSI.
Additionally, the blood endotoxin level was notably high (428.8 pg/mL) in our case, suggesting a probable endotoxin shock. The presence of endotoxemia in patients with septic shock and positive blood culture are related to higher mortality (39%) than that in patients without endotoxemia (7%) [
23]. This implies that endotoxemia with sepsis might have worsened the patient’s condition and indicated a poor prognosis in our case. Further investigations are needed.