Infection and Isolation | Anti-infective Lock Therapy – Adult/Pediatric – Inpatient/Ambulatory
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Anti-Infective Lock Therapy – Adult/Pediatric –
Inpatient/Ambulatory Clinical Practice Guideline
Note: Active Table of Contents – Click each header below to jump to the section of interest
Table of Contents
INTRODUCTION ....................................................................................................................... 3
SCOPE ...................................................................................................................................... 3
DEFINITIONS ............................................................................................................................ 3
RECOMMENDATIONS .............................................................................................................. 4
TABLE 1. VENOUS ACCESS DEVICES ................................................................................... 7
TABLE 2. CENTRAL VENOUS CATHETER TYPE AND CAPACITY ....................................... 8
METHODOLOGY ...................................................................................................................... 9
APPENDIX 1. NON-HEMODIALYSIS ALT PREPARATIONS AVAILABLE AT UW HEALTH 11
APPENDIX 2. HEMODIALYSIS (HD) ALT PREPARATIONS AVAILABLE AT UW HEALTH 12
APPENDIX 3. ALT PREPARATIONS AVAILABLE FROM CHARTWELL MIDWEST
WISCONSIN HOME INFUSION SERVICES FOR CENTRAL LINES .......................................13
REFERENCES .........................................................................................................................14
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Content Expert:
Name: Lucas Schulz, PharmD, BCIDP
Phone Number: 608-890-8617
Email Address: Lschulz@uwhealth.org
Contact for Changes:
Name: Philip Trapskin, PharmD, BCPS
Phone Number: 608-263-1328
Email Address: ptrapskin@uwhealth.org
Guideline Authors:
Marie H. Pietruszka, PharmD
Rohan Pradhan PharmD
Workgroup Members:
Joshua Vanderloo, PharmD
Reviewers:
Christopher Crinch, MD – Infectious Diseases
Nasia Safdar, MD – Infectious Diseases
Sheryl Henderson, MD – Pediatric Infectious Diseases
Barry Fox, MD – Infectious Diseases
Dennis Maki, MD – Infectious Diseases
Laura Maursetter DO – Nephology
David Yang, MD – Laboratory
Susan Luskin, PharmD – Pharmacy
Nicole Lubcke, PharmD – Pharmacy
Gretchen Manthei, PharmD – Chartwell Midwest Wisconsin
Lucas Schulz, PharmD – Pharmacy
Committee Approvals:
Laboratory Practice Committee May 2019
Antimicrobial Use Subcommittee June 2019
Pharmacy and Therapeutics Committee June 2019
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Introduction
ALT is used for the prevention or treatment of device-related bacteremia or fungemia resulting from the
colonization of bacteria or fungi within the lumen of an intravascular device.1 ALT as developed to allow a
concentrated anti-infective solution to dwell within the catheter lumen for an extended time to eradicate
infectious pathogens. Guidelines have been developed by international clinical groups for ALT
management.2
The most commonly reported CLABSI pathogens are coagulase-negative staphylococci, Staphylococcus
aureus, enterococci, Candida species, and Gram-negative bacilli.3 Important pathogenic determinants of
CRBSI include: (1) device material; (2) formation of fibrin sheaths around the catheter; (3) intrinsic
virulence factors of the infecting organism (extracellular polymeric substance production, biofilm
formation).3 The formation of a biofilm within a catheter lumen limits the penetration of solution. Bacteria
within a biofilm require a 100 to 1000 times greater anti-infective concentration to achieve killing versus
planktonic bacteria. 4 Standard intravenous therapy does not reach a sufficient concentration in the
catheter lumen to reduce microorganism burden within the biofilm of the catheter. One report concluded
that, in hemodialysis patients with dialysis catheter-related infection, systemic vancomycin administration
produces a therapeutic plasma concentration; however, during the intradialytic period, the diffusion of the
vancomycin from the plasma into the catheter lumen was negligible.5
Additionally, the success of ALT is dependent on the stability and compatibility of the ALT solution.6 The
stability and compatibility of ALT solutions is dependent on a number of factors including: temperature,
dwell time, syringe materials, pH, device materials, and anti-infective concentrations.6
Scope
Intended Users: Physicians, Advanced Practice Providers, Nurses, and Pharmacists
Objectives: To provide an evidence-based resource that will maximize the safe, efficacious and efficient
use of anti-infective lock therapy
Target Population: Patients at risk for developing and/or diagnosed with a catheter-related bloodstream
infection (CRBSI)
Clinical Questions Considered:
1. What is the sterility and stability of anti-infective lock therapy preparations?
2. What are the catheter salvage rates?
Definitions
1. Anti-infective lock technique (ALT)7: the installation of a highly concentrated anti-infective
solution into a catheter lumen and allowing the solution to dwell for a specified period for the
purpose of sterilizing the lumen.
2. Catheter-related blood stream infection (CRBSI)8: Defines the catheter as the cause of a
blood stream infection. CRBSI is a clinical definition used when diagnosing or treating patients.
Criteria for CRBSI include the following: Presence of bacteremia or fungemia in a patient who has
an intravascular catheter; AND at least 1 positive blood culture obtained peripherally; AND clinical
signs of infection (fever, chills, or hypotension); AND absence of infection at another site; AND
one of the following: (a) Positive semiquantitative [>15 colony forming units (CFU) per catheter
segment] or quantitative [>102 CFU per catheter segment] catheter tip culture, (b) Quantitative
blood culture with a ratio >3:1 CFU/mL (catheter vs peripheral), (c) Differential time to positivity
(blood culture from catheter is detected at least 2 hours before detection of peripheral blood
culture).
3. Central-line associated blood stream infection (CLABSI)8: Describes a blood stream
infection in a patient who had a recent central catheter. Used by the National Healthcare Safety
Network (NHSN) for surveillance. Criteria for CLABSI include: Presence of bacteremia or
fungemia (a single positive blood culture is required for most organisms, whereas 2 positive blood
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cultures are required for skin flora organisms), AND presence of central line within 48 hours, AND
absence of an infection at a different site.
4. Catheter volume: the intraluminal volume of the catheter
4.1. French (Fr) scale9 - describes the external diameter of the catheter (1Fr = 1/3mm) using an
ascending scale (i.e., higher Fr size indicates larger catheter diameter)
4.2. Gauge - describes both inner and outer diameter using a descending scale (i.e. higher
gauge indicates smaller catheter diameter)
5. Catheter overfill: a specified volume in addition to the catheter volume that ensures that the ALT
solution totally fills the catheter, including the portion closest to the blood interface
5.1. For patient weighing fewer than 15 kg, the overfill volume is 0.1 mL.10
5.2. For patient weighing 15 kg or greater, the overfill volume is 0.2 mL.10
Recommendations
1. ALT for the prevention of CRBSI
1.1. Routine use of ALT in general patient populations is not recommended.2 (UW Health Strong
Recommendation, Low Quality of Evidence)
1.2. Use of ALT is beneficial when vascular access device use is required for a long-term/indefinite
duration and cannot easily be replaced in patients with a history of CRBSI despite maximal
adherence to aseptic technique.2 (UW Health Strong Recommendation, Low Quality of
Evidence)
1.3. Selection of the ALT solution should consider the following: (UW Health Strong
Recommendation, Low Quality of Evidence)
1.3.1. Catheter indication (e.g., hemodialysis, non-hemodialysis)
1.3.2. Catheter composition and compatibility with ALT solution(s) (e.g., prolonged
exposure to ethanol can affect the integrity of certain catheter materials)11
1.3.3. History of CRBSIs and previous culture/sensitivity results
1.3.4. History of previous ALT use/failure
1.3.5. Need for anticoagulant as part of ALT therapy
1.3.6. Medication allergies or adverse drug reactions
1.3.7. Risk of systemic exposure and adverse effects associated with ALT (e.g. ethanol
intoxication in pediatric population)10
1.3.8. Targeted microorganism(s)
1.3.9. Patient age (neonate, pediatric, adult)
1.3.10. Risks of adverse effects from ALT systemic exposure
1.3.11. Regimens available at UW Health (see Appendix 1 and Appendix 2)
2. ALT catheter salvage
2.1. ALT can be beneficial for patients with CRBSI involving long-term catheters with no signs of exit
site or tunnel infection for whom catheter salvage is the goal.4 (UW Health Strong
Recommendation, Low Quality of Evidence)
2.2. For CRBSI, antibiotic lock should not be used alone; instead, it is reasonable to be used in
conjunction with systemic antimicrobial therapy.4 (UW Health Strong Recommendation, Low
Quality of Evidence)
2.3. Dwell times for ALT solutions generally should not exceed 48 hours before reinstallation of lock
solution. Reinstallation is probably indicated every 24 hours for ambulatory patients with
femoral catheters.12 (UW Health Strong Recommendation, Low Quality of Evidence)
2.3.1. For patients who are undergoing hemodialysis, the lock solution can be renewed
after every dialysis session.4 (UW Health Strong Recommendation, Low Quality of
Evidence)
2.4. Catheter removal is probably recommended for CRBSI due to S. aureus and Candida species,
instead of treatment with ALT and catheter retention, unless there are unusual extenuating
circumstances (e.g., no alternative catheter insertion site).4 (UW Health Strong
Recommendation, Low Quality of Evidence)
2.5. For patients with multiple positive catheter-drawn blood cultures that grow coagulase-negative
staphylococci or Gram-negative bacilli and concurrent negative peripheral blood cultures,
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antibiotic lock therapy may be considered without systemic therapy for ten to fourteen days.4
(UW Health Weak/Conditional Recommendation, Low Quality of Evidence)
2.6. Long-term catheter removal is probably indicated in patients with CRBSI associated with any of
the following conditions: severe sepsis; suppurative thrombophlebitis; endocarditis;
bloodstream infection that continues despite 72 hours of antimicrobial therapy to which the
infecting microbes are susceptible; or infections due to S. aureus, P. aeruginosa, fungi, or
mycobacteria.4 (UW Health Strong Recommendation, Low Quality of Evidence)
2.7. Short-term catheter removal is probably indicated in patients with CRBSI due to Gram-negative
bacilli, S. aureus, enterococci, fungi, or mycobacteria.4 (UW Health Strong Recommendation,
Low Quality of Evidence)
2.8. In patients with CRBSI for whom catheter salvage is attempted, additional blood cultures are
reasonable. Catheter removal is probably indicated if peripheral blood culture results (e.g., two
sets of blood cultures obtained on a given day;) remain positive when blood samples are
obtained 72 hours after the initiation of appropriate therapy.4 (UW Health Strong
Recommendation, Low Quality of Evidence)
3. ALT pathogen-specific salvage recommendations.
3.1. An Infectious Diseases consult should be considered for the determination of CRBSI catheter-
salvage recommendations. (UW Health Conditional Recommendation, Very Low Quality of
Evidence)
4. ALT dwell times
4.1. Dwell times should be specified as part of the ALT orders.4 (UW Health Strong
Recommendation, Low Quality of Evidence)
4.2. Dwell times for ALT solutions generally should not exceed 48 hours before reinstallation of lock
solution. Reinstallation is probably indicated every 24 hours for ambulatory patients with
femoral catheters.4 (UW Health Strong Recommendation, Low Quality of Evidence)
4.2.1. For patients who are undergoing hemodialysis, the lock solution can be renewed
after every dialysis session.4 (UW Health Strong Recommendation, Low Quality of
Evidence)
4.3. Minimum effective dwell time is not well defined and is dependent on the rate and extent of
antimicrobial penetration into a biofilm penetration.13-16
4.4. Flushing of the instilled ALT solution through the catheter into the systemic circulation is not
recommended as to reduce the risk adverse effects and the emergence of microorganism
resistance. (UW Health Strong Recommendation, Very Low Quality of Evidence)
5. Determining catheter volume
5.1. The volumes of common catheters currently used at UW Health are specified in the
Flushing/Locking of Venous Access Devices – Adult/Pediatric – Inpatient/Ambulatory Clinical
Practice Guideline and Treatment of Central Venous Access Device Occlusion –
Neonatal/Pediatric/Adult – Inpatient – Clinical Practice Guideline.
6. ALT solution-specific precautions and considerations
6.1. Stability and compatibility
6.1.1. The stability and compatibility of the ALT solution should be considered when
ordering ALT for prophylaxis or treatment. ALT solutions without documented
stability or compatibility should not be used.6,7 (UW Health Strong Recommendation,
Moderate Quality of Evidence)
6.1.2. Temperature, dwell time, and solution concentration can influence stability and
compatibility. Also, stability may be altered by manufacturer changes that are not
reflected in the published stability studies. ALT solutions should be examined for
evidence of physical incompatibility (discoloration or precipitation) prior to instillation
into the catheter. (UW Health Strong Recommendation, Very Low Quality of
Evidence)
6.1.3. ALT solutions may be stable for short durations and require admixture in the clinical
care area instead of the pharmacy. In these scenarios, it is reasonable for the
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pharmacy servicing the ambulatory site to supply the necessary supplies and
instructions for admixture of the ALT solution. (UW Health Conditional
Recommendation, Very Low Quality of Evidence)
6.2. Ciprofloxacin
6.2.1. In clinical trials, admixed solution was allowed to dwell for at least 12 hours and was
changed daily.13 Some references cite ciprofloxacin is compatible with heparin,
however, experience at UW Health has shown ciprofloxacin and heparin have
variable compatibility. Therefore, ciprofloxacin lock solutions should not include
heparin. (UW Health Conditional Recommendation, Low Quality of Evidence)
6.3. Daptomycin
6.3.1. Daptomycin has a unique mechanism of action involving a calcium-dependent
dissipation of membrane potential, leading to the release of intracellular ions from
the cell and the killing of bacteria. Daptomycin ALT solution requires the addition of
calcium for antimicrobial activity. The addition of Lactated Ringer’s to the
daptomycin ALT provides 3.6 mEq/L of calcium ions.17
6.4. Ethanol and other alcohol-containing solutions18
6.4.1. Ethanol compatibility with heparin and trisodium citrate is variable.6 Ethanol should
not be considered compatible with heparin or trisodium citrate and neither heparin
nor trisodium citrate should be used with ethanol in ALT. (UW Health Strong
Recommendation, Low Quality of Evidence)
6.4.2. When ethanol lock solutions are considered, the effect of ethanol on the mechanical
and structural integrity of the catheter should be considered.11 (UW Health Strong
Recommendation, Low Quality of Evidence)
6.4.3. It is reasonable to use of ethanol ALT with silicone and carbathane catheters only
until sufficient data are available to ensure that ethanol has no effect on catheter
integrity of non-silicone catheters (e.g. polyurethane catheters).11,19 (UW Health
Strong Recommendation, Low Quality of Evidence)
6.4.4. It is reasonable to aspirate and discard ethanol ALT from the catheter lumen and at
the end of the dwell, and catheter should be flushed with 0.9% sodium chloride.11,19
(UW Health Strong Recommendation, Low Quality of Evidence)
6.5. Gentamicin
6.5.1. Gentamicin precipitates at a concentration of 10 mg/mL or higher when mixed with
heparin.20
6.6. Vancomycin
6.6.1. In vancomycin ALT solution, it is reasonable that the vancomycin concentration be
at least 1000 times greater than the MIC of the microorganism involved.4 (UW
Health Conditional Recommendation, Low Quality of Evidence)
7. ALT Preparation
7.1. To maximize the sterility and stability of the ALT, it is reasonable to prepare all ALT aseptically
in a pharmacy when feasible.4 (UW Health Strong Recommendation, Moderate Quality of
Evidence)
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Table 1. Venous access devices (from Flushing/Locking of Venous Access Devices – Adult/Pediatric –
Inpatient/Ambulatory Clinical Practice Guideline) 21-23
Type of Device
Common
Catheter
Length
Insertion Location Duration of Use
Umbilical Venous
and Arterial
Catheter
(UVC/UAC)
< 5 cm
Inserted through the umbilical vein and
joins the left portal vein or umbilical
artery and joins arteries either at the
thoracic or lumbar vertebral bodies
Short-term access up to 7 days
after birth
Peripheral (PIV) < 3 in
Terminates in a vein of the forearm or
hand, location may vary in pediatric
patients
Short-term access < 1 week
Midline 3 – 8 in
Peripheral device terminating in the
basilic, cephalic or brachial vein distal to
the shoulder
Access needed for ≤ 29 days, not
appropriate for vesicant
administration
Non-Tunneled
Central ≥ 8 cm
Percutaneous device terminating in the
superior or inferior vena cava
Short term access when
peripheral not suitable, ex.
resuscitation and central venous
pressure monitoring
Peripherally
Inserted Central
(PICC)
≥ 20 cm Peripheral device terminating in the superior or inferior vena cava
Medium-term (up to 6 months)
access
Tunneled Central ≥ 8 cm Implanted into the subclavian, internal jugular, or femoral veins
Frequent medium-term (up to 6
months) access and a PICC line
is contraindicated
Implanted
Central (Port) ≥ 8 cm
Tunneled under skin with port accessed
by needle; implanted in subclavian or
internal jugular vein terminating in the
superior vena cava
Infrequent long-term (> 6
months) access
Dialysis and
Apheresis ≥ 15 cm
Non-cuffed catheter placed in the neck
or chest terminating in the superior or
inferior vena cava
Long or short term access for the
maintenance of dialysis therapy
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Table 2. Central venous catheter type and capacity (from Central Venous Access Device Occlusion –
Neonatal/Pediatric/Adult – Inpatient/Ambulatory/ED – Clinical Practice Guideline)
Catheter Type Adult Capacity Pediatric Capacity Neonatal Capacity
Dialysis-Pheresis Catheters
Volume on catheter
lumen (common 2
mL)
1 mL or less
Implanted Venous Port 2 mL 1 mL or less
Non-tunneled Triple Lumen
(ex. Arrow) 1 mL 1 mL or less
PICC 1 mL 1 mL or less 0.1 mL (1.9 Fr)
Powerline 1 mL 1 mL or less
Tunneled Cuff Catheter
(ex. Groshong) 1 mL 1 mL or less
Tunneled or Non-Tunneled Central
(ex. Hickman, Broviac) 2 mL 1 mL or less
Umbilical Catheters (Double and
Single Lumen 3.5 and 5 Fr) 0.5 mL or less
Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and treatment of
patients. This guideline outlines the preferred approach for most patients. It is not intended to replace a
clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit
the clinical condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
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Methodology
Development Process
Each guideline is reviewed and updated a minimum of every 3 years. All guidelines are developed using
the guiding principles, standard processes, and styling outlined in the UW Health Clinical Practice
Guideline Resource Guide. This includes expectations for workgroup composition and recruitment
strategies, disclosure and management of conflict of interest for participating workgroup members,
literature review techniques, evidence grading resources, required approval bodies, and suggestions for
communication and implementation.
Methods Used to Collect the Evidence:
The following criteria were used by the guideline author(s) and workgroup members to conduct electronic
database searches in the collection of evidence for review.
Literature Sources:
• Electronic database search (e.g., PubMed)
• Databases of systematic reviews (e.g., Cochrane Library)
Time Period: 2000 to 2018
Search Terms:
• Antibiotic lock
• Antibiotic lock solution
• Antibiotic lock therapy
• Antimicrobial lock
• Antimicrobial lock therapy
• Antimicrobial lock solution
• Catheter-related infections
• Catheter-related blood stream infections
• Central venous catheter
Methods to Select the Evidence:
• Inclusion Criteria: time range (2000-18, studies conducted in which the primary language was
English, randomized controlled trials
• Exclusion Criteria: Studies conducted prior to 2000, studies in which the primary language was
not English, in-vitro data, animal models, case reports, studies without outcomes
Describe the inclusion/exclusion criteria used for selecting the literature; consider describing chosen
variables such as language, study design, outcomes, and comparisons as appropriate.
Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external organizations and/or
created recommendations internally via a consensus process using discussion of the literature and expert
experience/opinion. If issues or controversies arose where consensus could not be reached, the topic
was escalated appropriately per the guiding principles outlined in the UW Health Clinical Practice
Guideline Resource Guide.
Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade assigned within
the original source document and were adopted for use at UW Health.
Internally developed recommendations, or those adopted from external sources without an assigned
evidence grade, were evaluated by the guideline workgroup using an algorithm adapted from the Grading
of Recommendations Assessment, Development and Evaluation (GRADE) methodology (see Figure 1).
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Figure 1. GRADE Methodology adapted by UW Health
Rating Scheme for the Strength of the Evidence/Recommendations:
GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.
GRADE Ratings for Recommendations For or Against Practice
Strong (S) Generally should be performed (i.e., the net benefit of the treatment is clear, patient values and circumstances are unlikely to affect the decision.)
Conditional (C)
May be reasonable to perform (i.e., may be conditional upon patient values and
preferences, the resources available, or the setting in which the intervention will
be implemented.)
Recognition of Potential Health Care Disparities: None identified
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Appendix 1. Non-hemodialysis ALT preparations available at UW Health
Lock Base Solution Record Number in HealthLink Notes
Ciprofloxacin 2 mg/mL13, A D5W 760332
Ceftazidime 2 mg/mL and
heparin 100 units/mL6,24 Normal saline 701155
Daptomycin 1 mg/mL and
heparin 100 units/mL25, A Lactated Ringers 701156
Daptomycin 5 mg/mL17,26 Lactated Ringers Not available at UW Health
Available for ambulatory use
only through Chartwell Midwest
Wisconsin
Ethanol 50% (v/v)10,19,27-33 Normal Saline 701153 • Do not use with
polyurethane catheters
• Incompatible with heparin and
sodium citrate Ethanol 70% CVAD
Occlusion (v/v)10,19,27-33 Sterile water 760352
Vancomycin 2 mg/mL and
heparin 100 units/mL13 Normal saline 701161
Vancomycin 2 mg/mL and
heparin 20 units/mL13 Normal saline 701160
A Note: not available through Chartwell Midwest Wisconsin home infusion services
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Appendix 2. Hemodialysis (HD) ALT preparations available at UW HealthA,B
Lock Base Solution Record Number in HealthLink
Ceftazidime 10 mg/mL and heparin
5000 units/mL (HD)6,34 Normal saline 701154
Daptomycin 1 mg/mL and heparin
1000 units/mL (HD)25 Lactated Ringers 701157
Gentamicin 1 mg/mL and heparin
2500 units/mL (HD)20 Normal Saline 701158
Gentamicin 2.5 mg/mL and 4%
sodium citrate base (40 mg/mL)
(HD)35
No base 701159
Vancomycin 2.5 mg/mL and heparin
2500 units/mL (HD)20 Normal Saline 701162
Vancomycin 3 mg/mL and 4%
sodium citrate base (40 mg/mL)
(HD)36
No base 701163
A Note: Chartwell Midwest Wisconsin does not provide any HD ALT preparations
B ALT for HD include anticoagulant of high-dose heparin (1000 units/mL or greater) or sodium citrate (40
mg/mL)
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Appendix 3. ALT preparations available from Chartwell Midwest Wisconsin home
infusion services for central lines (May 2019)
Lock Base Solution
Cefazolin 0.5 mg/mL and heparin 100 units/mL Normal saline
Cefazolin 10 mg/mL and heparin 10 units/mL Normal saline
Ceftazidime 0.5 mg/mL and heparin 100 units/mL Normal saline
Ceftazidime 2 mg/mL and heparin 100 units/mL Normal saline
Ciprofloxacin 0.125 mg/mL and heparin 100 units/mL Normal saline
Daptomycin 5 mg/mL Lactated Ringers
Daptomycin 5 mg/mL and heparin 100 units/mL or heparin 10
units/mL Lactated Ringers
Ethanol 50% Sterile water
Ethanol 70% Sterile water
Vancomycin 25 mcg/mL, ciprofloxacin 0.002 mg/mL and heparin 10
units/mL Normal saline
Vancomycin 50 mcg/mL, ciprofloxacin 0.002 mg/mL and heparin 10
units/mL Normal saline
Vancomycin 0.5 mg/mL and heparin 100 units/mL 0.45% saline
Vancomycin 25 mcg/mL and heparin 10 units/mL Normal saline
Vancomycin 2 mg/mL and heparin 10 units/mL Normal saline
Vancomycin 2 mg/mL and heparin 100 units/mL Normal saline
Vancomycin 2 mg/mL and heparin 20 units/mL Normal saline
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References
1. Norris LB, Kablaoui F, Brilhart MK, Bookstaver PB. Systematic review of antimicrobial lock
therapy for prevention of central-line-associated bloodstream infections in adult and pediatric
cancer patients. International journal of antimicrobial agents. 2017;50(3):308-317.
2. Pittiruti M, Bertoglio S, Scoppettuolo G, et al. Evidence-based criteria for the choice and the
clinical use of the most appropriate lock solutions for central venous catheters (excluding dialysis
catheters): a GAVeCeLT consensus. The journal of vascular access. 2016;17(6):453-464.
3. O'Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular
catheter-related infections. Am J Infect Control. 2011;39(4 Suppl 1):S1-34.
4. 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):1-45.
5. Bastani B, Minton J, Islam S. Insufficient penetration of systemic vancomycin into the PermCath
lumen. Nephrol Dial Transplant. 2000;15(7):1035-1037.
6. Bookstaver PB, Rokas KE, Norris LB, Edwards JM, Sherertz RJ. Stability and compatibility of
antimicrobial lock solutions. Am J Health Syst Pharm. 2013;70(24):2185-2198.
7. Bestul MB, Vandenbussche HL. Antibiotic lock technique: review of the literature.
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06/2019CCKM@uwhealth.org
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Copyright © 2019 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
06/2019CCKM@uwhealth.org
Effective date 6/25/2019. Contact CCKM@uwhealth.org for previous versions.
Introduction
Scope
Definitions
Recommendations
Methodology
Appendix 1. Non-hemodialysis ALT preparations available at UW Health
Appendix 2. Hemodialysis (HD) ALT preparations available at UW HealthA,B
References