Treatment guidelines for dialysis catheter-related bacteremia: an update

A Retrospective Study of Central Line-Associated Bloodstream Infections in Children Treated With Hemodialysis in a Tertiary Care Center

Background Central venous catheter (CVC) poses a significant risk of infectious complications in children undergoing hemodialysis. A major concern is the occurrence of central line-associated bloodstream infections (CLABSIs), which are most critical and lead to significant morbidity. Methods We conducted a study in our pediatric hemodialysis center in King Abdullah Specialized Children's Hospital, Riyadh, Saudi Arabia. We included pediatric patients (younger than 14 years old) with a positive central line blood culture who underwent hemodialysis from 2015 until 2023. We collected data pertaining to age, sex, underlying disease, clinical manifestations, and microbiological features, as well as their management strategies. We compared this group's epidemiological and biochemical markers to a group of hemodialysis patients who did not develop CLABSI. Results In our pediatric hemodialysis center, we have an overall incidence of 4.2 CLABSIs per 1,000 catheter days, with mainly gram-positive organisms. We found that more than half of the patients required hospitalization, indicating a lower threshold for admission in pediatric patients than adults. We also found that patients with catheter infections had higher white blood cell counts as well as neutrophils, which can be used to raise suspicion of catheter infection. Most patients (85%) did not require catheter removal and were treated with intravenous antibiotics only. Conclusion CLABSIs cause high morbidity and mortality; therefore, clinicians should have a high index of suspicion, especially in patients with fever and a high white blood cell count. Such patients require intravenous antibiotics, lock therapy in some cases, and, occasionally, catheter removal/replacement as indicated.

A Dedicated Nephrology Daycare Unit: A Step Toward a Patient-Centered Approach

Background Nephrology services encompass a wide range of day-care procedures. Securing beds for day admissions can be challenging and may lead to significant delays in patient management. Objective This study aims to describe the impact of establishing a dedicated nephrology daycare unit at a tertiary care center. Methods Since January 2021, a dedicated nephrology daycare unit has been operational at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia. This observational study retrospectively reviewed the admission records to the KAUH nephrology daycare unit from January 2021 to December 2023. Admissions with missing data were excluded from the analysis. The study outcomes included: 1. the number of patients served in the unit, 2. the scope of services provided, 3. the "time to completion" of immunosuppressive therapy administered in the unit, and 4. the rate of complications related to admission to the unit. Results There were 233 admissions for 157 patients. The scope of procedures included: 1. administration of immunosuppressive therapy (42 doses of cyclophosphamide, 70 doses of rituximab, three doses of methylprednisolone), 2. renal biopsies (25 procedures), 3. tunneled dialysis catheter procedures (40 procedures, both insertion and removal), 4. dialysis access angioplasty (three procedures), 5. IV iron therapy (45 admissions), and 6. other miscellaneous causes (five admissions). Ideal time to completion of cyclophosphamide therapy was achieved in 86% of patients, with the remaining 14% experiencing delays due to reasons other than bed availability. Time to completion of rituximab therapy was achieved without delay in 85% of patients, with a time interval of less than 21 days. There were no reported complications associated with admission to the unit. Conclusions Establishing a dedicated nephrology daycare unit facilitates the delivery of nephrology day-procedures and reduces delays in therapy.

Antibiotic lock solutions as adjunct therapy for catheter-related blood stream infections in pediatric hemodialysis patients

The predominant use of intravenous catheters as primary access type in the pediatric hemodialysis population is associated with an increased risk of catheter related blood stream infections. While strict adherence to catheter placement and long-term care guidelines have helped to decrease the incidence of these infections, blood stream infections remain an infection burden in pediatric patients with long term hemodialysis catheters. The formation of biofilms on the surfaces of these catheters has been shown to be a source of microbes causing blood stream infections. One of the strategies for preventing bacterial colonization, inhibiting microbial multiplication, and suppressing the seeding of these microbes from biofilms upon maturation, has been the use of antibiotic-based lock solutions in-between dialysis treatments. Although clinical guidelines for the use of antibiotic lock solutions are yet to be developed, available evidence suggests a beneficial role of antibiotic lock solutions in the management of catheter related blood stream infections. Additionally, a clear understanding of how biofilms are formed and their role in the pathogenesis of catheter related bloodstream infection will facilitate the development of solutions that can prevent biofilm formation and inhibit their multiplication, maturation and seeding into the bloodstream.

Implementation of a new surveillance system for dialysis-associated infection events in outpatient dialysis facilities in Germany

INTRODUCTION

Patients receiving maintenance haemodialysis are at risk of catheter-related infections. Up to now, there has been no standardized surveillance tool in Germany to evaluate infection events in haemodialysis outpatients. As such, this study aimed to implement an online-based surveillance tool in outpatient dialysis facilities, and to report the first national surveillance data for haemodialysis patients in Germany from October 2019 until September 2021.

METHODS

Outpatient dialysis facilities reported three types of dialysis-associated infection event (DAIE): bloodstream infections, intravenous antimicrobial starts, and local access site infections. Denominator data were provided by the number of haemodialysis treatments at each facility per month. DAIE rates stratified by vascular access type were calculated.

RESULTS

In total, 43 outpatient dialysis facilities reported 723 DAIEs, including 63 bloodstream infections, 439 intravenous antimicrobial starts, and 221 local access site infections. The overall incidence of DAIEs was 0.51 per 1000 dialysis treatments (723/1,413,457) during the surveillance period. The overall incidence of DAIEs was 0.13 per 1000 dialysis treatments among patients with arteriovenous fistulas (AVFs; 126/990,392), 0.41 per 1000 dialysis treatments among patients with arteriovenous grafts (41/99,499), and 1.68 per 1000 dialysis treatments among patients with central venous catheters (CVCs; 535/318,757). The rate ratio of DAIEs between CVC and AVF rates was 13.2 (95% confidence interval 10.9-16.0; P<0.001).

DISCUSSION

These 2-year infection data represent the first standardized data of outpatient dialysis facilities in Germany. Rates of infection were highest among patients with CVCs compared with other vascular access types. This online-based surveillance tool may be helpful to identify effective targets for infection prevention measures in haemodialysis patients.

Endogenous Panophthalmitis and Eye Enucleation Secondary to Methicillin-Resistant Staphylococcus aureus Bacteremia: A Rare Complication of Tunneled Dialysis Catheter Use

Catheter-related bloodstream infections are among the lethal complications of central venous catheter use. Patients with end-stage kidney disease use tunneled dialysis catheters (TDC) in the absence of arteriovenous access. We report a case of a patient using a TDC who developed panophthalmitis. This patient presented with painful and swollen eyes, fever, and chills. Positive methicillin-resistant Staphylococcus aureus (MRSA) blood cultures were thought to be secondary to a catheter-related bloodstream infection originating from his TDC. A maxillofacial computed tomography scan showed an enlarged, elongated, and proptotic left globe with suspected scleral irregularity suggestive of panophthalmitis. Despite TDC removal and systemic antibiotics, his left eye had to be enucleated. A new TDC was placed after treating the catheter-related bloodstream infection. He continued antibiotic therapy for a total of eight weeks. Panophthalmitis, a rare complication of catheter-related bloodstream infection among hemodialysis patients using a TDC, represents another reason to avoid TDC as hemodialysis access.

Effect of taurolidine citrate and unfractionated heparin on inflammatory state and dialysis adequacy in hemodialysis patients

BACKGROUND AND AIM

HD patients using dialysis catheters have been associated with chronic inflammatory state. In Egypt 6.6% of HD patients use catheters, of which short term catheters represent 59.6% and 40.4% with long-term catheters. In this study, we aimed to assess the effect of Taurolidine citrate and unfractionated heparin combination (Taurolock-hep500™) as a lock solution compared to unfractionated heparin alone on inflammatory markers, incidence of catheter related blood stream infections (CRBSI) and dialysis adequacy in HD patients with temporary HD catheters only, for 4 weeks duration.

METHODS

Sixty ESRD patients from hemodialysis units in Ain-Shams University hospitals (ASUH) at the time of catheter insertion we enrolled in our study. They were randomized into two groups: Group 1: Thirty patients received Taurolock-hep500™ as a catheter lock solution at the end of each hemodialysis session. Group 2: Thirty patients received unfractionated heparin as a catheter lock solution. hsCRP and IL-6 were measured at baseline and 1 month after using the lock solutions. Blood cultures were done in patients who developed symptoms of catheter related infections.

RESULTS

At the end of the study, Inflammatory markers were significantly higher in group 2 (p-value: 0.045, 0.001, and 0.018 for WBCs, hsCRP and IL-6, respectively). Group 1 had better dialysis adequacy assessed by URR (p-value: 0.007 and 0.001, respectively). CRBSI were demonstrated in nine patients in group 2 (30%) in contrast to one patient only in group 1(3.3%) (p-value: 0.006) with pseudomonas being the most common isolated organism (27.7%).

CONCLUSION

Use of (Taurolock-hep500™) for temporary hemodialysis catheters was associated with lower levels of inflammation markers and lower incidence of CRBSI and better catheter performance.

Performance of real-time PCR in suspected haemodialysis catheter-related bloodstream infection: a proof-of-concept study

Background

Catheter-related bloodstream infections (CRBIs) remain a major cause of mortality in haemodialysis (HD) patients with central venous catheters (CVCs), especially because of the non-specific symptomatology and the delay in microbiological diagnosis with possible use of non-optimal empiric antibiotics. Moreover, empiric broad-spectrum antibiotics increase antibiotic resistance development. This study aims to evaluate the diagnostic performance of real-time polymerase chain reaction (rt-PCR) in suspected HD CRBIs compared with blood cultures.

Methods

A blood sample for rt-PCR was collected simultaneously with each pair of blood cultures for suspected HD CRBI. The rt-PCR was performed on the whole blood, without any enrichment stage and with specific DNA primers: 16S (universal bacterial), Staphylococcus spp., Staphylococcus aureus and mecA. Each successive patient with a suspected HD CRBI in the HD centre of Bordeaux University Hospital was included. Performance tests were used to compare the result obtained in each rt-PCR assay with its corresponding routine blood culture.

Results

Eighty-four paired samples were collected and compared for 40 suspected HD CRBI events in 37 patients. Among these, 13 (32.5%) were diagnosed as HD CRBI. All rt-PCRs except mecA (insufficient number of positive samples) showed high diagnostic performances within 3.5 h: 16S (sensitivity 100%, specificity 78%), Staphylococcus spp. (sensitivity 100%, specificity 97%), S. aureus (sensitivity 100%, specificity 99%). Based on the rt-PCR results, antibiotics could be more appropriately targeted, thus cutting anti-cocci Gram-positive therapy from 77% to 29%.

Conclusions

The performance of rt-PCR in suspected HD CRBI events showed fast and high diagnostic accuracy. Its use would improve HD CRBI management with an antibiotic consumption decrease.

The Epidemiology of Multidrug-Resistant Sepsis among Chronic Hemodialysis Patients

Sepsis is one of the leading causes of hospitalization and death among hemodialysis patients. Infections due to multidrug-resistant organisms (MDROs) are common among these patients, but empiric broad-spectrum coverage for every septic patient is associated with unfavorable outcomes. A retrospective case–control study was conducted at Shamir Medical Center, Israel (July 2016–April 2020), to determine predictors of MDRO infections among septic (per SEPSIS-3) ambulatory adult hemodialysis patients with permanent dialysis access (i.e., fistula, graft, or tunneled Perm-A-Cath). MDROs were determined according to established definitions. Least Absolute Shrinkage and Selection Operator (LASSO) regression was used to construct a prediction score and determine its performance. Of 509 patients, 225 (44%) had microbiologically confirmed infection, and 79 patients (35% of 225) had MDROs. The eventual independent predictors of MDRO infections were Perm-A-Cath access (vs. fistula or graft, aOR = 3, CI-95% = 2.1–4.2) and recent hospitalization in the previous three months (aOR = 2.3, CI-95% = 1.6–3.3). The score to predict MDRO sepsis with the highest performances contained seven parameters and displayed an area under the receiver operating characteristic curve (ROC AUC) of 0.74. This study could aid in defining a group of hemodialysis patients for which empiric broad-spectrum agents could be safely avoided.

[Diagnosis and treatment of catheter-related bloodstream infection in hemodialysis: 10 years later]

Patients in hemodialysis on central venous catheter as vascular access are at risk of infections. Catheter-related bloodstream infection is one of the most serious catheter-complications in hemodialysis patients. Its clinical and microbiological diagnosis is challenging. The implementation of empiric antibiotic therapy is based on old recommendations proposing the combination of a molecule targeting methicillin-resistant Staphylococcus aureus and a betalactamin active on P. aeruginosa, and also adapting this probabilistic treatment by carrying out a microbiological register on a local scale, which is rarely done. In our hemodialysis center at Bordeaux University Hospital, an analysis of the microorganisms causing all catheter-related bloodstream infection over the period 2018-2020 enabled us to propose, in agreement with the infectious disease specialists, an adapted probabilistic antibiotic therapy protocol. This approach allowed us to observe a low incidence of meticillinoresistance of Staphylococcus. For catheters inserted more than 6 months ago, we observed no Staphylococcus, no multi-resistant Pseudomonas, and only 2% of Enterobacteria resistant to cephalosporins. A frequent updating of the microbiological epidemiology of catheter-related bloodstream infection, in partnership with the infectious diseases team in each hemodialysis center, allowing an adaptation of the probabilistic antibiotic therapy, and seems to have a good feasibility. This strategy might favor the preservation of microbial ecology on an individual and collective scale in maintenance hemodialysis patients.

Treatment of MRSA infections in India: Clinical insights from a Delphi analysis

PURPOSE

International and Indian guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections are available, but the local guidelines are not MRSA-specific. This study aimed to provide clinical insights for the treatment of MRSA infections in India.

METHODS

We used a three-step modified Delphi method to obtain insights. Ten experts comprising infectious disease specialists, microbiologists, pulmonologists, and critical care experts agreed to participate in the analysis. In round 1, a total of 161 statements were circulated to the panel and the experts were asked to 'agree' or 'disagree' by responding 'yes' or 'no' to each statement and provide comments. The same process was used for 73 statements in round 2. Direct interaction with the experts was carried out in round 3 wherein 35 statements were discussed. At least 80% of the experts had to agree for a statement to reach concordance.

RESULTS

Eighty-eight statements in round 1, thirty-eight statements in round 2, and eight statements in round 3 reached concordance and were accepted without modification. The final document comprised 152 statements on the management of various syndromes associated with MRSA such as skin and soft tissue infections, bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system infections.

CONCLUSIONS

This analysis will assist clinicians in India to choose an appropriate course of action for MRSA infections.

The Effect of Pre-TURP Bladder Irrigation with 0.2% Chlorhexidine in Patients with Foley Catheter Regarding Postoperative Bacteremia Decrease

Background: Transurethral resection of the prostate (TURP) has been widely used for patients suffering from bladder colonization with bacteria, increasing the probability of bacteremia and sepsis despite consuming prophylaxis antibiotics. Objectives: The study aimed to evaluate the effect of pre- TURP bladder irrigation with 0.2% chlorhexidine in reducing postoperative bacteremia. Methods: This clinical trial study was conducted on 60 benign prostatic hyperplasia (BPH) patients who were candidates for TURP in the urology department of Al-Zahra Hospital. All patients suffered from urinary catheters, and they were allocated into two groups (n = 30). Antibiotic prophylaxis was prescribed for all the patients. In the case group, the bladder was rinsed by chlorhexidine 0.2% before TURP; however, and the bladder in the control group was rinsed by distilled water. Postoperative bacteremia were evaluated using procalcitonin (PCT) measurement and BACTEC automated blood culture six hours after surgery. Results: Positive BACTEC blood culture was observed in three (10%) and no (0%) patients in the control and case groups, respectively (P = 0.071). Moreover, 6.6 % and 46.6 % of the patients in the control group had low and high PCT levels, respectively. Furthermore, 40 % and 6.66 % of the patients in the case group had low and high PCT levels, respectively. There was a significant difference between the two groups in terms of the PCT level (P < 0.01). Conclusions: The frequency of patients with a high PCT level was higher in the control group than in the case group, suggesting that chlorhexidine in the catheterized patients undergoing TURP reduced the number of bacteria in the bladder.

Drug-induced tolerance: the effects of antibiotic pre-exposure in Stenotrophomonas maltophilia

Aim: To investigate if the prior use of nontargeted antibiotics induces cross-tolerance in Stenotrophomonas maltophilia. Methods: Antibiotic induction was performed to evaluate daptomycin and vancomycin as possible tolerance-inducing drugs measured by minimum bactericidal concentration/minimum inhibitory concentration (MIC) ratio, adapted disk-diffusion tests and time-kill curves. Results: After antibiotic exposure, three potentially tolerant strains were isolated, maintaining the same MIC value of levofloxacin, with minimum bactericidal concentration/MIC ratio slightly higher than the parental. In the adapted disk-diffusion test, one strain (D25) showed high tolerance level for levofloxacin, ceftazidime and ticarcillin-clavulanate. In time-kill activity of levofloxacin, D25 presented a subpopulation of persisters with survival rate higher (1.6-fold) than the parental. Conclusion: Previous exposure of S. maltophilia to daptomycin can induce cross-tolerance to ceftazidime and ticarcillin-clavulanate and cross-persistence to levofloxacin.

Challenges of Vascular Access in the Pediatric Population

The incidence and prevalence of renal replacement therapy has continued to increase in the pediatric population. Recent data have shown that hemodialysis was the most frequently used dialysis modality, especially in pediatric ESRD patients (age 0-21 years). A well-functioning vascular access is required for effective hemodialysis and choosing the best vascular access option for pediatric patients can be difficult. Pediatric vascular options include arteriovenous fistula, arteriovenous graft, and central venous catheters (CVCs). There is a national initiative for fistula first-catheter last approach; however, CVCs have been reported as the most conventionally utilized vascular access option in pediatric patients. The use of CVCs should be minimized or avoided as they are associated with high risk of infections, thrombosis, and other complications. Thus, it is important for practitioners to plan appropriately in advance, practice good clinical judgment, and assure that the best vascular access is placed according to the patient's needs. Therefore, this article reviews the different types of pediatric vascular access and the associated benefits and potential complications of each.

The Effect of Risk of Maturation Failure and Access Type on Arteriovenous Access-Related Costs among Hemodialysis Patients

BACKGROUND

Several studies report lower costs associated with attaining and maintaining patency for arteriovenous (AV) fistulas as compared to AV grafts among patients receiving hemodialysis. However, these costs may vary according to the AV access's risk of failure to mature (FTM). The aim of this study was to examine the effect of AV access type and risk of FTM on the total costs of attaining and maintaining AV access patency over 1, 3, and 5 years postcreation, among incident accesses.

METHODS

All first AV access creations (January 1, 2002-January 1, 2018), revisions/resections, and interventions from a single academic institution were prospectively captured. The units costs (from 2011 in CA$) were estimated primarily through the provincial patient Ontario Case Costing Initiative database. The present value of total vascular access-related costs from a third-party payer perspective was calculated by multiplying specific unit costs by the number of AV access creations, revisions/resections, and interventions from the date of creation to 1, 3, and 5 years post creation. The potential associations of AV access type and FTM risk stratum with AV access cost were examined using log-linear models and generalized estimating equations.

RESULTS

A total of 906 patients were included in the study, of which 696 had fistulas and 210 had grafts. The median present value of total costs to attain and maintain AV access over 1, 3, and 5 years was positively associated with the highest FTM risk stratum in all models. It was not associated with AV access type when the interaction between AV access type and FTM risk stratum was considered.

CONCLUSIONS

The costs of attaining and maintaining AV access were increased among patients with high/very high FTM risk. Risk of FTM, related interventions, and costs should be considered when choosing vascular access type for an individual patient.

Racial and Sex Disparities in Catheter Use and Dialysis Access in the United States Medicare Population

BACKGROUND

Despite efforts to increase arteriovenous fistula and graft use, 80% of patients in the United States start hemodialysis on a central venous catheter (CVC).

METHODS

To better understand in incident hemodialysis patients how sex and race/ethnicity are associated with time on a central venous catheter and transition to an arteriovenous fistula and graft, our observational cohort study analyzed US Renal Data System data for patients with incident ESKD aged ≥66 years who started hemodialysis on a CVC in July 2010 through 2013.

RESULTS

At 1 year, 32.7% of 74,194 patients transitioned to an arteriovenous fistula, 10.8% transitioned to an arteriovenous graft, 32.1% stayed on a CVC, and 24.5% died. Women spent a significantly longer time on a CVC than men. Compared with white patients, patients who were black, Hispanic, or of another racial/ethnicity minority spent significantly more days on a CVC. In competing risk regression, women were significantly less likely than men to transition to a fistula and more likely to transition to a graft. Compared with white patients, blacks were significantly less likely to transition to a fistula but more likely to transition to a graft, Hispanics were significantly more likely to transition to a fistula, and other races/ethnicities were significantly more likely to transition to either a fistula or a graft.

CONCLUSIONS

Female patients spend a longer time on a CVC and are less likely to transition to permanent access. Compared with white patients, minorities also spend longer time on a CVC, but are more likely to eventually transition to permanent access. Strategies to speed transition to permanent access should target groups that currently lag in this area.

High success rate in salvage of catheter-related bloodstream infections due to Staphylococcus aureus, on behalf of project group of Italian society of nephrology

BACKGROUND

Catheter-related bloodstream infections caused by Staphylococcus aureus represent one of the most fearful infections in chronic haemodialysis patients with tunnelled central venous catheters. Current guidelines suggest prompt catheter removal in patients with positive blood cultures for S. aureus. This manoeuvre requires inserting a new catheter into the same vein or another one and is not without its risks.

METHODS

A protocol based on early, prompt diagnosis and treatment has been utilized in our renal unit since 2012 in an attempt to salvage infected tunnelled central venous catheters. We prospectively observed 247 tunnelled central venous catheters in 173 haemodialysis patients involving 167,511 catheter days.

RESULTS

We identified 113 catheter-related bloodstream infections (0.67 episodes per 1000 days/tunnelled central venous catheter). Forty were caused by S. aureus, including 19 by methicillin-resistant S. aureus (79% saved) and 21 by methicillin-sensitive S. aureus (90% saved), of which 34 (85%) were treated successfully. Eight recurrences occurred and six (75%) were successfully treated. A greater than 12 h time to blood culture positivity for S. aureus was a good prognostic index for successful therapy and tunnelled central venous catheter rescue.

CONCLUSION

Our data lead us to believe that it is possible to successfully treat catheter-related bloodstream infection caused by S. aureus and to avoid removing the tunnelled central venous catheter in many more cases than what has been reported in the literature. On the third day, it is mandatory to decide whether to replace the tunnelled central venous catheter or to carry on with antibiotic therapy. Apyrexia and amelioration of laboratory parameters suggest continuing systemic and antibiotic lock therapy for no less than 4 weeks, otherwise, tunnelled central venous catheter removal is recommended.

Complications of Hemodialysis Catheter Bloodstream Infections: Impact of Infecting Organism

BACKGROUND

Catheter-related bloodstream infections -(CRBSI) are associated with a high burden of morbidity and mortality, but the impact of infecting organism on clinical outcomes has been poorly studied.

METHODS

This retrospective analysis of a prospective vascular access database from a large academic dialysis center investigated whether the organism type affected the clinical presentation or complications of CRBSI.

RESULTS

Among 339 patients with suspected CRBSI, an alternate source of infection was identified in 50 (15%). Of 289 patients with CRBSI, 249 grew a single organism and 40 were polymicrobial. Fever and/or rigors were presenting signs in ≥90% of patients with Staphylococcus aureus or Gram-negative CRBSI, but only 61% of Staphylococcus epidermidis infections (p < 0.001). Hospitalization occurred in 67% of patients with S. aureus CRBSI versus 34% of those with S. epidermidis and 40% of those with a Gram-negative bacteria (p < 0.001). Admission to the intensive care unit was required in 14, 9, and 2% (p = 0.06); metastatic infection occurred in 10, 4, and 4% (p = 0.42); and median length of stay among patients admitted to the hospital was 4, 4, and 5.5 days (p = 0.60), respectively. Death due to CRBSI occurred in only 1% of patients with CRBSI.

CONCLUSION

CRBSI is confirmed in 85% of catheter-dependent hemodialysis patients in whom it is suspected. S. epidermidis CRBSI tends to present with atypical symptoms. S. aureus CRBSI is more likely to require hospitalization or intensive care admission. Metastatic infection is relatively uncommon, and death due to CRBSI is rare.

A retrospective study of tunnelled haemodialysis central line-associated bloodstream infections

Infection is a serious complication of tunnelled haemodialysis catheters. We aimed to describe the epidemiology of tunnelled haemodialysis central line-associated bloodstream infections (CLABSI) in an Australian centre. We performed a retrospective audit of tunnelled haemodialysis CLABSI from June 2010 to June 2014. From 674 catheter insertions, 70 CLABSI occurred in 55 patients at a rate of 0.95 infections per 1000 catheter days. Aboriginal and Torres Strait Islanders (ATSI) compared to non-ATSI had a higher rate of CLABSI (1.70 vs 0.58 CLABSI per 1000 catheter days, p < 0.001). Staphylococcus aureus (n = 22, 31.4%), coagulase negative Staphylococci (n = 14, 17.5%), and Gram negative bacilli (n = 28, 35.0%) were the predominant causative organisms. Two patients who died both had Staphylococcus aureus infection. In conclusion, our infection rate and microbiology are similar to prior reports. Morbidity and mortality are associated with Staphylococcus aureus as the causative organism.

Diagnosis and treatment of catheter-related bloodstream infection: Clinical guidelines of the Spanish Society of Infectious Diseases and Clinical Microbiology and (SEIMC) and the Spanish Society of Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)

Catheter-related bloodstream infections (CRBSI) constitute an important cause of hospital-acquired infection associated with morbidity, mortality, and cost. The aim of these guidelines is to provide updated recommendations for the diagnosis and management of CRBSI in adults. Prevention of CRBSI is excluded. Experts in the field were designated by the two participating Societies (the Spanish Society of Infectious Diseases and Clinical Microbiology and [SEIMC] and the Spanish Society of Spanish Society of Intensive and Critical Care Medicine and Coronary Units [SEMICYUC]). Short-term peripheral venous catheters, non-tunneled and long-term central venous catheters, tunneled catheters and hemodialysis catheters are covered by these guidelines. The panel identified 39 key topics that were formulated in accordance with the PICO format. The strength of the recommendations and quality of the evidence were graded in accordance with ESCMID guidelines. Recommendations are made for the diagnosis of CRBSI with and without catheter removal and of tunnel infection. The document establishes the clinical situations in which a conservative diagnosis of CRBSI (diagnosis without catheter removal) is feasible. Recommendations are also made regarding empirical therapy, pathogen-specific treatment (coagulase-negative staphylococci, Staphylococcus aureus, Enterococcus spp., Gram-negative bacilli, and Candida spp.), antibiotic lock therapy, diagnosis and management of suppurative thrombophlebitis and local complications.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

A Prospective Clinical Study of a Percutaneous Vascular Access System for Hemodialysis Catheters

INTRODUCTION

Dysfunctional or infected hemodialysis polyester-cuffed catheters often require removal and are dissected out. The DermaPort™, percutaneous vascular access system (PVAS) permanently integrates a titanium mesh with the skin forming a stable, sterile barrier that allows for catheter placement, adjustment, or catheter exchange. This study aimed to describe the use and clinical outcomes of the DermaPort PVAS.

METHODS

Thirty-eight patients who were receiving hemodialysis via a tunneled catheter were enrolled in this prospective open-label study. Assessments were performed biweekly for the first month and monthly thereafter, which included physical examination of the site of implantation for infection, catheter blood flow, and need for interventions to maintain catheter patency. Patient satisfaction was assessed with a visual analog score.

RESULTS

Implantation of technical success was 100% with the implantation site demonstrating early tissue incorporation after 2 weeks and full incorporation within 4 weeks. The DermaPort™ successfully enabled 31 catheter exchanges and 10 repositions thru the port without dissection in 18 patients with nine repositions (90%) performed at bedside. The mean primary patency of the DermaPort™ was 172 ± 150 days, and mean secondary patency was 430 ± 203 days. There were no reportable serious adverse events in 12,100 catheter days of use and zero explantations of the device attributed to infection. The observed catheter infection rate was 0.33/1000 days.

CONCLUSIONS

The DermaPort™ system can be effectively implanted and facilitates catheter interventions in hemodialysis patients requiring long-term catheter use and has a lower infection rate than historical catheter infection rates. Clinical Trial Protocol Number DermaPort-001 (no clinicaltrials.gov number as study was performed 9 years ago). Health Canada Reference Application Number: 118393.

Recommended Clinical Trial End Points for Dialysis Catheters

Central venous catheters are used frequently in patients on hemodialysis as a bridge to a permanent vascular access. They are prone to frequent complications, including catheter-related bloodstream infection, catheter dysfunction, and central vein obstruction. There is a compelling need to develop new drugs or devices to prevent central venous catheter complications. We convened a multidisciplinary panel of experts to propose standardized definitions of catheter end points to guide the design of future clinical trials seeking approval from the Food and Drug Administration. Our workgroup suggests diagnosing catheter-related bloodstream infection in catheter-dependent patients on hemodialysis with a clinical suspicion of infection (fever, rigors, altered mental status, or unexplained hypotension), blood cultures growing the same organism from the catheter hub and a peripheral vein (or the dialysis bloodline), and absence of evidence for an alternative source of infection. Catheter dysfunction is defined as the inability of a central venous catheter to (1) complete a single dialysis session without triggering recurrent pressure alarms or (2) reproducibly deliver a mean dialysis blood flow of >300 ml/min (with arterial and venous pressures being within the hemodialysis unit parameters) on two consecutive dialysis sessions or provide a Kt/V≥1.2 in 4 hours or less. Catheter dysfunction is defined only if it persists, despite attempts to reposition the patient, reverse the arterial and venous lines, or forcefully flush the catheter. Central vein obstruction is suspected in patients with >70% stenosis of a central vein by contrast venography or the equivalent, ipsilateral upper extremity edema, and an existing or prior history of a central venous catheter. There is some uncertainty about the specific criteria for these diagnoses, and the workgroup has also proposed future high-priority studies to resolve these questions.

Emergency medicine evaluation and management of the end stage renal disease patient

BACKGROUND

End stage renal disease (ESRD) is increasing in the U.S., and these patients demonstrate greater all-cause mortality, cardiovascular events, and hospitalization rates when compared to those with normal renal function. These patients may experience significant complications associated with loss of renal function and dialysis.

OBJECTIVE

This review evaluates complications of ESRD including cardiopulmonary, neurologic, infectious disease, vascular, and access site complications, as well as medication use in this population.

DISCUSSION

ESRD incidence is rapidly increasing, and patients commonly require renal replacement therapy including hemodialysis (HDS) or peritoneal dialysis (PD), each type with specific features. These patients possess greater risk of neurologic complications, cardiopulmonary pathology, infection, and access site complications. Focused history and physical examination are essential. Neurologic issues include uremic encephalopathy, cerebrovascular pathology, and several others. Cardiopulmonary complications include pericarditis, pericardial effusion/tamponade, acute coronary syndrome, sudden cardiac death, electrolyte abnormalities, pulmonary edema, and air embolism. Infections are common, with patients more commonly presenting in atypical fashion. Access site infections and metastatic infections must be treated aggressively. Access site complications include bleeding, aneurysm/pseudoaneurysm, thrombosis/stenosis, and arterial steal syndrome. Specific medication considerations are required for analgesics, sedatives, neuromuscular blocking agents, antimicrobials, and anticoagulants.

CONCLUSIONS

Consideration of renal physiology with complications in ESRD can assist emergency providers in the evaluation and management of these patients. ESRD affects many organ systems, and specific pharmacologic considerations are required.

Renal Replacement Therapy in Acute Kidney Injury: Controversies and Consensus

Acute kidney injury (AKI) is a common complication among critically ill patents, and 5% of intensive care unit (ICU) patients require initiation of renal replacement therapy (RRT). In recent years, clinical trials have provided evidence-based guidance for some important aspects of RRT management in patients with AKI, such as dialysis dosing and approaches to anticoagulation in patients undergoing continuous RRT. However, there remain many areas of uncertainty, and delivery of RRT in the ICU requires clinical judgment, flexibility, and an understanding of dialysis principles. This article reviews the components of RRT prescription and provides an update on best practices.

Evaluating Approaches for the Diagnosis of Hemodialysis Catheter-Related Bloodstream Infections

BACKGROUND AND OBJECTIVES

Guideline-recommended diagnostic criteria for hemodialysis (HD) catheter-related bloodstream infections (CRBSIs) are based on data from indwelling central catheters in patients not on HD and non-HD situations, and upon which peripheral vein cultures are the gold standard. We aimed to examine the validity of these criteria in patients on HD.

DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS

Adult patients on in-center HD using catheters were prospectively followed from 2011 to 2014 at a large academic-based HD facility (Toronto, Canada). When a CRBSI was suspected, blood culture sets were obtained from four sites (peripheral vein, both catheter hubs, and HD circuit) to determine the guideline-recommended differential time to positivity (DTTP). DTTP criteria were met when catheter hub cultures turned positive ≥120 minutes before peripheral vein cultures. The sensitivity, specificity, and accuracy were first calculated using peripheral vein cultures as the gold standard and then these same calculations were repeated with additional information, including exit site/catheter tip and HD circuit cultures, as the true gold standard. The feasibility of obtaining peripheral vein cultures was determined.

RESULTS

Of 178 suspected CRBSIs, 100 had peripheral vein blood cultures. Using the true gold standard, sensitivity, specificity, and accuracy of blood culture results were highest in samples from the HD circuit (93.5%, 100%, and 95%, respectively). The guideline recommended combination of peripheral vein and arterial hub blood cultures was the least sensitive, specific, and accurate (91.7%, 93.1%, and 92.7%, respectively). The diagnostic criteria using measured DTTP were met in less than one third of events.

CONCLUSIONS

In patients on HD, blood culture results are the most sensitive, specific, and accurate for diagnosing CRBSIs when taken from the HD circuit and the venous catheter hub, and blood culture results are the least sensitive, specific, and accurate in any combination with peripheral vein cultures. The DTTP does not increase diagnostic accuracy, reducing the necessity for venipuncture and its potential vein damage. Future guidelines should consider the applicability of criterion on specific patient populations and tailor them accordingly.

Hemodialysis Catheter-related Infection: Prophylaxis, Diagnosis and Treatment

Purpose

Infectious complications associated with central venous catheters (CVCs) are a major source of morbidity and mortality among hemodialysis (HD) patients. This review aims to discuss prevention, diagnosis criteria and management of CVC-related infections in HD patients.

Methods

We searched Medline for articles published in the last 10 years, with the keywords “catheter,” “hemodialysis,” “infection,” “treatment,” “diagnosis,” “prophylaxis” and “adults.” Only English language articles were reviewed. We reviewed prophylaxis and surveillance protocols, diagnosis criteria, including new molecular tools, and the management of catheter-related infections, including antibiotic regimen, empiric and according to causal agents, lock therapy, catheter salvage or removal choice and treatment of complications.

Results

To prevent infectious complications, first of all we need to avoid using catheters. If we need CVC, adoption of prophylaxis and surveillance protocols, and antibiotic ointment at the exit site reduce infectious complications. The diagnosis of CVC-related infections should be made with drainage and/or blood cultures. Empiric systemic antibiotics should cover Gram-positive and -negative microorganisms, and final regimen should be based on culture results. In selected cases, salvage of site, by CVC exchange over wire, or salvage of catheter, using antibiotic lock, under the cover of systemic antibiotics, could be attempted.

Conclusions

The best approach to prevent CVC-related infection would be to avoid the use of CVC. However, in patients for whom it is impossible, the adoption of adequate prophylaxis protocols, early diagnosis and effective treatment of infectious complications are essential to improve outcomes.

Vascular access for hemodialysis: current perspectives

A well-functioning vascular access (VA) is a mainstay to perform an efficient hemodialysis (HD) procedure. There are three main types of access: native arteriovenous fistula (AVF), arteriovenous graft, and central venous catheter (CVC). AVF, described by Brescia and Cimino, remains the first choice for chronic HD. It is the best access for longevity and has the lowest association with morbidity and mortality, and for this reason AVF use is strongly recommended by guidelines from different countries. Once autogenous options have been exhausted, prosthetic fistulae become the second option of maintenance HD access alternatives. CVCs have become an important adjunct in maintaining patients on HD. The preferable locations for insertion are the internal jugular and femoral veins. The subclavian vein is considered the third choice because of the high risk of thrombosis. Complications associated with CVC insertion range from 5% to 19%. Since an increasing number of patients have implanted pacemakers and defibrillators, usually inserted via the subclavian vein and superior vena cava into the right heart, a careful assessment of risk and benefits should be taken. Infection is responsible for the removal of about 30%-60% of HD CVCs, and hospitalization rates are higher among patients with CVCs than among AVF ones. Proper VA maintenance requires integration of different professionals to create a VA team. This team should include a nephrologist, radiologist, vascular surgeon, infectious disease consultant, and members of the dialysis staff. They should provide their experience in order to give the best options to uremic patients and the best care for their VA.

Catheter-related infection and septicemia: impact of seasonality and modifiable practices from the DOPPS

Hemodialysis (HD) catheter-related infection (CRI) and septicemia contribute to adverse outcomes. The impact of seasonality and prophylactic dialysis practices during high-risk periods remain unexplored. This multicenter study analyzed DOPPS data from 12,122 HD patients (from 442 facilities) to determine the association between seasonally related climatic variables and CRI and septicemia. Climatic variables were determined by linkage to National Climatic Data Center of National Oceanic and Atmospheric Administration data. Catheter care protocols were examined to determine if they could mitigate infection risk during high-risk seasons. Survival models were used to estimate the adjusted hazard ratio (AHR) of septicemia by season and by facility catheter dressing protocol. The overall catheter-related septicemia rate was 0.47 per 1000 catheter days. It varied by season, with an AHR for summer of 1.46 (95% CI: 1.19-1.80) compared with winter. Septicemia was associated with temperature (AHR = 1.07; 95% CI: 1.02-1.13; p < 0.001). Dressing protocols using chlorhexidine (AHR of septicemia = 0.55; 95% CI: 0.39-0.78) were associated with fewest episodes of CRI or septicemia. Higher catheter-related septicemia in summer may be due to seasonal conditions (e.g., heat, perspiration) that facilitate bacterial growth and compromise protective measures. Extra vigilance and use of chlorhexidine-based dressing protocols may provide prophylaxis against CRI and septicemia.

Identifying and classifying bloodstream infections among hemodialysis patients

Bloodstream infections (BSIs) are a prominent clinical problem in patients undergoing hemodialysis. These infections appear to be more common among patients who have a central line as their dialysis access and can be associated with substantial morbidity and mortality. Accurately diagnosing BSIs clearly influences patient management, but is also an important part of an infection prevention program; particularly as facility BSI rates are becoming a recognized quality measure for which dialysis facilities might be held accountable. Blood cultures remain the gold standard for diagnosing BSIs and a number of practices can affect the sensitivity and specificity of this important laboratory test. Optimizing the collection of blood cultures can assist providers with interpretation of positive blood cultures and can help minimize the impact of false-positive and false-negative cultures. This review will describe differences between BSI definitions, examine the use of blood cultures to identify these infections including the use of recommended best practices to maximize culture yield, and highlight characteristics that can assist in the clinical interpretation of positive blood cultures.

Predictors of Failure of Catheter Salvage in Incident Hemodialysis Patients

Purpose

Catheter-related bloodstream infection is a frequent complication for patients who use catheter as dialysis access. This study was performed to identify the risk factors for failed catheter salvage.

Methods

We enrolled patients who received non-tunneled catheters as initial vascular access during a two-year period. Catheter salvage was attempted in all symptomatically mild patients. Patients were prospectively followed for 8 weeks starting from the day of infection. Risk factors for salvage failure were explored.

Results

A total of 77 bacteremia episodes occurred in 69 patient, with an infection rate of 1.61 per 1,000 catheter days. Salvage was successful in 73.4% of all episodes. We found that higher ferritin levels (greater vs. lower than 500 mg/l, (odds ratio (OR) 6.388, 95% confidence interval (CI) 2.073, 19.686), higher phosphate levels (greater vs. lower than 5.5 mg/dl, OR 4.084, 95% CI 1.391, 11.978) and shorter time intervals between catheterization and infection (within vs. beyond 3 weeks, OR 4.190, 95% CI 1.279, 13.725) predicted salvage failure.

Conclusions

Catheter salvage can be a reasonable initial strategy for symptomatically mild patients. We propose salvaging aggressively and waiting watchfully; however, clinical judgment is prior to any specific management protocol.

Neutropenic patients and their infectious complications at a University Hospital

OBJECTIVE

The aim of this study was to analyze the characteristics and infectious complications of neutropenic patients in a referral hospital.

METHODS

A cross-sectional study was carried out between April and September 2008, which enrolled all neutropenic patients identified by daily blood counts in the Universidade Federal de Minas Gerais. Demographic data and information on infections were obtained from the Hospital Infection Control Committee. Statistical analysis was performed using the Statistical Package for Social Sciences.

RESULTS

One hundred and sixteen patients were followed up during 129 hospitalizations. The patients had a mean age of 48.7 years old. Sixty-four (55.2%) patients were male and 25 (21.6%) died during the follow-up. In 97 (75.2%) of the hospitalizations, patients had episodes of febrile neutropenia. Patients classified as low-risk had a mortality rate of 16.2% (n = 12) vs. 39.1% (n = 9) among high-risk patients (p-value = 0.02). The death rate of the patients who had been submitted to hematopoietic stem cell transplantation was 13.5% (n = 5) vs. 26.7% (n = 16) among patients not submitted to transplantation (p-value = 0.13). Of the 155 infections diagnosed, 45.5% were defined as clinically documented. The etiological agent most frequently isolated was Escherichia coli and the main topography reported was bloodstream infections. The most used antimicrobial agents were cefepime, vancomycin and fluconazole. Approximately 24% of patients evolved with impaired renal function during hospitalization.

CONCLUSION

Most reported infections in neutropenic patients were defined as clinically documented, which shows the importance of suspicion in patients without specific signs and symptoms for early diagnosis and the need for the classification of risk for timely interventions.

Antibiotic catheter locks in the treatment of tunneled hemodialysis catheter-related blood stream infection

We prospectively examined the efficacy of systemic antibiotics and antibiotic catheter locks for the treatment of tunneled hemodialysis catheter related blood stream infections (CRBSI). Patients with clinical signs of tunnel or metastatic infection were excluded. All patients with suspected CRBSI were treated empirically with systemic antibiotics at the onset of symptoms before final culture and susceptibility results were available. Once the organism was identified, antibiotics treatment was tailored and antibiotic catheter locks were instilled after each dialysis treatment. Clearance of infection was documented by negative surveillance cultures after completion of antibiotic course. Out of 46 episodes of CRBSI; 16 were due to gram positive organisms, 22 were due to gram negative organisms, and 8 were polymicrobial (≥2 organisms) infections. 19 cases required removal of dialysis catheter. Antibiotic lock protocol was successful for eradicating infection in 27 of 46 episodes (59%). The likelihood of a clinical cure was identical in both gram-positive and gram-negative infections (63% and 62% respectively). Antibiotic lock protocol remains an option in the treatment of clinically stable patients with CRBSI; however, success rate of this protocol in eradicating the infection is modest.

The choice of vascular access for therapeutic apheresis

Therapeutic apheresis (TA) is performed using either centrifugation-based or filter-based systems. The blood flow rate (BFR) used for TA using centrifugation-based systems is less than 100 mL/min. Because of this low BFR requirement, even peripheral veins can be considered as an option for TA, especially for less-frequent treatments and those performed for short periods. Other options for vascular access (VA) include central venous catheters (temporary or tunneled), totally implantable ports, and arteriovenous fistulae (AVF) or grafts (AVG). Nontunneled catheters should be considered as the choice of VA for relatively short-term treatments mainly in the inpatient settings. For long-term treatments, ports and tunneled catheters should be considered because of lower rates of infections compared to nontunneled catheters. However, studies in hemodialysis (HD) patients have demonstrated significantly higher morbidity and mortality rates associated with the use of tunneled catheters as compared to AVF. Therefore, if TA is being considered for several years, AVG and AVF would be the preferred options of VA. Studies in HD population indicate far better outcomes with the use of AVF as compared to AVG. This article, as presented at the Therapeutic Apheresis Academy in September 2011, is an overview of the available VA options for TA based on indication and duration of treatment. Pros and cons of each option are mentioned briefly. Finally, for those considered for AVF placement for chronic TA, specific recommendations are made for the care of AVF based on our own experience at University of Virginia.

A randomized trial comparing gentamicin/citrate and heparin locks for central venous catheters in maintenance hemodialysis patients

BACKGROUND

Central venous catheters (CVCs) are used for vascular access in hemodialysis patients who have no alternative access or are awaiting placement or maturation of a permanent access. The major complications of CVCs are catheter-related bloodstream infection and clotting in the catheter lumen.

STUDY DESIGN

Parallel-group, randomized, multicenter clinical trial, with patients blinded to study intervention.

SETTING & PARTICIPANTS

16 free-standing dialysis facilities in Northern California belonging to a single provider. 303 adult maintenance hemodialysis patients who were using a tunneled cuffed CVC for vascular access.

INTERVENTION

The treatment group received an antibiotic lock containing gentamicin 320 μg/mL in 4% sodium citrate, whereas the control group received the standard catheter lock containing heparin 1,000 U/mL. Both groups received triple-antibiotic ointment on the catheter exit site during dressing changes at each dialysis treatment.

OUTCOMES

Catheter-related bloodstream infection and catheter clotting.

MEASUREMENTS

Catheter-related bloodstream infection was defined as the occurrence of symptoms consistent with bacteremia together with positive blood culture results in the absence of another obvious source of infection. Catheter clotting was measured as the rate of thrombolytic agent use required to maintain adequate blood flow. A single patient could contribute more than one infection or clotting episode.

RESULTS

The rate of catheter-related bloodstream infection was 0.91 episodes/1,000 catheter-days in the control group and 0.28 episodes/1,000 catheter-days in the treatment group (P = 0.003). The time to the first episode of bacteremia was significantly delayed (P = 0.005). The rates of tissue plasminogen activator use were similar in the treatment and control groups: 2.36 versus 3.42 events/1,000 catheter-days, respectively (P = 0.2).

LIMITATIONS

The requirement for dialysis facility staff to prepare the treatment intervention prevented a completely blinded study.

CONCLUSION

Gentamicin 320 μg/mL in 4% sodium citrate used as a routine catheter lock in CVCs in patients on maintenance hemodialysis therapy markedly decreases the incidence of catheter-related bloodstream infection and is as effective as heparin 1,000 U/mL in preventing catheter clotting.

Clinical management of dialysis catheter-related bacteremia with concurrent exit-site infection

Dialysis catheter-related bacteremia (CRB) can frequently be treated with systemic antibiotics, in conjunction with an antibiotic lock, in an attempt to salvage the catheter. It is unknown whether CRB associated with an exit-site infection can be treated with such an approach. We retrospectively queried a prospective, computerized vascular access database, and identified 1436 episodes of CRB, of which 64 cases had a concurrent exit site. The frequency of concurrent exit-site infection was 9.6% with Staphylococcus epidermidis, 6.1% with Staphylococcus aureus, and only 0.7% with Gram negative CRB (p < 0.001 for Staphylococcus vs. Gram negative rods). Five serious complications (four major sepses and one endocarditis) occurred in 24 patients with S. aureus infection, but none in 32 episodes of S. epidermidis infection (p = 0.01). Catheter survival was significantly shorter in patients with S. aureus infections. The median catheter survival (without infection or dysfunction) was 14 days with S. aureus vs. 30 days with S. epidermidis infection (p = 0.035). In conclusion, concurrent exit-site infection is seen most commonly in association with Staphylococcal CRB. When the infecting organism is S. epidermidis, attempted salvage with systemic antibiotics and an antibiotic lock is reasonable. However, prompt catheter removal is indicated when the pathogen is S. aureus.

The spectrum of infections in catheter-dependent hemodialysis patients

BACKGROUND AND OBJECTIVES

Catheter-dependent hemodialysis patients may develop access-related and nonaccess-related infections that may be managed in the outpatient arena or in the hospital. The goal of this study was to quantify infections in such patients, to characterize their clinical presentations, and to evaluate factors determining need for hospitalization.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We collected prospective data on the clinical management of catheter-dependent hemodialysis patients with suspected infection at a large dialysis center. We documented the presenting symptoms, type of infection, pathogen, and whether hospitalization occurred.

RESULTS

An infection was suspected in 305 separate cases and confirmed in 88%. The 268 diagnosed infections included catheter-related bacteremia (69%), another access-related infection (19%), and nonaccess-related infection (12%). The overall frequency of infection was 4.62 per 1000 catheter-days. Hospitalization occurred in 37% of all infections, but it varied greatly (72% for nonaccess-related infection, 34% for catheter-related bacteremia, and 4% for exit-site infection). Among patients with catheter-related bacteremia, the likelihood of hospitalization varied by pathogen, being 53% for Staphylococcus aureus, 30% for Enterococcus, 23% for Staphylococcus epidermidis, and 17% for gram-negative rods (P < 0.001). The likelihood of hospitalization was not associated with age, gender, or diabetes. Fever was a presenting symptom in only 47% of cases of catheter-related bacteremia.

CONCLUSIONS

Catheter-dependent patients have a high burden of infection. It is important to evaluate patients with suspected infection for various access-related and nonaccess-related infections. A low threshold is indicated for suspecting catheter-related bacteremia because the patients frequently present without fever.

Arteriovenous graft placement in predialysis patients: a potential catheter-sparing strategy

BACKGROUND

When predialysis patients are deemed unsuitable candidates for an arteriovenous fistula, current guidelines recommend waiting until just before or after initiation of dialysis therapy before placing a graft. This strategy may increase catheter use when these patients start dialysis therapy. We compared the outcomes of patients whose grafts were placed before and after dialysis therapy initiation.

STUDY DESIGN

Retrospective analysis of a prospective computerized vascular access database.

SETTING & PARTICIPANTS

Patients with chronic kidney disease receiving their first arteriovenous graft (n = 248) at a large medical center.

PREDICTOR

Timing of graft placement (before or after initiation of dialysis therapy).

OUTCOME & MEASUREMENTS

Primary graft failure, cumulative graft survival, catheter dependence, and catheter-related bacteremia.

RESULTS

The first graft was placed predialysis in 62 patients and postdialysis in 186 patients. Primary graft failure was similar for pre- and postdialysis grafts (20% vs 24%; P = 0.5). Median cumulative graft survival was similar for pre- and postdialysis grafts (365 vs 414 days; HR, 1.22; 95% CI, 0.81-1.98; P = 0.3). Median duration of catheter dependence after graft placement in the postdialysis group was 48 days and was associated with 0.63 (95% CI, 0.48-0.79) episodes of catheter-related bacteremia per patient.

LIMITATIONS

Retrospective analysis, single medical center.

CONCLUSION

Grafts placed predialysis have primary failure rates and cumulative survival similar to those placed after starting dialysis therapy. However, postdialysis graft placement is associated with prolonged catheter dependence and frequent bacteremia. Predialysis graft placement may decrease catheter dependence and bacteremia in selected patients.

Current strategies for the prevention and management of central line-associated bloodstream infections

Central venous catheters are an invaluable tool for diagnostic and therapeutic purposes in today’s medicine, but their use can be complicated by bloodstream infections (BSIs). While evidence-based preventive measures are disseminated by infection control associations, the optimal management of established central line-associated BSIs has been summarized in infectious diseases guidelines. We prepared an overview of the state-of-the-art of prevention and management of central line-associated BSIs and included topics such as the role of antibiotic-coated catheters, the role of catheter removal in the management, and a review of currently used antibiotic compounds and the duration of treatment.

Emergence of gentamicin-resistant bacteremia in hemodialysis patients receiving gentamicin lock catheter prophylaxis

BACKGROUND AND OBJECTIVES

Antibiotic locks in catheter-dependent chronic hemodialysis patients reduce the rate of catheter-related blood stream infections (CRIs), but there are no data regarding the long-term consequences of this practice.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Over a 4-year period, from October 1, 2002, to September 30, 2006, we initiated a gentamicin and heparin lock (GHL) protocol in 1410 chronic hemodialysis patients receiving dialysis through a tunneled catheter in eight outpatient units.

RESULTS

Within the first year of the GHL protocol, our CRI rate decreased from 17 to 0.83 events per 1000 catheter-days. Beginning 6 months after initiation of the GHL protocol, febrile episodes occurred in 13 patients with coagulase-negative Staphylococcus bacteremia resistant to gentamicin. Over the 4 years of GHL use, an additional 10 patients developed 11 episodes of gentamicin-resistant CRI (including 7 with Enterococcus faecalis), in which there were 4 deaths, 2 cases of septic shock requiring intensive care unit admission, and 4 cases of endocarditis. Because of these events, the GHL protocol was discontinued at the end of 2006.

CONCLUSIONS

Although the use of GHL effectively lowered the CRI rate in our dialysis population, gentamicin-resistant CRIs emerged within 6 months. Gentamicin-resistant infections are a serious complication of the long-term use of GHLs. Alternative nonantibiotic catheter locks may be preferable to decrease the incidence of CRIs without inducing resistant pathogens.

Safety and Efficacy of Cefazolin Sodium in the Management of Bacterial Infection and in Surgical Prophylaxis

Cefazolin sodium is a first-generation cephalosporin antibiotic and has been used worldwide since the early 1970s. It is used for the treatment of bacterial infections in various organs, such as the respiratory tract, skin and skin structure, genital tract, urinary tract, biliary tract, and bone and joint infections. It has also been used for septicemia due to susceptible gram-positive cocci (except Enterococcus), some gram-negative bacilli including E. coli, Proteus, and Klebsiella may be susceptible, and for perioperative prophylaxis. After the introduction of penicillins and other cephalosporins, occasional outbreaks of methicillin-resistant Staphylococcus aureus were noted. As a result, vancomycin use was increased; however, very recently and most alarmingly, vancomycin-resistant strains have been described. In this setting, to avoid the risk of the development of vancomycin-resistant strains further, vancomycin use should be curtailed. In consideration of this historical background, the appropriate use of antibiotics, such as dosage, dosage intervals, and the duration of administration is required not only for the protection of patients’ health but also for the prevention of the development of drug resistance. Cefazolin has been used in clinical practice for about 40 years, and a large body of evidence has been accumulated, and its efficacy and safety are well established compared with other antibiotics. Therefore, cefazolin has been chosen as a first-line anti-microbial for prophylaxis after various surgical procedures, including cardiovascular surgery, hysterectomy, arthroplasty and so on. Based on these facts, especially for the prophylaxis of surgical site infections, the first-generation cephalosporin, cefazolin, is now being “re-visited”.