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

Fibrin sheath disruption during guidewire exchange for bacteremia: Low recurrence of infection and preservation of vascular access sites

BACKGROUND

Catheter-associated bacteremia (CAB) often leads to removal of tunneled dialysis catheters with delayed insertion (RDI). Exchange over a guidewire (ExW) can be considered for access site preservation. Fibrin sheath disruption (FSD) during exchange is not standard practice for infected catheters. Here we present the first analysis of outcomes after such exchanges (ExW-FSD).

METHODS

Retrospective analysis of catheter exchanges and removals performed by interventional nephrology for bacteremia in 2008-2011 observed for 20.5 months. Charts were reviewed for recurrent or new bacteremia and death at 3 months, and for occurrence of thrombosis or stenosis along the catheter site. Catheter exchange with central venogram and fibrin sheath disruption was our standard of care in all patients presenting for CAB. RDI was performed either for tunnel infection, non-clearing of infection or at the request of referring physicians.

RESULTS

Over 4 years, 66 patients were treated for CAB. Forty-two patients underwent ExW-FSD, which was performed even for Staph. aureus, gram negative bacteremia or candidemia. RDI was performed in 24 cases. Bacteremia recurred in 3 (7%) patients after ExW-FSD, and in 7 (30%) cases after RDI (p = 0.02). There was no significant difference in new infections: 5 (12%) after ExW-FSD and 2 (8%) after RDI. There was no death within 3 months after ExW-FSD and 4 (27%) (p = 0.005) deaths in the RDI group.There was one new central venous stenosis in the ExW-FSD group (2%) with no loss of access site, and 8 (33%) patients developed thrombosis/stenosis along the prior catheter track after RDI (33%) (p = 0.006) with loss of access site in (21%).

CONCLUSIONS

In this retrospective analysis of treatment of CAB, ExW-FSD was associated with lower recurrence of bacteremia, lower death rate and a lower incidence of access site loss compared to RDI. These data support ExW-FSD use in patients with CAB.

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.

Catheter Failure and Mortality in Hemodialysis Patients with Tunneled Cuffed Venous Catheters in a Single Center

Background: As of now, only a few studies have focused on the failure of tunneled cuffed venous catheter (tCVC) and mortality of hemodialysis (HD) patients using tCVC as long-term vascular access, whose vascular condition for arteriovenous fistula was not very satisfactory. In this study, we aimed to provide information about the first tCVC failure and survival rates of patients in this population. Methods: Fifty-nine patients who used tCVC from January 1, 2009 to December 31, 2014 in our HD center were analyzed in this retrospective study and followed up either until their death or until December 31, 2015. The first tCVC and patient survival rates were analyzed. Results: The incidence of catheter-related infections was 0.3 per 1,000 patient-days. The median survival duration of first tCVC was 45.0 (95% CI 29.3-69.7) months and the median survival time of all patients was 56.3 (95% CI 34.1-78.5) months by Kaplan-Meier analysis. Advanced age (hazard ratio [HR] 1.055, p < 0.05) and diabetic mellitus (HR 4.147, p < 0.05) at the initiation of HD were significant risk factors of first tCVC failure, while male (HR 2.712, p < 0.05) and cardiovascular diseases (CVDs; HR 4.139, p < 0.05) were significant risk factors for patient mortality as deduced by Cox proportional hazards methods. Conclusions: The study highlighted that first tCVC survival rates and patient survival rates were high in HD patients who were using tCVCs as long-term vascular access, with low incidence of catheter-related infections. In the study it was found that advanced age and diabetic mellitus at the initiation of HD influenced first tCVC failure, whereas male and CVDs seemed to be risk factors for patient mortality.

A Computer-Based Method for Teaching Catheter-Access Hemodialysis Management

Patients undergoing hemodialysis are highly susceptible to infections, which could lead to morbidity and mortality. One of the major sources of infections stems from the mishandling of hemodialysis access sites. Although healthcare workers receive training on how to aseptically handle hemodialysis catheters, the increasing number of blood infections associated with dialysis suggests that the conventional approach to training may not be sufficient to ensure a clear understanding of the necessary knowledge and skills. With advancements in digital technology, computer-assisted learning has been gaining popularity as an approach to teaching clinical skills. The purpose of this study was to evaluate the effectiveness of a computer-based training system developed to teach healthcare workers catheter-access hemodialysis management. Forty nurses were recruited and randomly assigned into two groups: the control group, which received conventional training only; and the experimental group, which received both conventional and computer-based training. A knowledge test and a skills competence test were administered to both groups before and after the intervention to evaluate their performance. The results show that the performance of the nurses in the experimental group was significantly better than that in the control group, indicating that the proposed training system is an effective tool for supplementing the learning of catheter-access hemodialysis management.

Antimicrobial lock therapy in central-line associated bloodstream infections: a systematic review

PURPOSE

Antimicrobial lock therapy (ALT) seems a promising approach for treatment of central line associated bloodstream infections (CLABSI). The recent introduction of molecules such as daptomycin and tigecycline, alone or in combination with other molecules, improved chances of efficacy of ALT, due to their activity on the bacterial biofilm. Our aim was to review the literature concerning ALT for CLABSI, including data concerning novel molecules.

METHODS

We included case-control studies evaluating two or more molecules as ALT in central venous catheter infections extracted from the Medline database. Among 221 available articles in Pubmed, 54 were selected for their particular interest concerning ALT.

RESULTS

Incidence of CLABSI is high worldwide. Mechanisms of catheter infection include contamination by skin bacteria, hand contamination and hematogenous diffusion. Catheter-infection is associated with biofilm formation, which reduces the efficacy of ALT. The most promising situation for ALT to succeed in salvaging a catheter appears to be coagulase-negative Staphylococcus infection, which is the main causative agent of CLABSI. Daptomycin, Tigecycline, Ethanol and Taurolidine appear as the best options for treating CLABSI; data are mostly available for Daptomycin, which showed, alone or associated with Rifampin, good in vitro potency on biofilm, but few in vivo data exist on efficacy.

CONCLUSIONS

The introduction of novel molecules has increased chances of catheter salvage with ALT in case of CLABSI, but further in vivo studies are needed.

Systematic review and meta-analysis on management of hemodialysis catheter-related bacteremia

Hemodialysis catheter-related bacteremia is a common clinical problem with several management options. We performed a systematic review and meta-analysis to determine cure proportions with systemic antibiotics, antibiotic lock solution, and guidewire exchange. We searched databases and registries; conference proceedings from relevant medical societies; and article reference lists. Data regarding management approach, cure, follow-up, recurrence, complications, and microbiology were abstracted and pooled from 28 selected publications. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated from a mixed effects logistic regression model. In total, 1596 patients with tunneled hemodialysis catheter-related bacteremia were divided into groups on the basis of treatment with systemic antibiotics (n=697), antibiotic lock solution (n=546), or guidewire exchange (n=353). Antibiotic lock solution and guidewire exchange had similar cure proportions that were superior to systemic antibiotics alone (OR, 2.08; 95% CI, 1.25 to 3.45; P<0.01 for antibiotic lock solution; OR, 2.88; 95% CI, 1.82 to 4.55; P<0.001 for guidewire exchange versus systemic antibiotics). Cure proportions were highest for coagulase-negative staphylococci followed by gram-negative rods and Staphylococcus aureus. Among S. aureus infections, guidewire exchange led to a higher cure proportion than systemic antibiotics or antibiotic lock solution (OR, 3.33; 95% CI, 1.17 to 9.46; P=0.02; OR, 4.72; 95% CI, 1.79 to 12.46; P=0.002, respectively). Thus, results of this study suggest that tunneled hemodialysis catheter-related bacteremia should be treated with either guidewire exchange or antibiotic lock solution. Future studies should address prospectively whether one strategy is better than the other overall and for specific pathogens.

Antibiotic-lock therapy: a clinical viewpoint

Antibiotic lock therapy (ALT) - instillation of high concentrations of anti-microbial agent with or without anti-coagulant into the lumen of central venous catheters - is considered a valid conservative treatment for catheter-related bloodstream infection (CRBSI) in patients highly dependent on maintaining the catheter. Results from randomized controlled studies have indicated that the effectiveness of ALT is moderate, but recent findings from experimental studies and observational case series point to considerable efficacy and safety of this therapy, which is usually associated with concomitant systemic treatment. In this article, the current knowledge about ALT for patients with CRBSI is reviewed and discussed, with emphasis on existing controversies and the results obtained according to the various uses of the catheters and the etiologies of infection.