Optimal Approach for the Diagnosis of Hemodialysis Catheter-Related Bacteremia

Central Venous Catheter Complications in the Poisoning Emergency Center: A 5-Year Cross-Sectional Study

Background

Central venous catheters (CVCs) are used widely in emergency centers, which may be associated with complications. There is a paucity of literature focusing on CVC complications, specifically in the poisoning emergency centers. In this study, we determined the frequency of CVC complications in patients with acute poisoning.

Materials and Methods

This was a cross-sectional study performed in the poisoning referral center. We reviewed the medical records of patients with acute poisoning who underwent CVC at the time of admission/during hospitalization in the poisoning intensive care unit or poisoning ward and were hospitalized between 2014 and 2019.

Results

During the study period, 33, l37 patients with acute poisoning had been admitted and CVC was placed for 400 patients (1.20% of total patients). Most of the CVCs had been placed via femoral (51%) (204 cases). The frequency of CVC complications was 13.75%. The CVC in the internal jugular (IJ) vein was associated with a higher complication (20.7%) (P value 0.02). Infection (9.2%) and pneumothorax (9.2%) were more observed with the IJ approach, while arterial puncture was more observed with subclavian (3.7%) (P value < 0.0001).

Conclusions

The frequency of CVC placement in acute poisoning patients was not noticeable. Although the femoral vein was the most commonly used approach in our institution, overall complications were more observed with the IJ vein approach.

Epidemiology of bloodstream infections in a Scottish haemodialysis population with focus on vascular access method

BACKGROUND

Infection is the second highest cause of mortality in end-stage renal disease, with a significant proportion relating to haemodialysis (HD) vascular access-related infection (VARI).

AIM

To report the rate and antimicrobial resistance (AMR) of all-source bloodstream infections (BSIs) by vascular access type in a Scottish HD cohort.

METHODS

Retrospective analysis was undertaken of data on adult patients attending seven HD units during 2017. Total HD days for each vascular access type were calculated. BSIs were analysed with rates expressed per 1000 HD days. AMR was verified using health board microbiology databases.

FINDINGS

Excluding contaminant organisms, there was an overall BSI rate of 0.57 per 1000 HD days. The highest all-source and vascular access-related infection (VARI) BSI rates per 1000 HD days were in the non-tunnelled central venous catheter (CVC) group (3.11 and 2.07 respectively), followed by tunnelled CVC (1.10 and 0.67), arteriovenous graft (0.51 and 0.31), and finally arteriovenous fistula (0.29 and 0.02). The non-VARI BSI rates were lowest in the arteriovenous graft group. Staphylococci comprised the majority of events, with Staphylococcus aureus implicated in 29%. Gram-negative BSIs were prevalent, particularly in CVC groups, and associated with higher mortality. Multidrug-resistant (MDR) S. aureus and carbapenem resistance were relatively low. MDR Gram-negatives were high compared with the Scottish population.

CONCLUSION

Arteriovenous fistula access is confirmed as having lowest all-source and VARI BSI rates, and arteriovenous graft access the lowest non-VARI BSI rates. Staphylococci remain the prevailing genus; however, the contributions of Gram-negative BSIs, the higher mortality, and proportion of MDR organisms in this group are notable.

Fast and furious: a retrospective study of catheter-associated bloodstream infections with internal jugular nontunneled hemodialysis catheters at a tropical center

BACKGROUND

Nontunneled hemodialysis catheters (NTHCs) remain the preferred vascular access at hemodialysis (HD) initiation in developing countries. We studied the incidence, risk factors and microbiological spectrum of jugular NTHC-associated bloodstream infections (CABSIs) at a tertiary care center in South Asia.

METHODS

In this retrospective cohort study, all adult (≥18 years) incident patients who underwent jugular NTHC insertion for HD between January 2016 and June 2017, had no prior history of temporary vascular access insertion and were followed up for ≥14 days were included.

RESULTS

A total of 897 patients underwent NTHC insertion during the study period and 169 patients fulfilled the inclusion criteria and contributed 7079 patient days of follow-up. CABSI incidence was 7.34 episodes per 1000 catheter days and median infection-free survival and time to CABSI were 96 and 24.5 days, respectively. In multivariate Cox regression analysis, immunosuppressive medication {hazard ratio [HR] 2.87 [95% confidence interval (CI) 1.09-7.55]; P = 0.033} and intravenous cefazolin use [HR 0.51 (95% CI 0.28-0.94); P = 0.031] was independently associated with CABSI. The cumulative hazard of CABSI was 8.3, 13.3, 17.6 and 20.9% at Weeks 1, 2, 3 and 4, respectively. Gram-negative organisms were the most common etiological agents (54.7%) and 40.3% of CABSIs were caused by drug-resistant organisms. Gram-negative and Gram-positive CABSIs were associated with neutrophil left shift and higher procalcitonin compared with coagulase-negative staphylococcal CABSIs.

CONCLUSION

In South Asia, NTHC-associated CABSIs occur early and are predominantly Gram negative. We hypothesize that poor hygiene practices may play a role in this phenomenon.

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.

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.