Hemodialysis catheter-related infections

Dogra GK, Herson H, Hutchison B Prevention of tunneled hemodialysis catheter-related infections using catheter-restricted filhng with gentamicin and citrate a randomized controlled study. J Am Soc Nephrol 2002 13 2133-2139. 

C Treatment for catheter-related infections is often initiated empirically, with definitive therapy based on culture results and susceptibility. Dialysis catheters are usually permanently inserted lines, and patients on chronic hemodialysis are at higher risk for developing catheter-related infections secondary to staphylococcal species, particularly coagulase-negative staphylococci. Oral vancomycin is not appropriate because it does not achieve adequate blood levels to treat systemic infections. 

Table 45-8 hsts the numerous medical comphcations of PD. An average PD patient absorbs up to 60% of the dextrose in each exchange. This continuous supply of calories leads to increased adipose tissue deposition, decreased appetite, malnutrition, and altered requirements for insulin in diabetic patients. Fibrin formation in dialysate is common and can lead to obstruction of catheter outflow. Infectious comphcations of PD are a major cause of morbidity and mortality and are the leading cause of technique failure and transfer from PD to hemodialysis. The two predominant infectious complications are peritonitis and catheter-related infections, which include both exit-site and tunnel infections. 

The number of people diagnosed with end-stage kidney disease (ESKD) in 2002 exceeded 400,000. There were over 100,000 new cases of ESKD in 2002. The primary therapeutic options for these individuals are hemodialysis, peritoneal dialysis, and/or renal transplantation. Renal transplantation is the preferred long-term therapeutic option for most patients with ESKD because it provides patients with the greatest potential improvement in overall quality of life. Dialysis catheter-related infections, update peritoneal dialysis-associated peritonitis, and scheduled dialysis treatments are avoided, and dietary restrictions are fewer. While the analysis of quality of life is complex, patients generally report improved quality of life following transplantation as compared with patients on maintenance dialysis. ... 

Venditto M, du Montcel ST, Robert J, Trystam D, Dighiero J, Hue D, Bessette C, Deray G, Mercadal L. Effect of catheter-lock solutions on catheter-related infection and inflammatory syndrome in hemodialysis patients heparin versus citrate 46% versus heparin/ gentamicin. Blood Purif 2010 29(3) 268-73. 

Published guidelines on the management of catheter-related infections are in favor of the use of ALT for the treatment of catheter-related infections [24]. The in vitro stability of antibiotic-heparin combinations in CVCs was studied by Vercaigne et al. [25]. While ciprofloxacin produced immediate precipitation with heparin, cefazolin, vancomycin and ceftazidime at 10 mg/ml and gentamycin at 5 mg/ml were successfully incubated with heparin (5,000 U/ml) for 72 h in the central venous catheter lumen. Although free antibiotic in CVC solution was reduced, the final concentration was still sufficient for an effective antibiotic-heparin lock [25]. Good evidence is available to support ALT in the prevention of catheter-related bacteremia in patients on hemodialysis [26,27]. However, others have reported that the use of ALT may be limited due to antibiotic toxicity and the appearance of antibiotic-resistant microbial isolates [28, 29]. 

Chatzinikolaou I, et ah Antibiotic-coated hemodialysis catheters for the prevention of vascular catheter-related infections a prospective, randomized study. Am J Med 2003 115 352-357. 

Mermel LA, 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 1-45. Ramanathan V, et al Characteristics of bio-film on tunneled cuffed hemodialysis catheters in the presence and absence of clinical infection. Am J Kidney Dis 2012 60 976-982. 

Coagulase-negative Staphylococcus species, particularly S. epidermidis, are the most common causes of catheter-related bacteremia [25], Heavy colonization of the skin-insertion site has been shown to be strongly correlated with catheter-related bacteremia. In hemodialysis patients, the risk of S. aureus bacteremia is six times greater than in nonhemodialysis patients. And numerous incidents of intravascular infection have been traced to microbially contaminated topical disinfectants. 

Delcour C, Bruninx G IncompatibiUty of contrast medium and trisodium citrate. Car-diovasc Intervent Radiol 2013 36 237-238. Camins BC, Richmond AM, Dyer KL, et al Crossover intervention trial evaluating the efficacy of a chlorhexidine-impregnated sponge in reducing catheter-related bloodstream infections among patients undergoing hemodialysis. Infect Control Hosp Epidemiol 2010 31 1118-1123. 

Infection and thrombosis are common across a variety of catheter designs and applications, while other complications arise as a result of the particular nature of the therapy being administered, such as recirculation in hemodialysis. Clatheter malfunction and related morbidity and mortality represent an area where significant strides are currently being made. 

Hemodialysis (HD) catheter-associated bloodstream infections (BSls) are a type of CLABSI due to a central venous catheter (CVC) specifically designed for HD. In 2002, it was estimated that 50,000 CLABSIs occur in dialysis patients in the US annually. A more recent surveillance study found the rate of access-related BSIs to be 0.73 events per 100 patient-months [5]. Aside from catheters, patients in need of renal replacement therapy should eventually use arteriovenous fistula (AVF) or arteriovenous grafts (AVG) for HD, or alternatively, may receive peritoneal dialysis. All renal replacement therapies are associated with a risk of infection however, this risk varies with the method selected. Data from a CDC surveillance program display nicely how the type of access influences the BSI rate per 100 patient-months 0.5 (for AVFs), 0.9 (AVG), 4.2 (permanent CVCs), and an impressive 27.1 for temporary CVCs [6]. Another, more practi-... 

Lee SC, et al An outbreak of methicillin-re-sistant Staphylococcus aureus infections related to central venous catheters for hemodialysis. Infect Control Hosp Epidemiol 2004 25 678-684. 

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