Approach to prophylactic measures for central venous catheter‐related infections in hemodialysis: A critical review

Abstract

Vascular access is the major risk factor for bacteremia, hospitalization, and mortality among hemodialysis (HD) patients. The type of vascular access most associated with bloodstream infection is central venous catheter (CVC). The incidence of catheter-related bacteremia ranges between 0.6 and 6.5 episodes per 1000 catheter days and increases linearly with the duration of catheter use. Given the high prevalence of CVC use and its direct association with catheter-related bacteremia, which adversely impacts morbidity and mortality rates and costs among HD patients, several prevention measures aimed at reducing the rates of CVC-related infections have been proposed and implemented. As a result, a large number of clinical trials, systematic reviews, and meta-analyses have been conducted in order to assess the effectiveness, clinical applicability, and long-term adverse effects of such measures. In the following article, prophylactic measures against CVC-related infections in HD patients and their possible advantages and limitations will be discussed, and the more recent literature on clinical experience with prophylactic antimicrobial lock therapy in HD CVCs will be reviewed.

Effectiveness of heparin versus 0.9% saline solution in maintaining the permeability of central venous catheters: a systematic review

“…Despite the potential benefits of saline solution, the change in clinical practice for a normal saline solution has not been widely suggested in the literature for the whole typology of patients and CVC. A possible explanation for this may be attributed to the long period of time that CVC remains in the patient (25)(26)(27) , complications associated with maintaining CVC (28)(29)(30)(31) , type of infusion used (medicinal, solutions…) (32) ; if the purpose of the CVC is hemodialysis (9)(10)(11)(12)(13)(14) and institutional procedures for locking and flushing can strengthen medical belief about heparin effectiveness (10) , thus ultimately leading to exploiting the effectiveness of other solutions (33) (i.e. citrate).…”

Peritoneal dialysis as the first dialysis treatment option initially unplanned

“…13,14 PeritoneAl diAlysis As the method of choice to urgently stArt therAPy Unplanned start dialysis, also known as urgent-start dialysis, may be defined as the initiation of HD without a definitive functioning vascular access -i.e., treatment is started with a CVC -or the start of PD within seven days of the implantation of a catheter. 15,16,17 Iversen et al 15 retrospectively reviewed the Danish Nephrology Registry (2008)(2009)(2010)(2011) and reported that 50% of the incident patients on RRT had unplanned therapy starts. In Brazil, approximately 60% of the incident patients on RRT do not have a definitive access and are treated with a CVC.…”

“…In the dialysis center of the University Hospital of the Medical School of Botucatu (Hospital Universitário da Faculdade de Medicina de Botucatu), the numbers are even more alarming: more than 90% of the incident patients have unplanned dialysis starts and 50% of the prevalent patients do not have a definitive functioning vascular access and are treated with tunneled CVCs. 16,17 In a recently published paper, Lok et al reported that about a third of the patients worldwide have unplanned RRT starts, an event that makes the discussions around the development of diagnosis and treatment, including the choice of mode of dialysis and the implantation of a dialysis access, more challenging to the health care team. 18 PD has been seen as a viable and safe alternative to HD in unplanned dialysis starts in developed and developing nations, nurturing the growth of PD programs.…”

Epidemiology and outcome of exit site infection catheter related among patients from a Brazilian haemodialysis unit

“…These include the use of prophylactic topical antimicrobial ointments at the catheter exit site, the use of prophylactic catheter locking solutions for the prevention of CRB, strategies for management of the catheter in BSI, and the use of vascular access managers and quality initiative programs [31][32][33][34][35].…”