Infection Associated with Tunneled Hemodialysis Catheters

Abstract

The use of tunneled dialysis catheters to deliver hemodialysis treatment may be associated with major problems. For this reason their use should be minimized as much as possible. Infection is the most serious of these problems. This complication causes very significant morbidity and mortality and has emerged as the primary barrier to long-term catheter use. Bacteremia is the most serious type of infection associated with catheter use. It can result in metastatic infection and even lead to death of the patient. Prophylaxis is important to decrease the risk of infection. The use of an antibiotic ointment at the exit site until it has healed and the long-term use of a dressing to cover the exit site are effective in decreasing the incidence of exit-site infection. With optimal catheter-use management, it should be possible to reduce the incidence of catheter-related bacteremia (CRB) to a level in the range of 1 ⁄ 1000 catheter days. Antibiotic and antimicrobial locking solutions show promise and may, if verified in appropriate clinical studies, prove to be important adjuncts to the management of catheterdependent patients. Aspirin has been shown to have anti-staphylococcal activity and warrants further clinical evaluation. The diagnosis of CRB is based upon positive blood cultures in association with typical clinical features. If a simple routine blood culture is positive, along with a high clinical probability based upon the patient's signs and symptoms, the sensitivity and specificity of the diagnosis is greater than 75%. CRB is in reality a biofilm infection and must be treated as such. Treatment needs to focus on appropriate systemic antibiotics which should be continued for a minimum of 3 weeks and catheter management to remove the biofilm. Catheter exchange has been shown to be effective and should be performed based upon the clinical presentation of the patient. While treatment with a combination of systemic antibiotics and antibiotic locking solution may be effective for gramnegative infections, this approach does not appear to be a good choice for Staphylococcus aureus CRB.The use of a tunneled dialysis catheter (TDC) to deliver hemodialysis (HD) treatment may be associated with major problems. Catheter dysfunction (inadequate flow) secondary to thrombosis and catheter-related infections are common occurrences. Although catheter dysfunction is the more common of the two complications, infection related to the use of a catheter is the more serious problem, representing a very significant cause of morbidity and mortality and has emerged as the primary barrier to long-term catheter use. The overall incidence of this problem can be appreciated from a review of the data generated by the HEMO study. This was a study of 1846 randomized HD patients designed primarily to evaluate the efficiency of dialysis, but secondarily also evaluated infection-related deaths and first infectionrelated hospitalizations. Catheters were present in 32% of all study patients admitted with access-related infection, even thoug...

Approaches to Prolong the Use of Uncuffed Hemodialysis Catheters: Results of a Randomized Trial

“…According to the DOPPS, for incident HD patients, UCs comprised 75% of catheters in Europe and 48% of catheters in the USA [3]. Previous studies regarding an antibiotic lock technique have focused largely on TCCs [1,9]. …”

“…They are temporarily used in acute kidney injury and in a substantial proportion of incident and prevalent HD patients until their permanent vascular access becomes available [1,2]. According to the Dialysis Outcomes and Practice Patterns Study (DOPPS), 60% of incident patients in the USA and 31% in Europe began HD with a catheter [3].…”

“…In prevalent HD patients, catheter use was 17% in the USA and 8% in Europe [3]. Widespread application of catheters exposes patients to an enhanced risk for catheter-related infections, a major cause of increased morbidity and mortality [1]. In particular, catheter-related bacteremia (CRB) is a severe complication that requires hospitalization, systemic antibiotic therapy and catheter removal or replacement [2].…”

“…Uncuffed catheters (UCs) have a higher reported rate of CRB, ranging from 3.8 to 12.8 events per 1,000 catheter-days, compared to tunneled cuffed catheters (TCCs), with 0.5–5.5 events per 1,000 catheter-days [1,8]. Therefore, the NKF-K/DOQI guidelines recommended that an UC should not be used for longer than 3 weeks and advocated TCC as a temporary vascular access in HD patients [16].…”

Daptomycin, Methicillin Resistant <i>Staphylococcus hominis</i> Catheter-Related Bacteraemia in a Hemodialysis Patient

“…It has significant impact on morbidity and mortality, which is likely to increase with the rising rate of indwelling catheters for vascular access (VA) in newly diagnosed dialysis patients [1]. Catheterdependent HD patients have a two-to three-fold increased risk for hospitalization and death compared to patients who have either an AV fistula or graft [2].…”