Prevention of catheter-related bacteremia in children on hemodialysis: time for action

Abstract

This editorial commentary discusses the strategies for prevention of catheter-related bacteremia (CRB) in children on hemodialysis, which is associated with high morbidity and the increase of hospital cost. There is evidence that the use of arteriovenous fistulae in children on hemodialysis is associated with lower infection rates. Therefore, the use of catheters in these patients should be decreased by improving arteriovenous fistulae use rates or by increasing peritoneal dialysis patient recruitment. However, despite the wide adoption of such policies, hemodialysis catheters are still being used in a significant number of cases. For these patients, implementation of effective strategies for preventing contamination of the catheter hub should be a priority. The appropriate recording and evaluation of CRB rates are important for assessing preventive policies. In addition, the successful management of a CRB is essential for preventing recurrence of bacteremia. Recently it was documented in a number of randomized clinical trials that antimicrobial lock solutions were effective for preventing CRB. It is suggested that the use of antimicrobial locks should be considered in children who are at high risk of developing CRB, with caution for their long-term use, because of the possibility of bacterial resistance. Now is the time for action, and all preventive steps should be performed simultaneously to minimize the risk of CRB.

Chronic Hemodialysis in Small Children

“…Yet, vascular catheter use among children on chronic HD is high . Actually, CVCs are often the only form of vascular access in young children with relatively small vessels, as the construction of an AVF might be technically very difficult or even impossible .…”

Reduction in catheter‐related infections after switching from povidone‐iodine to chlorhexidine for the exit‐site care of tunneled central venous catheters in children on hemodialysis

“…12,13,16,26 The Center for Disease Control recommends the use of 2% chlorhexidine, 25 but this recommendation is based on studies involving mainly adult intensive care patients with temporary catheters, and very few data are available concerning patients with tunneled HD catheters. 12,13,16,26 The Center for Disease Control recommends the use of 2% chlorhexidine, 25 but this recommendation is based on studies involving mainly adult intensive care patients with temporary catheters, and very few data are available concerning patients with tunneled HD catheters.…”

“…Optimal exit-site care is essential in order to prevent catheter-associated infections in patients on chronic HD, and the choice of the exit-site cleaning agent is critical. 12,13,16,26 The Center for Disease Control recommends the use of 2% chlorhexidine, 25 but this recommendation is based on studies involving mainly adult intensive care patients with temporary catheters, and very few data are available concerning patients with tunneled HD catheters. [17][18][19][20][21][22][23][24] It is therefore not surprising that a recent European survey found that different CVC management protocols are used in pediatric dialysis units.…”

“…[7][8][9][10][11] Although it is true that optimal CVC management can control such infections, most of the current recommendations are based on little evidence. [12][13][14][15][16] The choice of exit-site and hub cleaning solution is a key point in the prevention of exit-site infection (ESI), tunnel infection (TI), and bloodstream infection (BSI) in patients on HD, and the findings of many studies, metaanalyses, and guidelines suggest that a chlorhexidine gluconate solution is better than a povidone-iodine solution for this purpose. [17][18][19][20][21][22][23][24][25][26][27] Unfortunately, most of these studies involved temporary CVCs and adults not receiving HD, and only one retrospective single-centre study has compared 2% chlorhexidine and 5% povidone-iodine in the exit-site care of children on HD.…”

Biology of sepsis: Its relevance to pediatric nephrology

“…Given the challenges inherent to managing children with sepsis, this approach and other related efforts (e.g. antimicrobial lock solutions) aimed at preventing sepsis events by eliminating common triggers are not trivial achievements [77, 78]. Indeed, the KDIGO group’s AKI guidelines devote a chapter on vascular access for RRT in AKI with special attention towards decreasing the rate of catheter-related infections [79].…”