Salvage of Hemodialysis Catheter in Staphylococcal Bacteremia: Case Series, Revisiting the Literature, and the Role of the Pharmacist

Abstract

Catheter-related blood stream infections comprise a major concern in hemodialysis patients, leading to increased mortality, morbidity, and cost of treatment. Prompt appropriate systemic antibiotics treatment, which includes administration of appropriate systemic antibiotics and, frequently, catheter removal and replacement, is warranted. However, in hemodialysis patients, repeated catheter insertions may cause central vein stenosis and thrombosis which limits the future availability of hemodialysis access. Lock solutions containing antibiotics and anticoagulants, instilled directly into the catheter lumen after each dialysis, have been successfully utilized for catheter salvage but higher rates of recurrence and complications were observed in infections resulting from staphylococcal species. We report several cases of catheter salvage using antibiotic lock solution in staphylococcal bacteremia with the purpose of stimulating the interest in randomized clinical trials. Evaluating the risk and benefits of catheter salvage in this patient subset in light of optimized systemic antibiotic dosing, improved lock solution use, and multidisciplinary involvement, balanced with the critical need to prevent unnecessary vascular trauma, is of great importance.

Factors predicting vancomycin therapy outcomes in hemodialysis outpatients and the role of the nephrology stewardship pharmacist

“…The venipuncture for drug monitoring, use of peripheral intravenous lines for drug administration, and PICC lines damage vasculature and render them unsuitable for AVF creation . Hence, the role of the nephrology stewardship pharmacist is paramount to empirically select the antibiotics, which could be appropriately dosed and administered through the dialysis access during the last 60 minutes of dialysis, rather than after the complete end of HD to reduce the use of other lines . In addition, administration of antibiotics during last hour of dialysis will increase patient compliance and consequently clinical cure.…”

“…As such, the administration of vancomycin during the last 30 to 90 minutes of HD session is recommended. In addition, using the dialysis circuit to obtain the pre‐HD level and other laboratory needs should be encouraged to avoid frequent venipuncture and compromising future fistulas …”

“…However, these recommendations were based on older studies in which vancomycin trough concentration targets were lower that the currently recommended ones and at a time where there was no use of antibiotics locks. Furthermore, case reports suggest the use of antibiotic locks with vancomycin 2.5 mg/mL in 4% citrate post each dialysis (MRSA cases) or cefazolin 5 mg/mL in heparin 5000 units/mL (methicillin‐sensitive staphylococcus aureus cases) . These findings emphasize that catheter removal should be limited to failed cases and critically ill patients to preserve the veins' patency.…”

“…Hemodialysis patients at an increased risk for developing bloodstream infections due to having frequent venipuncture and/or having a central venous catheter for HD purposes . Insertion of HD permanent central venous catheters is frequently done to establish HD access.…”

“…Several nephrology practice guidelines recommend selection of antibiotics which could be given through the dialysis access during active sessions, such as vancomycin, to prevent vascular trauma . Pharmacists can play pivotal role in selecting and dosing antimicrobials in these situations …”