Infectious complications of hemodialysis catheters
Müjdat YENİCESU, M. D.
October 24, 2014
Hemodialysis Catheters
Non-tunneled, non-cuffed catheters
Tunneled, cuffed catheters
Summary of bloodstream infection data
AJKD, 2002; 39 (3): 549-555
Frequencies and complications of catheter-related bacteremia in
hemodialysis-patients
M. Allon. Dialysis catheter-related bacteremia treatment and propylaxis. AJKD, 2004 (5): 779-791.
Risk factors for catheter-related bacteremia
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1. AJKD 2004, 44(5): 779
2. AJKD 2005, 46(3): 501
3. KI, 2000; 57(5): 2151
Duration of catheterization
Conditions for insertion
Catheter site and catheter site care
Repeated catheterization
Increased catheter maniplation
Tunneled vs nontunnelled catheters
Immunosuppressive therapy
Hypoalbuminemia
The most important risk factor for tunneled catheter-related bacteremia is prolonged
duratiom of usage
AJKD, 2005; 46 (3): 501. Lee T. Et all, «Tunneled catheters in hemodialysis patients: Reasons
and Subsequent Outcomes»
JASN, 1999: 10(5): 1045
Gerald A. Beathard
Clinical manifestations of hemodialysis catheter infections
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UpToDate, 2014
Fever and/or chills
Purulence at the catheter insertion site
Hemodynamic instability
Catheter dysfunction
Hypothermia
Acidosis
Hypotension
Manifestations of metastatic infections
Evaluation, diagnosis and differential diagnosis
• CRB suspect threshold should be low.
• Two blood cultures should be drawn;
• Peripheral vein and catheter
• Separate peripheral veins
• Differential diagnosis includes pneumonia, foot
infection and other infections
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The definitive diagnosis of CRB requires one of the following
• Concurrent positive blood cultures of the same organism from
the catheter and a peripheral vein.
• Culture of the same organism from both the catheter tip and at
least one percutaneous blood culture.
• Cultures of the same organism from two peripherally drawn
blood cultures and an absence of alternate focus of infection.
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TREATMENT
Management of diaysis-catheter induced bacteremia
• Antibiotic therapy
• Empiric systemic antimicrobial therapy
• Tailored systemic antimicrobial therapy
• Removal or exchange of catheter
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Empiric systemic antimicrobial therapy for hemodialysis
catheter infection
AJKD, 2009: 54(1): 13. Treatment guidelines for dialysis catheter-related bacteremia
Methicillin-resistant Staphylococcus
• With the isolation of a methicillin-resistant Staphylococcus,
• Continue to administer vancomycin if the organism has a lowminimal inhibitory concentration.
• Patients with vancomycin allergy can be treated with
daptomycin.
UpToDate, 2014
Methicillin-sensitive Staphylococcus
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With the isolation of a methicillin-sensitive Staphylococcus,
Vancomycin should be substituted with cephazolin.
20 mg/kg cephazolin, IV, after each hemodialysis session.
Vancomycin is the preferred treatment for patients who are
penisillin allergic.
1. Cephazolin as empiric therapy in hemodialysis-related infections. AJKD 1998, 32(3):410.
2. Use of vancomyin or cephazolin for treatment of hemodialysis-dependent patients with methicillinsusceptible staphyloccocus aureus bacteremia. Clin Infect Dis 2007, 44(2): 190.
Vancomycin-resistant Enterococcus
• Can be treated with daptomycin,
• 6 mg/kg, following a dialysis session in inpatients,
• 7 mg/kg (low- flux dialyzers), during the last 30 minutesof each
dialysis session,
• 9 mg/kg (high-flux dialyzers) , during the last 30 minutesof each
dialysis session
Intradialytic administration of daptomycin in end stage renal disease patients on hemodialysis
CJASN 2009, 4(7):1190
Gram-negative organisms
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Up to 95 percent of Gram-negative bacteria isolated in dialysis catheterrelated bacteremia are presently sensitive to both aminoglycosides and
third-generation cephalosporins.
prefer ceftazidime for longer-term treatment, rather than gentamycin,
given the risk of aminoglycoside ototoxicity.
In regions or institutions in which resistance to ceftazidime is more
common, aminoglycosides or carbepenems may be alternate choices.
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Candidemia
• catheter removal
• treatment with an appropriate antimicrobial agent
Management of hemodialysis catheter-related bacteremia with an adjunctive antibiotic lock solution.
KI 2002;61(3):1136
Monitoring issues
• Repeat blood cultures 48 to 96 hours after the institution
of treatment
• Evaluation for catheter removal,
• Evaluation for metastatic infection and endocarditis
(echocardiography)
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Duration of antimicrobial therapy for CRB
• Uncertain. It depends on clinical, microbiologic features and whether the
catheter is removed
• Treat uncomplicated CRB for two or three weeks.
• Treat uncomplicated CRB due to S. Aureus for four weeks.
• If there is evidence of metastatic infection, use of antibiotics at least six weeks.
• When blood cultures remain positive after three or more days of appropriate
therapy, use antibiotics at least six weeks.
• Among patients with osteomyelitis, experts advise treatment for six to eight
weeks.
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Catheter management in case of CRB
• Immediate catheter removal, followed by placement of a
temporary non-tunneled catheter for short-term dialysis access.
After bacteremia has resolved, a new tunneled dialysis catheter
can be inserted.
• Replacement of the infected catheter via exchange over a
guidewire.
• Use an antibiotic lock in the infected catheter.
• Leave the infected catheter in place (no replacing, no an antibiotic
lock)
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Conditions for immediate removal of infected hemodialysis
catheters
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Severe sepsis,
Hemodynamic instability,
Evidence of metastatic infection,
Signs of accompanying exit-site or tunnel infection,
If fever and /or bacteremia persist 48 to 72 hours after initiation
of antibiotics to which the organism is susceptible,
• When infection is due to difficult-to-culture pathogens, such as
S. Aureus, Pseudomonas, Candida, other fungi, or multiplyresistant bacterial pathogens.
UpToDate, 2014
Guidewire catheter exchange
«If there is no conditions of immediate catheter removal, delayed exchange of
the infected cuffed catheter over a guidewire with a new catheter two or three
days after institution of effective antimicrobial therapy is a reasonable option.»
KI 2000;57(5):2151. Bacteremia associated with tunneled dialysis catheters: comparison of two treatment strategies.
AJKD 1995;25(4):593. Catheter-related sepsis complicating long-term, tunnelled central venous dialysis catheters: management by guidewire exchange.
KI 1998;53(6):1792. Treatment of infected tunneled venous access hemodialysis catheters with guidewire exchange.
Conditions for guidewire replacement of the catheter
• Afebrile after 48 hours of antibiotic therapy
• Clinically stable patient
• No evidence of tunnel tract involvement
CJASN 2009, 4: 1102–1105. Catheter exchange over a guidewire in conjunction with antifungal therapy is an effective and safe treatment regimen
also in catheter-related candidemia cases.
Effect of bacterial pathogen on the success of an antibiotic-lock protocol in
hemodialysis patients with catheter-related bacteremia
M. Allon. Dialysis catheter-related bacteremia treatment and propylaxis. AJKD, 2004 (5): 779-791.
Leaving the catheter in place without intervention
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Only systemic antibiotics,
Without replacing the infected catheter,
Without instilling an antibiotic lock,
Clinical cure rate, 22-37 %
Eradication of bacteria imbedded in biofilms ?
UpToDate, 2014
Prevention of catheter related infection
General measures;
• Every dialysis unit must develop written protocol for
maniplation of hemodialysis catheters and exit-site dressing
technique,
• Hand hygiene before and after patient contact,
• Wear nonsterile gloves and masks during catheter
procedures,
Prevention of catheter related infection
Other methods;
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Elimination of S. Aureus nasal carriage,
Topical application of different substances,
Utilize antibiotic-lock technique,
Usage of different catheters (Are there catheters with a
lower infection rate?)
• impregnated with antimicrobial agents,
• with subcutaneos port,
• Usage of Tego needlefree hemodialysis connector
Topical antimicrobial exit-site application
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Povidone-iodine
Polysporin
Mupirocin
Bacitracin
Polymixin B
Gramicidine
Effect of exit-site antibiotic applications on rates of CRB and ESI expressed as episodes per
1000 catheter-days.
Rabindranath K S et al. Nephrol. Dial. Transplant.
2009;24:3763-3774
© The Author 2009. Published by Oxford University Press [on behalf of ERA-EDTA]. All rights
reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
Catheter lock solutions
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Vancomycin/ceftazidime/heparin
Vancomycin/heparin
Ceftazidime/heparin
Cefazolin/heparin
Gentamycine/heparin
Taurolidine
30 % citrate
70 % ethanol
Prophylaxis Against Dialysis Catheter–
Related Bacteremia: A Glimmer of Hope
AJKD, 2008; 51(2): 165-168
Effect of AMLS on catheter-related bacteraemia and exit-site infections expressed as episodes
per 1000 catheter-days.
Rabindranath K S et al. Nephrol. Dial. Transplant.
2009;24:3763-3774
© The Author 2009. Published by Oxford University Press [on behalf of ERA-EDTA]. All rights
reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
Citrate Versus Heparin Lock for
Hemodialysis Catheters: A Systematic
Review and Meta-analysis of
Randomized Controlled Trials
Y. Zhao, Z. Li, L. Zhang and et all.
AJKD,2014; 63(3): 479-490
(13 trials, 1770 patients)
Potential barriers against antimicrobial lock solution usage and exit-site
antimicrobial application in catheter care
• Antibiotic resistant microorganisms and infection,
• Systemic toxicity (ototoxicity/gentamicin;
Hypocalcemia/citrate),
• Economic.
CRI rates and cases of gentamicin resistance.
Landry D L et al. CJASN 2010;5:1799-1804
©2010 by American Society of Nephrology
NDT 2012; 27(9): 3575-3581
Systematic review of antimicrobials for the prevention of
haemodialysis catheter-related infections
K. S. Rabindranath, T. Bansal, J. Adams, et all.
NDT, 2009; 24(12): 3763
• We do not have sufficient evidence to draw conclusions regarding the effectiveness of
antimicrobial coating or impregnation of HD catheters or peri-operative systemic
administration of antibiotics in the form of intravenous vancomycin for the reduction of
HD-CRI.