Infectious complications of hemodialysis catheters Müjdat YENİCESU, M. D. October 24, 2014

Hemodialysis Catheters Non-tunneled, non-cuffed catheters Tunneled, cuffed catheters You are seeing here, both non-tunneled, non-cuffed catheters and tunneled, cuffed catheters are available. At present, tunneled, cuffed, double-lumen catheters are the preferred access for short- and long-term use in dialysis patients.

Summary of bloodstream infection data Major and the most serious complication of HD catheters is infection. If you look at BSI data according to Access type, nativ AVF have the lowest rates of infection. Synthetic AV grafts have intermediate risk and catheters have the highest risk. In this study, published 2002; researchers from the US, report here the result of 36 months vascular Access infection surveillance. Infection rate is the highest ptnts with hdx catheters for 1000 DSs, the lowest ptnts with AV fistulae for 1000 DSs. 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 Duration of catheterization Conditions for insertion Catheter site and catheter site care Repeated catheterization Increased catheter maniplation Tunneled vs nontunnelled catheters Immunosuppressive therapy Hypoalbuminemia AJKD 2004, 44(5): 779 AJKD 2005, 46(3): 501 KI, 2000; 57(5): 2151

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 Fever and/or chills Purulence at the catheter insertion site Hemodynamic instability Catheter dysfunction Hypothermia Acidosis Hypotension Manifestations of metastatic infections Although nonspecific, fever and/or chills are the most sensitive clinical manifestations of catheter-induced bacteremia. In three prospective clinical studies, the presence of fever or chills in catheter-dependent hemodialysis patients was associated with positive blood cultures in approximately 60 to 80 percent of patients. UpToDate, 2014

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 UpToDate, 2014

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. UpToDate, 2014

Management of diaysis-catheter induced bacteremia TREATMENT Management of diaysis-catheter induced bacteremia Antibiotic therapy Empiric systemic antimicrobial therapy Tailored systemic antimicrobial therapy Removal or exchange of catheter UpToDate, 2014

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 low-minimal inhibitory concentration. Patients with vancomycin allergy can be treated with daptomycin. UpToDate, 2014

Methicillin-sensitive Staphylococcus 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 methicillin-susceptible 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 Up to 95 percent of Gram-negative bacteria isolated in dialysis catheter-related 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. UpToDate, 2014

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

Evaluation for catheter removal, 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) UpToDate, 2014

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. UpToDate, 2014

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) UpToDate, 2014

Conditions for immediate removal of infected hemodialysis catheters 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 multiply-resistant 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 The success rate of an antibiotic lock (in conjunction with systemic antibiotics) in curing CRB is highly dependent on the infecting organism. For example, the success rate was highest 87 to 100 percent in patients with gram negative infections, 75 to 84 percent for S. Epidermidis infections, and 61 percent for Enteroccocus infections, but only 40 to 55 percent with S. Aureus infections. M. Allon. Dialysis catheter-related bacteremia treatment and propylaxis. AJKD, 2004 (5): 779-791.

Leaving the catheter in place without intervention 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; 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 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. 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 Vancomycin/ceftazidime/heparin Vancomycin/heparin Ceftazidime/heparin Cefazolin/heparin Gentamycine/heparin Taurolidine 30 % citrate 70 % ethanol You are seeing here some kind of lock solutions.

Prophylaxis Against Dialysis Catheter–Related Bacteremia: A Glimmer of Hope AJKD, 2008; 51(2): 165-168 the catheter-related bacteremia frequency was 50% to 100% lower in the group with antimicrobial lock, as compared with the heparin controls.

Effect of AMLS on catheter-related bacteraemia and exit-site infections expressed as episodes per 1000 catheter-days. 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

Y. Zhao, Z. Li, L. Zhang and et all. 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.