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

2. 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.

3. 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):

4. Frequencies and complications of catheter-related bacteremia in hemodialysis-patients
M. Allon. Dialysis catheter-related bacteremia treatment and propylaxis. AJKD, 2004 (5):

5. 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

6. 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»

7. JASN, 1999: 10(5): 1045
Gerald A. Beathard

8. 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

9. 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

10. 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

11. 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

12. Empiric systemic antimicrobial therapy for hemodialysis catheter infection
AJKD, 2009: 54(1): 13. Treatment guidelines for dialysis catheter-related bacteremia

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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.

23. 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):

24. Leaving the catheter in place without intervention
Only systemic antibiotics,
Without replacing the infected catheter,
Without instilling an antibiotic lock,
Clinical cure rate, %
Eradication of bacteria imbedded in biofilms ?
UpToDate, 2014

25. 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,

26. 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

28. Topical antimicrobial exit-site application
Povidone-iodine
Polysporin
Mupirocin
Bacitracin
Polymixin B
Gramicidine

29. 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:
© The Author Published by Oxford University Press [on behalf of ERA-EDTA]. All rights reserved. For Permissions, please

30. 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.

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

32. 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:
© The Author Published by Oxford University Press [on behalf of ERA-EDTA]. All rights reserved. For Permissions, please

33. 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):
 (13 trials, 1770 patients)

34. 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.

35. CRI rates and cases of gentamicin resistance.
Landry D L et al. CJASN 2010;5:
©2010 by American Society of Nephrology

36. NDT 2012; 27(9):

37. 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.