1. Antibiotic Prophylaxis in Chronic Renal Failure Hemodialysis Gregory A. Chambers, PA-S Lock Haven University February 25, 2009

2. Causes of End-Stage Renal Disease: Diabetic Nephropathy Hypertension Glomerulonephritis HIV Nephropathy Renal Artery Stenosis Polycystic Kidney Disease Others

3. The first three causes account for nearly 75% of all end stage renal disease! Diabetic Nephropathy (25-40%) Hypertension Glomerulonephritis

4. Diabetic Nephropathy Leading Cause: Obesity (AKA: Hypernutrition)

5. Obesity in the United States Percent of Obese (BMI > 30) in U.S. Adults play stop

6. Obesity in the United States 2007 State Obesity Rates State% % % % Alabama30.3Illinois24.9Montana21.8Rhode Island21.4 Alaska27.5Indiana26.8Nebraska26.0South Carolina28.4 Arizona25.4Iowa26.9Nevada24.1South Dakota26.2 Arkansas28.7Kansas26.9New Hampshire24.4Tennessee30.1 California22.6Kentucky27.4New Jersey23.5Texas28.1 Colorado18.7Louisiana29.8New Mexico24.0Utah21.8 Connecticut21.2Maine24.8New York25.0Vermont21.3 Delaware27.4Maryland25.4North Carolina28.0Virginia24.3 Washington DC21.8Massachusetts21.3North Dakota26.5Washington25.3 Florida23.6Michigan27.7Ohio27.5West Virginia29.5 Georgia28.2Minnesota25.6Oklahoma28.1Wisconsin24.7 Hawaii21.4Mississippi32.0Oregon25.5Wyoming23.7 Idaho24.5Missouri27.5Pennsylvania27.1

7. Obesity in the United States (BMI > 30) 1997 – 19.4% of adults 2004 – 24.5% of adults 2007 – 26.6% of adults

8. As a Result: End-stage renal disease will increase dramatically in the next several years as a result of the deconditioning of America!

9. Hemodialysis:

11. Outpatient procedure Attach catheter to Hemodialysis equipment Blood passes through chambers with semi-permeable membranes Dialysis solutions on opposite side of membranes Simple diffusion – toxins, excess water out – electrolytes and nutrients in Anticoagulation achieved with heparin

13. What is Missing

14. Antibiotic Therapy

15. Hemodialysis Complications: Hypotension - frequent Fatigue - frequent Nausea - frequent Headache - frequent Sepsis – 1-2 % of all dialysis hours Endocarditis – small percent of sepsis cases Stroke – small percent of endocarditis cases

16. Let’s Do The Math……… Hemodialysis 3 times per week……… Total times per year (52 weeks X 3 times per week) 156 trips to the dialysis center……… Average time per dialysis session = 4 hours……… Annual time in dialysis = 624 hours……… Rate to infection = 1 – 2%......... Total infections per year = 6.2 – 12.4………

17. Research In all the sources used, prophylaxis use of either topical or intra-luminal antibiotics decreased the rates of infection by 0.22 – 0.46%.

18. Research While this may not see to be a significant amount, it would reduce the incidence of infection by nearly 25.0%!

19. Research: Antibiotics Tested: Gentamicin (aminoglycoside) Cefazolin (1 st generation cephalosporin) Cefotaxime (3 rd generation cephalosporin) Vancomycin (glycopeptide) Minocycline (tetracycline) Taurolidine (antimicrobial properties and stimulates leucocytes)

20. Futures Studies: Although the research showed significant rates of infection with antibiotic prophylaxis, the study sizes were very small (n=70 – 6) and were mostly conducted outside the United States.

21. Future Studies: In addition, many of the studies revealed bias in either the design of the study or in the interpretation of the results.

22. Future Studies: A large cohort, double blinded, randomized study conducted in the United States is needed to truly identify the efficacy of antibiotic prophylaxis in hemodialysis patients.

23. Bibliography: James, M., Conley, J., Tonelli, M., Manns, B., MacRae, J., Hemmelgarn, B. (2008). Meta-analysis: antibiotics for prophylaxis against hemodialysis catheter- related infections. Annals of Internal Medicine. 148,596-605. Saxena, A., Panhotra, B., Sundaram, D., Al-Hafiz, A., Naguib, M., Venkateshappa, C., et. al. (2006). Tunneled catheters’ outcome optimization among diabetics on dialysis through antibiotic-lock placement. Kidney International. 70, 1629-1635. Tacconelli, E., Carmeli, Y., Aizer, A., Ferreira, G., Foreman, G., D’Agata, M. (2003). Mupirocin prophylaxis to prevent staphylococcus aureus infection in patients undergoing dialysis: a meta-analysis. Clinical Infectious Diseases. 37, 1629-1638.

24. Bibliography Continued: Allon, M. (2003). Prophylaxis against dialysis catheter-related bacteremia with a novel antimicrobial lock solution. Clinical Infectious Diseases. 36, 1539-1544. Stippoli GFM, Tong A, Johnson D, Schena FP, Craig JC. Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004679. DOI: 10.1002/14651858.CD004679.pub2.

25. GO BUCKS!!!