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Approach to Catheter-related Bloodstream Infections in Patients on Haemodialysis
Nephrology discussionRegistrar: Dr. Coetser
Consultants:Prof. Van Rensburg
Dr. Rossouw
Prevention of CRBSI 5 principles strongly recommended by CDC:
Hand washing Full barrier precautions during insertion of central venous
catheters Chlorhexidine for skin disinfection Avoidance of the femoral insertion site Removal of catheters when no longer indicated
If these principles are adhered to, showed a 12% sustainable reduction in incidence of CRBSI in intensive care unitsPronovost, PJ et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ 2010; 340
Unique features in the haemodialysis patient applicable in our setting Usually outpatients Hospitalization only indicated for severe sepsis or metastatic
infection Parenteral antibiotics can be given during dialysis sessions Preference given to antibiotics that can be delivered during
dialysis Peripheral venous access unavailable or should be avoided Catheter removal often requires urgent placement of a new
dialysis catheter Quantitative blood culture and/or determining differential
time to positivity frequently unable to be done
Risk of infection vs. location in dialysis catheters Subclavian catheters have least risk
of infection, but high incidence of
venous stenosis Femoral catheters have highest
risk of infection due to microbial
load and should be avoided if
possible Internal jugular catheters have an
intermediate risk of infection, but
is the most appropriate site for
acute haemodialysis access
Unique aspects in haemodialysis:Obtaining blood cultures Peripheral blood samples should spare veins for potential
fistula creation (A-III) If no sample can be obtained, blood culture can be taken from
bloodlines connected to the catheter during haemodialysis (B-II)
If no sample can be obtained from peripheral site, no other catheter is in situ and no drainage from exit site that can be cultured, accept positive culture from dialysis catheter as evidence of a CRBSI (B-II)
Category, grade Definition
Strength of recommendation
A Good evidence to support a recommendation for or against use
B Moderate evidence to support a recommendation for or against
use
C Poor evidence to support a recommendation
Quality of evidence
I Evidence from more than 1 properly randomized, controlled
trial
II Evidence from more than 1 well-designed clinical trial,
without randomization; from cohort or case-controlled analytic
studies; from multiple time series; or from dramatic results
from uncontrolled experiments
III Evidence from opinions of respected authorities, based on
clinical experience, descriptive studies, or reports of expert
committees
Unique aspects in haemodialysis:Removal of infected catheter Always remove catheter when these organisms are cultured
(A-II) S. aureus Pseudomonas spp Candida spp
If no alternative sites for catheter placement, exchange infected catheter over a guidewire (B-II)
Place longterm catheter again when blood cultures become negative (B-III)
Unique aspects in haemodialysis:Removal of infected catheter For other pathogens (gram-negative bacilli other than
Pseudomonas or coagulase-negative staph) catheter need not be removed immediately. Start empiric antibiotics (B-II)
3 options remain: If symptoms resolve within 2-3 days, exchange infected catheter over
guidewire (B-II) or Leave catheter in place and treat with antibiotic lock for 10-14 days
(B-II) If symptoms persist, or signs of metastatic infection present, remove
line
Unique aspects in haemodialysis:Removal of infected catheter Treating with antibiotics alone and not removing the infected
catheter is not satisfactory: Bloodstream infection returns in majority after therapy is stopped Treatment failure risk is 5x higher
Catheter should be inserted at a new sight or at least be exchanged over a guidewire
Unique aspects in haemodialysis:Empiric antibiotic coverage Include vancomycin and coverage for gram-negative bacilli
(e.g. 3rd generation cephalosporin, carbapenem or beta-lactam/beta-lactamase combination) (A-II)
Aminoglycosides, e.g. gentamycin, can be used, but risk of irreversible ototoxicity
If found to have methicillin-susceptible S.aureus, switch to cefazolin (20mg/kg) after each dialysis session
Unique aspects in haemodialysis:Duration of antibiotic treatment Uncomplicated infection and no evidence of metastatic
infection: Coagulase negative staph
5-7 days if catheter removed (B-III) 10-14 days if catheter retained, in combination with antibiotic lock (B-
III) S. aureus
4-6 weeks Shorter duration (minimum 14 days) can be considered in:- non-diabetics - non-immunosuppressed- catheter removed - no prosthetic intravascular device- no evidence of endocarditis - fever and bacteraemia resolve within
72h on TEE (5-7 days after onset) - no evidence of metastatic infection
Unique aspects in haemodialysis:Duration of antibiotic treatment 4-6 weeks if complicated infection, i.e.:
Persistent bacteraemia or fungaemia (>72h) after infected catheter was removed
If infective endocarditis or suppurative thrombophlebitis present
6-8 weeks for osteomyelitis Surveillance blood culture to be taken 1 week after
completion of antibiotic course. If culture postive, remove catheter and only place new longterm catheter when blood culture becomes negative
Antibiotic lock Definition
A solution of antibiotic and heparin instilled into a catheter lumen. Solution is then left in place for a certain time period.
Mechanism of action Bacteria form a biofilm on the endoluminal side of a long-term
placed catheter Bacteria are sequestered here from systemic levels of antibiotics Antibiotic lock delivers supratherapeutic levels of antibiotics to the
biofilm
Antibiotic lock therapy Indications (B-II):
CRBSI in patients with long-term (>2 weeks) catheters in which salvage is desirable
No signs of exit site or tunnel infection must be present
Success rates: Gram-negative pathogens (87-100%) Staphylococcus epidermidis (40-50%) Staphylococcus aureus (40-55%)
Antibiotic lock therapy:Practical aspects Use in conjunction with systemic antibiotic therapy for 7-14
days (B-II) Dwell times not >48h
Preferably q24h in patients with femoral catheters If undergoing haemodialysis, change lock with every session
Not all antiobiotics are suitable for use in combination with heparin, as precipitation can occur
Antibiotic lock is unlikely to have effect if catheter has been in place for <2 weeks
Antibiotic lock therapy:Practical aspects Do not use antibiotic lock and remove catheter for S.aureus
and candida infections, unless no alternative site available If multiple positive catheter culture results for coagulase-
negative staph or gram-negative bacilli, but negative peripheral cultures, antibiotic lock can be given for 10-14 days without systemic antibiotics (B-III)