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

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Presentation on theme: "Infectious complications of hemodialysis catheters Müjdat YENİCESU, M. D. October 24, 2014."— Presentation transcript:

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

2 Hemodialysis Catheters Tunneled, cuffed cathetersNon-tunneled, non-cuffed catheters

3 Summary of bloodstream infection data AJKD, 2002; 39 (3): 549-555

4 Frequencies and complications of catheter-related bacteremia in hemodialysis-patients M. Allon. Dialysis catheter-related bacteremia treatment and propylaxis. AJKD, 2004 (5): 779-791.

5 Risk factors for catheter-related bacteremia 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

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 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 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 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 M. Allon. Dialysis catheter-related bacteremia treatment and propylaxis. AJKD, 2004 (5): 779-791.

24 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

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 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 Prevention of catheter related infection

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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. 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

30 Catheter lock solutions Vancomycin/ceftazidime/heparin Vancomycin/heparin Ceftazidime/heparin Cefazolin/heparin Gentamycine/heparin Taurolidine 30 % citrate 70 % ethanol

31 Prophylaxis Against Dialysis Catheter– Related Bacteremia: A Glimmer of Hope AJKD, 2008; 51(2): 165-168

32 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

33 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)

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;5:1799-1804 ©2010 by American Society of Nephrology

36 NDT 2012; 27(9): 3575-3581

37 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. 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

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