Infections of av fistula

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CHAPTER 5
HEMODIALYSIS TUNNELED CATHETER-
RELATED INFECTIONS
AUTHORS:
Lisa M Miller MD, Edward Clark MD MSc, Christine Dipchand MD MSc,
Swapnil Hiremath MD MPH, Joanne Kappel MD, Mercedeh Kiaii MD,
Charmaine Lok MD MSc, Rick Luscombe RN, Louise Moist MD MSc,
Matthew Oliver MD MHSc, Jennifer MacRae MSc MD.
On Behalf Of The Canadian Society Of Nephrology Vascular Access Work Group

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CONTENTS
Introduction
Definitions
Clinical Features
Diagnostic Challenges
Definitions for CRBSI
CDC Surveillance Definitions for CRBSI
Risk Factors for Catheter-Related Infections
Prevention of Catheter Related infection
Summary of Core Interventions
Treatment of Catheter Related Infections
Infection Complications
Infection Surveillance
Summary of Recommendations

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INTRODUCTION
• Catheter-related bloodstream infections (CRBSIs), exit-site infections and
tunnel infections are frequent and important complications related to HD
CVC use
• Reported incidences of CRBSIs are 1.1 to 5.5 episodes /1000 catheter days;
associated with  morbidity, hospitalization, and death
• Metastatic infectious complications of CRBSIs include endocarditis,
osteomyelitis, spinal epidural abscess, septic arthritis, brain abscess, septic
pulmonary emboli
Causative Pathogens of CRBSIs
Gram -ve
organisms
Gram +ve bacteria w S. aureus;
Coagulase -ve Staphylococci
Polymicrobial infections
Fungal infections
<5% 10-20% 20-40% 40-80%
Chart Source: Lok, C.E. and M.H. Mokrzycki, Prevention and management of catheter-related infection in hemodialysis patients. Kidney Int,
2011. 79(6): p. 587-98.

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DEFINITIONS
CRBSIs: Catheter-related infection where all other apparent sources are
ruled out
EXIT SITE INFECTIONS:
• IDSA – Hyperemia, induration and/or tenderness ≤ 2 cm from catheter exit
site. May be associated with fever and purulent drainage from exit site.
may or may not be associated with bacteremia
• CDC - Erythema or induration within 2 cm of the catheter exit site, in the
absence of concomitant bloodstream infection (BSI) and without
concomitant purulence
TUNNEL INFECTIONS:
• IDSA – Tenderness, hyperemia and/or induration that extends > 2 cm from
the exit site and along the subcutaneous tunnel. It may or may not be
associated with bacteremia
• CDC - Tenderness, erythema, or site induration >2 cm from the catheter
site along the subcutaneous tract of a tunneled catheter, in the absence of
concomitant BSI

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60 – 80%
5%
25%
Clinical Features Associated w Positive Blood Cultures
Fever/Chills
Exit Site/Tunnel Infection
Other
CLINICAL FEATURES
 Hemodynamic instability
 Altered mental status
 Catheter dysfunction
 Hypothermia
 Nausea/vomiting
 Generalized malaise
• In some cases, complications related to a CRBSI may actually be the first
clues to the presence of a CRBSI

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DIAGNOSTIC CHALLENGES
• Peripheral blood cultures not obtained in HD patients
 Veins can’t be accessed or vein needs to be preserved for AVF
• Handling of blood cultures in outpatient HD may not be ideal
 Variable period before culture bottles are eventually placed in an
incubator
 Differences in temperature during transport to a microbiology
laboratory
• Physician unable to exclude other sources of infection at time of clinical
presentation
• ing role of catheter salvage means  catheter tips sent for cultures
• Use of antibiotic locks for prevention may interfere with diagnosis

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KDOQI CDC IDSA Public Health Agency of Canada
Definite: Same organism
from semiquantitative (>15
CFU/catheter segment)
culture of catheter tip and
from a blood culture (BC)*
Probable: Defervescence of
symptoms after antibiotic
therapy with or without
removal of the catheter (BC
confirms infection but
catheter does not, or vice-
versa)*
Possible: Defervescence of
symptoms after antibiotic
treatment or after removal of
catheter in the absence of
laboratory confirmation of
bloodstream infection (BSI)*
Clinical manifestations and at
least one positive BC from a
peripheral vein and no other
apparent source, with either
positive semiquantitative or
quantitative (>103
CFU/catheter segment)
culture, same organism is
isolated from the catheter
segment and peripheral
blood sample;
Simultaneous quantitative
cultures of blood samples with
a ratio of ≥3:1 (catheter vs.
peripheral);
Differential period of catheter
culture versus peripheral BC
positivity of 2 h
OR
Isolate same organism from
semiquantitative or
quantitative culture segment
and from blood (preferably
from a peripheral vein) *
Bacteremia/fungemia in a patient
with an intravascular catheter
with at least one positive BC and
with clinical manifestations of
infections (i.e., fever, chills,
and/or hypotension) and no
apparent source for the
bloodstream infection except the
catheter
AND
One of the following should be
present:
- A positive semiquantitative or
quantitative culture whereby the
same organism (species and
antibiogram) is isolated from the
catheter segment and peripheral
blood.
- Simultaneous quantitative BC
with a >5:1 ratio catheter vs.
peripheral
- Differential time period of
catheter culture vs. peripheral
blood culture positivity of >2h.
Definite: single positive BC and positive culture result
of catheter segment with identical organism or ≥ 10-
fold colony count difference in blood cultures drawn
from device and peripheral blood
OR
single positive BC and positive culture from discharge
from exit site or tunnel with identical organism
OR
Probable: ≥ 2 positive BC results with no evidence for
source other than the device
OR
single positive BC for S aureus or Candida species with
no evidence for source other than the device
OR
single positive BC for coagulase-negative
staphylococci, Bacillus, Corynebacterium jeikeium,
Enterecoccus,Trichophyton, or Malassezia species in
immunocompromised or neutropenic host or patient
receiving total parenteral nutrition with no evidence
for source other than a centrally placed device
Possible: single positive BC result with no evidence for
source except a centrally placed device and
patient or organism does not fit criteria for probable
*in a symptomatic patient with no other apparent source of
infection
DEFINITIONS FOR CRBSI

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CDC SURVEILLANCE DEFINITIONS FOR CRBSI
Laboratory-Confirmed Blood stream
Infection (BSI)
Clinical Sepsis Catheter Associated
BSI
Should meet at least ONE of the following criteria:
Criterion 1. Patient has a recognized pathogen cultured from one or
more BC, and the pathogen cultured from the blood is not related
to an infection at another site.
Criterion 2. Patient has at least one of the following signs or
symptoms: fever (>100.4°F [>38°C]), chills, or hypotension, and at
least one of the following:
1. Common skin contaminant (e.g., diphtheroids, Bacillus spp.,
Propionibacterium spp., coagulase-negative staphylococci, or
micrococci) cultured from two or more BC drawn on separate
occasions.
2. Common skin contaminant (as in 1 above) cultured from at least
one BC from a patient with an intravenous line, and the physician
institutes appropriate antimicrobial therapy.
3. Positive antigen test on blood (e.g., Haemophilus influenzae,
Streptococcus pneumoniae, Neisseria meningitidis, or group B
streptococcus).
AND
Signs and symptoms with positive laboratory results are not related
to an infection at another site.
Should meet at least one of the following
criteria:
Criterion 1. Patient has at least one of the
following clinical signs with no other
recognized cause: fever (>100.4°F [>38°C]),
hypotension (systolic pressure <90 mm Hg), or
oliguria (<20 mL/hr), and BC not done or no
organisms or antigen detected in blood and
no apparent infection at another site, and
physician institutes treatment for sepsis.
Criterion 2. Patient aged <1 year has at least
one of the following clinical signs or symptoms
with no other recognized cause: fever
(>100.4°F [>38°C]), hypothermia (<98.6°F
[<37°C]), apnea, or bradycardia, and blood
culture not done or no organisms or antigen
detected in blood and no apparent infection
at another site, and physician institutes
treatment for sepsis.
Vascular access device that
terminates at or close to the
heart or one of the great vessels.
An umbilical artery or vein
catheter is considered a central
line.
* BSI is considered to be
associated with a central venous
catheter if the catheter was in
use during the 48-hour period
before development of the BSI. If
the time interval between onset
of infection and device use is >48
hours, there should be
compelling evidence that the
infection is related to the central
venous catheter.

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RISK FACTORS - CATHETER RELATED INFECTIONS
• Submaximal barrier precautions at time of insertion
• Non-tunneled catheter
• Site of insertion: femoral is highest risk of infection, followed by internal
jugular and subclavian is lowest risk
• Prolonged duration of catheter use
• Previous episode of CRBSI
• Staphylococcus aureus nasal carriage
• Diabetes
• Hypoalbuminemia
• Recent surgery

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PREVENTION OF CATHETER RELATED INFECTION
Site selection
(tunneled)
• Preferred site: right internal jugular (IJ)
Max. barrier
precautions at
time of insertion
• Use cap, mask, sterile gown, and sterile gloves
• Prep site using sterile technique
• Use sterile full body drape leaving only a small opening
Dressing type and
replacement
intervals
• Use sterile gauze or sterile, semipermeable dressing
• Change when damp, loose, soiled, non-occlusive or non-adherent
• CSN guideline: change exit site dressing at every HD treatment
Antimicrobials/anti
septic application
• Chlorhexidine superior to povidone-iodine/alcohol; use povidone-
iodine If chlorhexidine is contraindicated
Topical
antimicrobial
application
• Mupirocin:  risk exit site infection from S. aureus;  risk of CRBSI
• Polysporin triple:  risk of CRBSI;  in all-cause mortality
• Povidone-iodine ointment:  risk of CRBSI
Antimicrobial locks
(Need further study)
• Reduction in bacteremia rates with use of antimicrobial locks
• Potential risk of developing antimicrobial resistance

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SUMMARY OF CORE INTERVENTIONS
CDC recommends several core interventions to decrease CRBSI from CVCs:
CORE
INTERVENTIONS
Surveillance
& feedback
Hand
hygiene
observations
Catheter/
vascular
access care
observations
Staff
education &
competenc
y
Patient
education/
engagement
Catheter
reduction
Chlorhexidine
for skin
antisepsis
Catheter
hub
disinfection
Antimicrobial
ointment

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TREATMENT OF CATHETER RELATED INFECTIONS
Exit Site Infection Tunnel Infection
• Obtain cultures of any drainage
from exit site, before administering
antibiotics
• Treat empirically w antibiotics to
cover gram +ve organisms
• Modify antibiotic regimen once
culture and sensitivity results
available
• Treat 7-14 days
• Obtain cultures of any drainage from
exit site; send blood cultures from
catheter
• Remove catheter, without exchange
over a wire; insert new catheter in a
separate site
• Start empiric broad spectrum
antibiotics to cover gram +ve/-ve
organisms
• Modify antibiotic regimen when
culture and sensitivity results
available
• Treat 10-14 days (longer if also CRBSI)

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TREATMENT OF CATHETER RELATED INFECTIONS
Empirical Management:
• Send blood cultures from catheter and dialysis circuit or peripheral sites
• Initiate broad spectrum antibiotics to cover gram +ve/-ve organisms
• Should cover methicillin resistant S. aureus (MRSA) and Pseudomonas, but
also dictated by local infection rates or center specific antimicrobial
resistance patterns

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TREATMENT OF CATHETER RELATED INFECTIONS
Definitive Management:
Systemic Antibiotics
• Dependent on blood culture result/sensitivity
Antibiotic Locks
• Adjunctive to systematic antibiotics
• Consider use when immediate removal is not possible
Catheter Removal & Replacement in New Site
• Immediate catheter removal, followed by placement of a temporary
catheter at a different site, then conversion back to tunneled catheter
Catheter exchange Over a Guidewire
• Dependent on bacterial culture results and sensitivity
Catheter Salvage
• Consider in HD patients with limited vascular access.
*View protocols in the’ Protocol repository’ available on CSN website

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INFECTION COMPLICATIONS
• Thought to occur in ~15-20% CRBSIs; most common for S. aureus infections
Endocarditis •Most frequent and severe complication of CRBSIs
•Most common with S. aureus, reported in 25-35% of S. aureus bacteremias
•Consider transthoracic echocardiography in all patients w S. aureus CRBSI
•Associated with mortality rates 30-50%
•Requires min. 6 wks IV antibiotics
Vertebral
Osteomyelitis/
discitis
•Most commonly caused by S. Aureus
•Fever/back pain are common presenting symptoms
•Diagnosis made primarily by CT or MRI
•Requires min. 6 wks antibiotics; may require up to 3 mths of IV antibiotics
Spinal Epidural
Abscess
•Uncommon; symptoms are back pain, fever, weakness
•MRI is best diagnostic modality
•Requires antibiotic therapy for min. 6 wks; neurosurgical evaluation required
Septic Arthritis •Presents as an acute inflammatory monoarthritis
•Knee, hip, shoulder, ankle are most commonly affected joints
•Diagnose by joint aspiration; fluid sent for cell count, gran stain, cultures,
crystals
•Requires joint irrigation and debridement and min. 2 wks antibiotics

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INFECTION SURVEILLANCE
• Would facilitate identification of catheter related complications/infections
and timely interventions.
• An infection surveillance program should include the following
components:
Track catheter
placement
• Date/place of catheter insertion and/or removal
• Selected vein for insertion
• Type of catheter inserted: temporary vs. tunneled, heparin coated, etc..
• Reason for insertion and removal
Monitor CRBSI
rates
• Identify all exit site infections, tunnel infections, and CRBSIs
• Identify type of bacteria isolated in each infection
• Calculate infection rates (e.g. CRBSI per 1000 catheter days)
• Set a benchmark rate of infection (e.g., less than1 per1000 catheter days)
• Analyze infection rates on a routine basis (e.g. quarterly, semi-annually)
• Monitor for development of antibiotic resistance
Intervene • Evaluate current infection rates vs. set benchmark, is it too high?
• If rates are high, design and implement intervention
• Re-evaluate the intervention: Has benchmark been achieved?
• Continue education and staff engagement

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SUMMARY OF RECOMMENDATIONS
• CRBSIs are a major cause of hospitalization and mortality in HD patients
• Prevention is key! General preventative measures include:
 Maximal barrier precautions with insertion and catheter care
 Topical antibiotics
 Education and Surveillance
• Gram-positive organisms are responsible for most CRBSIs; S. aureus and
coagulase -ve staphylococci comprising 40-80%
• S. aureus bacteremias are associated with 30-50% mortality in
hemodialysis patients.
• Treatment strategies for CRBSIs can be categorized into systemic
antibiotics, antibiotics locks, and catheter management
• CRBSI management decisions depend on clinical presentation of the
patient, micro-organism isolated, and vascular access options of the
patient
• All CRBSIs require a minimum 2-3 weeks’ systemic antibiotic therapy

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SUMMARY OF RECOMMENDATIONS
• S. aureus CRBSIs and complicated infections should be treated with
systemic antibiotic therapy for minimum 4-6 weeks
• Antibiotics locks have been shown to be effective adjunctive therapy
to systemic antibiotics in the treatment of CRBSIs.
• CRBSI catheter management options include immediate catheter
removal with insertion of temporary catheter at another site,
guidewire exchange, or catheter salvage with an antibiotic lock
• Catheters should be removed in patients who are hemodynamically
unstable, have metastatic complications, or have the following
organisms on blood culture – S. aureus, Pseudomonas, fungus
• If catheter salvage is attempted, an adjunctive lock should be used in
conjunction with the systemic antibiotics
• Every dialysis program should have an infection surveillance program
with dedicated personnel and resources, to facilitate identification of
catheter related infections and timely interventions to reduce
infection rates and improve patient clinical outcomes