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Preven&on	  of	  catheter	  related	    infec&ons	  in	  hemodialysis   	           Maurizio	  Gallieni                   ...
DisclosureDirector, Nephrology and Dialysis UnitSan Carlo Borromeo Hospital, Milano, ItalyPresident Elect, the Vascular Ac...
the	  Vascular	  Access	  Society	  	          http://www.vas2013.org/http://www.vascularaccesssociety.com/
Background	  •  Central	  venous	  catheters	  (CVCs)	  are	     increasingly	  used	  as	  vascular	  access	  for	     h...
Ideal	  Dialysis	  Catheter	      •    Easy	  to	  insert	  and	  remove	      •    Inexpensive	      •    Free	  of	  inf...
Mechanisms	  of	  infec&on	  
Risk of CVC-related infection in         hemodialysis    Mayo	  Clinics	  Proceedings	         September	  2006	  
Risk of CVC-related infection in          hemodialysis (16 studies)HD CVC non tunneled   4.8/1000 catheter daysHD CVC tunn...
Risk of CVC-related infection in                   hemodialysisBeathard GA, Urbanes A. Infection associated with tunneledh...
Guidelines - 1
Guidelines - 2Vanholder et al. NDT Plus 2010; 3: 234–246
Review - 32011; 7: 257–265
Temporary vs tunnelled catheters•  If	  temporary	  access	  is	  needed	  for	  dialysis,	  a	     tunneled	  cuffed	  cat...
Tunneled CVCs reduce EXTRALUMINAL, not     INTRALUMINAL route infections
Preven&on	  of	  catheter	  related	  infec&ons	  in	                        hemodialysis	  •  Preven&ve	  approaches	    ...
Hand	  washing	  
FaUori	  di	  rischio	  •    Inesperienza	  dell’operatore	  •    Colonizzazione	  baUerica	  del	  sito	  di	  inserzione...
Pa&ent’s	  skin	  cleansing	     Use a 2% chlorhexidine wash for daily skin   cleansing to reduce CRBSI. Category IIBleasd...
Vanholder et al. NDT Plus 2010; 3: 234–246
Preven&on	  of	  catheter	  related	  infec&ons	  in	                        hemodialysis	  •  Preven&ve	  approaches	    ...
Sutureless attachment devices Catheter Securement Devices Use a sutureless securement device to reduce the risk of infecti...
Sutureless attachment devicesTeichgräber et al. JVA 2011;12:17-20
Sutureless attachment devicesTeichgräber et al. JVA 2011;12:17-20
Sutureless attachment devices  72 dialysis patients with cuffed tunneled CVC.  Study group (n=36): CVC secured with a sutu...
Preven&on	  of	  catheter	  related	  infec&ons	  in	                        hemodialysis	  •  Preven&ve	  approaches	    ...
Topical ointments•  Do	  not	  use	  topical	  an=bio=c	  ointment	  or	     creams	  on	  inser=on	  sites,	  except	  fo...
Topical ointments•  Use	  povidone	  iodine	  an=sep=c	  ointment	  or	     bacitracin/gramicidin/	  polymyxin	  B	  ointm...
Posi&on	  statement	  of	  European	              Renal	  Best	  Prac&ce	  (ERBP)	     Use of antibiotic ointments at the ...
Topical ointments and dressings•  Chlorhexidine-­‐impregnated	  dressings	  and	  sponges	     are	  available,	  but	  th...
INTERVENTION   CONTROL
Topical ointments and dressingsCamins, BC et al. A crossover intervention trial evaluating the efficacy of achlorhexidine-...
Preven&on	  of	  catheter	  related	  infec&ons	  in	                        hemodialysis	  •  Preven&ve	  approaches	    ...
Antimicrobial lock•  Use	  prophylac=c	  an=microbial	  lock	  solu=on	  in	     pa=ents	  with	  long	  term	  catheters	...
Antimicrobial lock  Antimicrobial lock solutions  substantially reduce the risk of  CRBSI (relative risk 0.23).Labriola	  ...
Allon M. AJKD 2008; 51: 165-9
European	  Renal	  Best	  Prac&ce	  (ERBP)	  Vanholder et al. NDT Plus 2010; 3: 234–246
Preven&on	  of	  catheter	  related	  infec&ons	  in	                        hemodialysis	  •  Preven&ve	  approaches	    ...
Needle	  free	  connectors                                       	  A	  needle	  free	  connector	  creates	  a	  mechanic...
Needle	  free	  connectors                                      	            One FDA approved device•  No clear evidence o...
Preven&on	  of	  catheter	  related	  infec&ons	  in	                        hemodialysis	  •  Preven&ve	  approaches	    ...
Prevention of tunnell infections
Silvergard	  Trial	  –	  the	  only	                  available	  RCT	  in	  dialysis	   •  RCT,	  adequate	  number	  of	...
Silvergard	  trial	  -­‐	  Results	        •  No	  significant	  difference	  in	  the	  number	  of	           infec&ons	  ...
Heparin	  Coa&ng	  and	  Silver	  Ion	           An&microbial	  Sleeve	  	  «The xxx Heparin Coated and Silver IonAntimicr...
Heparin	  Coa&ng	  and	  Silver	  Ion	            An&microbial	  Sleeve	  	  The antimicrobial silver ions in the sleeve w...
From	  the	  manufacturer	  web-­‐site:	  Is	  there	  a	  clinical	  study	  to	  show	  efficacy	  of	  the	  xxx	  –	  He...
Poten&al	  problems	  of	  coated	  CVCs	    –  Coa=ng	  has	  been	  used	  mainly	  in	  short-­‐term	  catheters	  	   ...
Conclusions	  •  Various	  interven=ons	  aimed	  at	  reducing	  the	     incidence	  of	  CRBSI	  are	  available.	  Pre...
Conclusions	  •  .	  	  
WoCoVA	  abstracts	  in	  the	  Journal	       of	  Vascular	  Access	  
the	  Journal	  of	  Vascular	  Access	    Volunteers to participate as  reviewers and subsequently  as Editorial Board me...
09.30 10.00 maurizio gallieni - publiceren
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09.30 10.00 maurizio gallieni - publiceren

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09.30 10.00 maurizio gallieni - publiceren

  1. 1. Preven&on  of  catheter  related   infec&ons  in  hemodialysis   Maurizio  Gallieni  
  2. 2. DisclosureDirector, Nephrology and Dialysis UnitSan Carlo Borromeo Hospital, Milano, ItalyPresident Elect, the Vascular Access SocietyCoordinating Editor – the Journal of Vascular AccessConsultant, NICAST (dialysis grafts), Israel
  3. 3. the  Vascular  Access  Society     http://www.vas2013.org/http://www.vascularaccesssociety.com/
  4. 4. Background  •  Central  venous  catheters  (CVCs)  are   increasingly  used  as  vascular  access  for   hemodialysis,  but  infec=ous  complica=ons   remain  a  major  clinical  problem.    •  Catheter-­‐related  bloodstream  infec=ons  affect   survival,  hospitaliza=on,  mortality,  and  the   overall  cost  of  care,  poin=ng  out  the   importance  of  preven=on.    
  5. 5. Ideal  Dialysis  Catheter   •  Easy  to  insert  and  remove   •  Inexpensive   •  Free  of  infec&on   •  Free  of  fibrin  sheath  (“invisible  to  body”)   •  Does  not  cause  venous  thrombosis  or  stenosis   •  Delivers  high  flow  (>400  ml/min)  reliably   •  Durable   •  Does  not  presently  exist  Scott Trerotola - Radiology 2000; 215:651-658
  6. 6. Mechanisms  of  infec&on  
  7. 7. Risk of CVC-related infection in hemodialysis Mayo  Clinics  Proceedings   September  2006  
  8. 8. Risk of CVC-related infection in hemodialysis (16 studies)HD CVC non tunneled 4.8/1000 catheter daysHD CVC tunneled 1.6/1000 catheter days
  9. 9. Risk of CVC-related infection in hemodialysisBeathard GA, Urbanes A. Infection associated with tunneledhemodialysis catheters. Semin Dial. 2008;21(6):528-38.
  10. 10. Guidelines - 1
  11. 11. Guidelines - 2Vanholder et al. NDT Plus 2010; 3: 234–246
  12. 12. Review - 32011; 7: 257–265
  13. 13. Temporary vs tunnelled catheters•  If  temporary  access  is  needed  for  dialysis,  a   tunneled  cuffed  catheter  is  preferable  to  a   non-­‐cuffed  catheter,  even  in  the  ICU  seRng,  if   the  catheter  is  expected  to  stay  in  place  for  >  3   weeks    
  14. 14. Tunneled CVCs reduce EXTRALUMINAL, not INTRALUMINAL route infections
  15. 15. Preven&on  of  catheter  related  infec&ons  in   hemodialysis  •  Preven&ve  approaches   – Universal  precau&ons   –  Sutureless  aGachment  devices   –  Topical  ointments  and  dressings   –  Locking  solu&ons   –  Needle  free  connectors   –  Coated  catheters  
  16. 16. Hand  washing  
  17. 17. FaUori  di  rischio  •  Inesperienza  dell’operatore  •  Colonizzazione  baUerica  del  sito  di  inserzione  •  Colonizzazione  baUerica  del  catetere  •  Frequen=  manipolazioni  del  catetere  •  Rapporto  infermiere-­‐paziente  •  Tipo  di  catetere  •  U=lizzo  della  nutrizione  parenterale  •  CaraUeris=che  del  paziente  •  Contaminazione  del  materiale  •  Scarsa  cura  del  catetere  come  mancata  compliace  alle  linee  guida   (Queensland  Goverment)  
  18. 18. Pa&ent’s  skin  cleansing   Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBSI. Category IIBleasdale SC, et al. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients.Arch Intern Med 2007; 167:2073–9.No published data have addressed this same question in studieswith hemodialysis patients
  19. 19. Vanholder et al. NDT Plus 2010; 3: 234–246
  20. 20. Preven&on  of  catheter  related  infec&ons  in   hemodialysis  •  Preven&ve  approaches   –  Universal  precau&ons   – Sutureless  aGachment  devices   –  Topical  ointments  and  dressings   –  Locking  solu&ons   –  Needle  free  connectors   –  Coated  catheters  
  21. 21. Sutureless attachment devices Catheter Securement Devices Use a sutureless securement device to reduce the risk of infection for intravascular catheters *. Category II* Yamamoto AJ, Solomon JA, Soulen MC, et al. Sutureless securementdevice reduces complications of peripherally inserted central venouscatheters. J Vasc Interv Radiol 2002; 13:77–81.
  22. 22. Sutureless attachment devicesTeichgräber et al. JVA 2011;12:17-20
  23. 23. Sutureless attachment devicesTeichgräber et al. JVA 2011;12:17-20
  24. 24. Sutureless attachment devices 72 dialysis patients with cuffed tunneled CVC. Study group (n=36): CVC secured with a sutureless StatLock attachment device. Control group (n=36): CVC secured with sutures. Mean use of the tunneled CVC: 42 ± 7 days (until use of the AV fistula). Results: No infections in both groups Four local irritations at the CVC entry site were seen only in the control groupTeichgräber et al. JVA 2011;12:17-20
  25. 25. Preven&on  of  catheter  related  infec&ons  in   hemodialysis  •  Preven&ve  approaches   –  Universal  precau&ons   –  Sutureless  aGachment  devices   – Topical  ointments  and  dressings   –  Locking  solu&ons   –  Needle  free  connectors   –  Coated  catheters  
  26. 26. Topical ointments•  Do  not  use  topical  an=bio=c  ointment  or   creams  on  inser=on  sites,  except  for  dialysis   catheters,  because  of  their  poten=al  to   promote  fungal  infec=ons  and  an=microbial   resistance.  Category  IB    
  27. 27. Topical ointments•  Use  povidone  iodine  an=sep=c  ointment  or   bacitracin/gramicidin/  polymyxin  B  ointment  at  the   hemodialysis  catheter  exit  site  a]er  catheter   inser=on  and  at  the  end  of  each  dialysis  session  only   if  this  ointment  does  not  interact  with  the  material  of   the  hemodialysis  catheter  per  manufacturer’s   recommenda=on.  Category  IB    
  28. 28. Posi&on  statement  of  European   Renal  Best  Prac&ce  (ERBP)   Use of antibiotic ointments at the exit siteVanholder et al. NDT Plus 2010; 3: 234–246
  29. 29. Topical ointments and dressings•  Chlorhexidine-­‐impregnated  dressings  and  sponges   are  available,  but  the  evidence  of  their  efficacy  in   preven=ng  infec=on  (as  compared  to  appropriate   skin  cleansing  with  2%  chlorhexidine  in  alcohol   solu=ons)  is  not  convincing.  An  RCT  in  pa=ents  on   hemodialysis  with  CVCs  did  not  show  that  these   dressings  (BIOPATCH)  conferred  any  addi=onal   benefit.  Camins, BC et al. A crossover intervention trial evaluating the efficacy of achlorhexidine-impregnated sponge in reducing catheter-related bloodstreaminfections among patients undergoing hemodialysis. Infect. Control Hosp.Epidemiol. 2010; 31: 1118–1123. Betjes Nat Rev Nephrol 2011; 7: 257–265
  30. 30. INTERVENTION CONTROL
  31. 31. Topical ointments and dressingsCamins, BC et al. A crossover intervention trial evaluating the efficacy of achlorhexidine-impregnated sponge in reducing catheter-related bloodstreaminfections among patients undergoing hemodialysis. Infect. Control Hosp.Epidemiol. 2010; 31: 1118–1123.
  32. 32. Preven&on  of  catheter  related  infec&ons  in   hemodialysis  •  Preven&ve  approaches   –  Universal  precau&ons   –  Sutureless  aGachment  devices   –  Topical  ointments  and  dressings   – Locking  solu&ons   –  Needle  free  connectors   –  Coated  catheters  
  33. 33. Antimicrobial lock•  Use  prophylac=c  an=microbial  lock  solu=on  in   pa=ents  with  long  term  catheters  who  have  a   history  of  mul=ple  CRBSI  despite  op=mal   maximal  adherence  to  asep=c  technique.   Category  II    
  34. 34. Antimicrobial lock Antimicrobial lock solutions substantially reduce the risk of CRBSI (relative risk 0.23).Labriola  L  et  al.  Preven=ng  haemodialysis  catheter  related  bacteraemia  with  an  an=microbial  lock  solu=on:  a  meta-­‐analysis  of  prospec=ve  randomized  trials.  Nephrol  Dial  Transplant  2008;  23:1666–1672  Rabindranath, K. S. et al. Systematic review of antimicrobials for theprevention of haemodialysis catheter-related infections. Nephrol. Dial.Transplant 2009; 24: 3763–3774Jaffer Y et al. A meta-analysis of hemodialysis catheter locking solutions in theprevention of catheter-related infection. Am J Kidney Dis 2008; 51:233-241
  35. 35. Allon M. AJKD 2008; 51: 165-9
  36. 36. European  Renal  Best  Prac&ce  (ERBP)  Vanholder et al. NDT Plus 2010; 3: 234–246
  37. 37. Preven&on  of  catheter  related  infec&ons  in   hemodialysis  •  Preven&ve  approaches   –  Universal  precau&ons   –  Sutureless  aGachment  devices   –  Topical  ointments  and  dressings   –  Locking  solu&ons   – Needle  free  connectors   –  Coated  catheters  
  38. 38. Needle  free  connectors  A  needle  free  connector  creates  a  mechanically  and  microbiologically  closed  system  when  aUached  to  the  hub  of  a  catheter,  elimina=ng    open  catheter  hubs  and  lowering  the  chance    of  contamina=on  and  infec=on  
  39. 39. Needle  free  connectors   One FDA approved device•  No clear evidence of a benefit (possible benefit: in patients with mulfunctioning catheters, needing line inversions?)•  No recommendations in guidelines
  40. 40. Preven&on  of  catheter  related  infec&ons  in   hemodialysis  •  Preven&ve  approaches   –  Universal  precau&ons   –  Sutureless  aGachment  devices   –  Topical  ointments  and  dressings   –  Locking  solu&ons   –  Needle  free  connectors   – Coated  catheters  
  41. 41. Prevention of tunnell infections
  42. 42. Silvergard  Trial  –  the  only   available  RCT  in  dialysis   •  RCT,  adequate  number  of  pa=ents  (n=100)   •  Two  groups  with  same  CVC  (one  silver  coated)   •  All  CVC  in  the  right  internal  jugular  vein   •  Follow-­‐up  with  venography  (evalua=on  of   thrombosis  and  infec=on)   •  Colture  of  CVC  =p  upon  removal  Trerotola et al, Radiology 1998;207:491-496
  43. 43. Silvergard  trial  -­‐  Results   •  No  significant  difference  in  the  number  of   infec&ons   –  (indeed,  infec=on/coloniza=on  more  common   in  the  silver  coated  group,  p=NS)   •  4%  vein  thrombosis  /  stenosis   •  2  pa=ents  with  permanent  skin  lesions  in   the  silver  coated  group  Trerotola et al, Radiology 1998;207:491-496
  44. 44. Heparin  Coa&ng  and  Silver  Ion   An&microbial  Sleeve    «The xxx Heparin Coated and Silver IonAntimicrobial Dialysis Catheter is the firstchronic catheter to provide dual protectionagainst clotting and microbialcolonization»
  45. 45. Heparin  Coa&ng  and  Silver  Ion   An&microbial  Sleeve    The antimicrobial silver ions in the sleeve work toreduce the colonization of clinically relevantmicrobes on the external surface of the catheterin the subcutaneous tunnel tract.The unique silver-polymer system delivers acontrolled release of silver ions, which have beentested against a broad spectrum of recent clinicalisolates and is specifically designed for thedialysis catheter environment.
  46. 46. From  the  manufacturer  web-­‐site:  Is  there  a  clinical  study  to  show  efficacy  of  the  xxx  –  Heparin  Coated  and  Silver  Ion  An&microbial  Dialysis  Catheter?    The silver ion sleeve was tested against recentclinical isolates including S. Aureus, coagulase-negative Staphylococcus, C. Albicans and E. Coli.In vitro testing demonstrated a statistically significantreduction of microbial colonization by 99.2%–99.999%.In vivo testing resulted in a statistically significantreduction of microbial colonization by 99.7%–99.999% in Staphylococcus aureus.
  47. 47. Poten&al  problems  of  coated  CVCs   –  Coa=ng  has  been  used  mainly  in  short-­‐term  catheters     –  Coa=ng  usaully  limited  to  the  external  surface  (beUer   protec=on  from  skin  bacteria,  not  from  intraluminal   contamina=on)   –  Higher  cost:  cost-­‐effec=veness  should  be  demonstrated   –  Possibility  of  allergies  or  induc=on  of  an=bio=c  resistance   •  Anaphylaxis  to  chlorhexidine-­‐impregnated  central  venous  catheter.   (Kluger,  Anaesth  Intensive  Care  2003)   –  Transient  an=microbic  effect  (days  to  week?)   –  No  RCT  avalable,  besides  Silvergard  trial.  
  48. 48. Conclusions  •  Various  interven=ons  aimed  at  reducing  the   incidence  of  CRBSI  are  available.  Preven=on  of   intraluminal  contamina=on  of  the  CVC  is   pivotal  and  of  proven  efficacy,  as  are  strict   asep=c  CVC  inser=on  and  handling  protocols,   use  of  chlorhexidine  in  alcohol  solu=ons  for   skin  cleansing,  topical  applica=on  of   an=microbial  ointments,  and  an=microbial   lock  solu=ons.    
  49. 49. Conclusions  •  .    
  50. 50. WoCoVA  abstracts  in  the  Journal   of  Vascular  Access  
  51. 51. the  Journal  of  Vascular  Access   Volunteers to participate as reviewers and subsequently as Editorial Board members are welcomeHome page:http://www.vascular-access.info/Article submission:http://www.editorialmanager.com/jva/

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