Hemodialysis catheter related infection 5

Hemodialysis Catheter-related
infection
JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 1

CAN YOU MAKE A DIFFERNCE??

OUTLINE
 Statistics.
 How to reduce infection?
 Infection types.
 CDC data.
 Ochsner data.
 Proposed protocol for dialysis infection control.

ESRD Prevalence
USRDS 2020

In Center
HD
Transplant
PD
Home HD

Vascular access use at initiation and on day
of eligibility, 2011.
Figure 1.21 (Volume 2) Incident hemodialysis patients, 2011. USRDS
2013.
USRD
S2013
50%

Access use at first outpatient hemodialysis,
by pre-ESRD nephrology care, 2011
Figure 1.22 (Volume 2) Incident hemodialysis patients, 2011. USRDS 2013
USRDS
2020
HD
catheter

HD Catheters
70%
USRDS 2020

USRDS 2020

92%

We have to learn how to live with the
hemodialysis catheters, whether we like it or not.
Jafar Alsaid

How can we improve our catheter care and
reduce infection?

Hemodialysis catheter infection
 Second cause of mortality.
 First cause of Morbidity.
 Bacterial flora migration.
 Exoluminal and Endoluminal growth.
 Increased catheter loss, bacteremia, hospitalization.
Ishani A, Collins AJ, Herzog CA, Foley RN: Septicemia, access and cardiovascular disease in dialysis patients: The
USRDS Wave 2 study. Kidney Int 68: 311–318, 2005

Catheter Bacterial Colonization
C

Types of catheters
 Cuffed / non-Cuffed.
 Gauge.
 Length.
 Luminal design.
 Material.
 Tip design.
 Antiseptic impregnated.

Catheter related Bacteremia
 Cuffed rate 1.6-5.5/1000 d.
 Non cuffed 3.8-6.6/1000 d.
High mortality and morbidity.
Related with Catheter tip colonization.
Higher risks:
 Immunosuppressed patients.
 S. Alb < 3.5g/dl.
Organisms; G+, less common G- bacilli.
Beathard GA, Urbanes A: Infection associated with tunneled hemodialysis catheters. Semin dial 21: 528–538, 2008.

DURATION

Hemodialysis catheter infection
Rate of uncuffed cath. infection:
 8% by 2wks.
 25% by 1 month.
 50% by 2 months.
Catheter related septicemia is 2 -20%.
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.

Recommended duration for HD catheters:
Vascath:
 IJ 2-3wks?
 Subclavian 2-3wks?
 Femoral. 2-5days?
Cuffed tunneled:
 1 year –Indefinite.

Cuffed Tunneled Cath. Duration
Catheter survival will depend on:
1. Design.
2. Site of insertion.
3. Rt. IJ > Lt IJ> Femoral.
4. Non Dm.
Fry AC, Stratton J, Farrington K, Mahna K, Selvakumar S, Thompson T, Warwicker P: Factors affecting long-term survival of tunneled
haemodialysis catheters: A prospective audit of 812 tunneled catheters. Nephrol Dial Transplant 23: 275–281, 2008

Catheter
Location
JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021
25

Complication in relation with location 865 patient from 14 HD centers
Wang K, et al. BMJ Open 2015;5:e007136. doi:10.1136/bmjopen-2014-007136

Location of HD catheters

Signs and symptoms of Hemodialysis Catheter
related infection
 Immunosuppressed patients.
 Inflammatory signs:
 redness, hotness, pain, swelling, discharge.
 Fever during Hemodialysis.
The catheter is the cause of fever unless proven otherwise.
 Redness over the exit site.
 Discharge from the exit site.

Classification of Hemodialysis Catheter related infection
Types:
1. Exit site infection.
2. Tunnel Infection.
3. Blood steam infection.
4. Distant organ septic embolization and abscesses.

Investigations for catheter infection
 CBC.
 Blood Culture peripheral and from catheter.
 Catheter tip Cx. ??
 Exit site discharge.
 Others: Urine, Sputum, Drains..etc.
 Radiology: CXR, US, …etc.

Catheter Exit Site infection & Tunnel infection

Definition of Exit Site infection
Lok CE, Huber TS, Lee T, et al; KDOQI Vascular Access Guideline Work Group. KDOQI clinical
practice guideline for vascular access: 2019 update. Am J Kidney Dis. 2020;75(4)(suppl 2):S1-S164.
• Erythema.
• Area < 2cm.
• Purulent Discharge.
• May be associated with
Bacteremia, fever ..etc.

Exit site infection
• Erythema, discharge and tenderness.
• Obtain Cx.
• Could be treated with Local and oral AB.
• Rarely required removing the catheter.

Catheter Tunnel infection
Lok CE, Huber TS, Lee T, et al; KDOQI Vascular Access Guideline Work Group. KDOQI clinical practice guideline
for vascular access: 2019 update. Am J Kidney Dis. 2020;75(4)(suppl 2):S1-S164.

Clinical picture:
 Fever with chills.
 May be only during HD.
 patient with Central catheter.
 No other focus.
 Sepsis.
Dx: Blood Cx > 15CFU. From peripheral and catheter.
Treatment: AB for 2-3 wks with exchange of the catheter.
Catheter related Bacteremia

Definition of Central Venous Catheter Blood stream infection
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Lok CE, Huber TS, Lee T, et al; KDOQI Vascular Access Guideline Work Group. KDOQI clinical practice
guideline for vascular access: 2019 update. Am J Kidney Dis. 2020;75(4)(suppl 2):S1-S164.

 Clinical symptoms.
 Blood Cx. from Peripheral. Or dialysis circuit.
 Catheter (Hub or tip Cx.) >15 CFU/cath. seg. or > 100 /Cath semiquantitative
 Same organism from catheter and peripheral.
 No other apparent source.
 2 hours interval.
 Ratio > 3/1 Catheter / peripheral .
 Positive Blood Cx with no other possible source.
Definition of Central Venous Catheter Blood stream infection
CLINICAL + BLOOD (Peripheral / Catheter) + No other source

Investigations for catheter infection
 CBC.
 Blood Culture peripheral + from catheter.
 Catheter tip Cx. / Hub culture ??
 Exit site discharge.
 Others: Urine, Sputum, Drains..etc.
 Radiology: CXR, US, CT …etc.

Proposed protocol for catheter related for Central Venous catheter related infection
Lok CE, Huber TS, Lee T, et al; KDOQI Vascular Access Guideline Work Group. KDOQI clinical
practice guideline for vascular access: 2019 update. Am J Kidney Dis. 2020;75(4)(suppl 2):S1-

Strict Infection Control Protocol.
Can it work?

Nurses' catheter
care
Infection Control
Protocol
47

6%
56%
18%
20%
0% 20% 40% 60%
Vascath.
Cuffed
cath.
AVG
AVF
%
Access types:
BSH Hemodialysis population,
over 112 months. Jan. 2004 – May. 2013
N= 147 patients.
8741 HD
Jafar Alsaid. 2013. ASN poster
JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021
69

0
200
400
600
800
1000
1200
1400
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Access Type per dialysis over the years
AVF AVG VC PC
72

ASN Poster

HD related blood stream infection progress
International Our Unit
2011
Our Unit
2015
Our Unit
2017
Out Unit
2019
Hemodialysis Blood stream
infection rate /100 patient
month
0.75-4.4 0.019 0.007 0.004 0.003
Admission rate for HD
bacteremia/1000 patient year
108 0.79 0.68 0.73 0.4
Admission for vascular access
infection
110 0 0 0 0
76

0.02
0.007
0.004
0.003
0
0.005
0.01
0.015
0.02
0.025
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Hemodialysis Blood steam infection at BSH
Jan. 2004 - Sep. 2019
International data 0.75-4.4
/100
patient
month
77
Year

Admission for Hemodialysis related blood stream infection per 1000 patient-year
0.79
0.68
0.73
0.4
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
2011 2015 2017 2019
78
International rate 108
/
1000
patient
Year
Years

Hemodialysis catheter related infection.
Exit site or Blood stream infection
Design and sample size:
• Prospective, RCT.
• Open label.
• Alpha 0.05. Power 80%.
• Significant difference 15%
• Sample size 150.
• Duration: 1 year or fulfill
recruitment.
Sample:
• ESRD or AKI on HD with dialysis Catheters.
temporary or cuffed tunneled catheter.
• No previous exit site infection.
• No documented bacteremia or active
infection in other sites.
Primary outcome:
• Exit site infection.
• Catheter related blood stream
infection.
Secondary outcome:
• Catheter malfunction.
• Require catheter exchange < 7
days for temporary.
• Exchange of cuffed tunneled
catheter during admission.
• Use of Thrombolysis.
Intervention:
Catheter care protocol by trained and
educated staff. Certain protocol.
Controlled:
Regular followed practice.
At 7 days and during the whole admission
Jafar Alsaid, M.B. ChB. MD. FASN. FACP 79
Benefit: Improving quality of care for
dialysis patients. Better HD catheter care.

Catheter Salvage in poor access
30% AB treatment could clear infection.
80% AB with exchange over guide wire.
Tanriover B, Carlton D, Saddekni S, Hamrick K, Oser R, Westfall AO, Allon M: Bacteremia associated
with tunneled dialysis catheters: Comparison of two treatment strategies. Kidney Int 57: 2151–2155,
2000
Exchange:
 72 hours post AB.
 No need for negative blood Cx.
National Kidney Foundation: KDOQI clinical practice guidelines and clinical practice
recommendations for vascular access 2006. Am J Kidney Dis 48[Suppl 1]: S176–S322, 2006

Antibiotic Lock
 Is indicated in reinfection with same organism.
 In limited catheter sites.
 Catheter Salvage is acceptable.
Onder AM, Chandar J, Simon N, Diaz R, Nwobi O, Abitbol CL, Zilleruelo G: Comparison of tissue plasminogen activator–
antibiotic locks with heparin–antibiotic locks in children with catheter-related bacteraemia. Nephrol Dial Transplant 23:
2604–2610, 2008.
Rijnders BJ, Van Wijngaerden E, Vandecasteele SJ, Stas M, Peetermans WE: Treatment of long-term intravascular catheter-
related bacteremia with antibiotic lock: Randomized, placebo-controlled trial. J Antimicrob Chemother 55: 90–94, 2005

Antibiotic locking solutions

Types of Antibiotic Lock
 Cefazolin, Cephotaxim, Vancomycin, Tobramycin, Gentamyin.
Concentration: 5mg/ml.
mixed with Citrate, EDTA, Heparin, rtPA. .
Systemic AB with Antibiotic lock more effective for
 G. Neg.
 Less effective for Staph. Epidermidis.
 Worst for Staph aureus.
Maya ID, Carlton D, Estrada E, Allon M: Treatment of dialysis catheter-related Staphylococcus aureus bacteremia with antibiotic lock: A
quality improvement report. Am J Kidney Dis 50: 289–295,2007

Different AB surface coating catheters
Dwyer A: Surface-treated catheters: A review. Semin Dial 21: 542–546, 2008

RCT
 79 children.
 264 episodes of Catheter related bacteremia.
 Early or Late Antibiotic lock.
 All with systemic AB.
Results:
 Less likely to exchange with early AB lock.
 Infection recurrence within 45 days was similar.
 Infection free survival of catheter was longer for early
AB lock.
Antibiotic Lock
Onder AM, Chandar J, Billings AA, Simon N, Diaz R, Francoeur D, Abitbol C,
Zilleruelo G: Comparison of early versus late use of antibiotic locks in the treatment
of catheter-related bacteremia. Clin J Am Soc Nephrol 3: 1048–1056, 2008

RCT.
 18 children.
 24 episodes of Catheter related Bacteremia.
 Randomized to Heparin or rtPA AB lock.
 No significant difference in both.
Antibiotic Lock
Onder AM, Chandar J, Simon N, Diaz R, Nwobi O, Abitbol CL, Zilleruelo G:
Comparison of tissue plasminogen activator–antibiotic locks with heparin–
antibiotic locks in children with catheter-related bacteraemia. Nephrol Dial
Transplant 23: 2604–2610, 2008

Hemodialysis Catheter distant infection
 Osteomyelitis.
 Endocarditis.
 Septic arthritis.
 Spinal epidural abscess.

Historic Point
Belding Scribner MD.
1921-2003
University of Berkley 1941.
Stanford University Medical School 1945.
Minnesota University Masters 1951.
Washington University 1958-1982

Hemodialysis catheter related infection 5

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