Antibiotic-coated hemodialysis catheters for the prevention of vascular catheter-related infections: a prospective, randomized study

PURPOSE: To determine the efficacy of minocycline-rifampin-coated hemodialysis catheters in reducing catheter-related infections in patients requiring hemodialysis for acute renal failure. METHODS: Between May 2000 and March 2002, 66 patients were randomly assigned to receive a minocycline-rifampin-impregnated central venous catheter and 64 were randomly assigned to receive an unimpregnated catheter. Patients were followed prospectively until the catheter was removed. Catheter-related infection was determined through quantitative catheter cultures, quantitative blood cultures, or both. RESULTS: Both groups of patients were similar in age, sex, underlying disease, type of dialysis (continuous vs. intermittent), neutropenia during catheterization and its duration, catheter insertion difficulties, and administration of blood products or medication. The mean (+/- SD) catheter dwell time was the same in both groups (8 +/- 6 days, P = 0.7). There were seven catheter-related infections (11%), all associated with the use of unimpregnated catheters. Kaplan-Meier estimates for the risk of catheter-related infection showed that coated catheters were less likely to be associated with infection (P = 0.006). CONCLUSION: The use of polyurethane hemodialysis catheters impregnated with minocycline and rifampin decreases the risk of catheter-related infection in patients with acute renal failure.     

长期深静脉留置透析导管相关性真菌感染及其易感因素分析

目的探讨长期深静脉留置透析导管相关性感染真菌谱、治疗转归及其易感因素。方法选择2004年1月~2006年9月在我院行长期深静脉留置透析导管的患者24例次为观察对象,根据是否出现导管相关性真菌感染将24例次患者分为真菌感染组和非真菌感染组2组。观察并分析真菌感染发生率、临床表现、真菌培养、药物敏感试验、治疗转归及其相关易感因素。结果(1)本组资料中导管相关性真菌感染发生率为20.83%,氟康唑导管内应用联合氟康唑封管治疗有效率为60%;(2)本组资料中感染真菌均为假丝酵母菌,治疗前对氟康唑敏感性最高;(3)导管相关性真菌感染与近期抗生素的应用、导管置入时间小于1年有关。结论导管相关性真菌感染是影响导管寿命的重要并发症之一,与近期抗生素的应用、导管置入时间小于1年有关,氟康唑导管内治疗部分有效。     

Single-lumen subcutaneous ports inserted by interventional radiologists in patients undergoing chemotherapy: incidence of infection and outcome of attempted catheter salvage

BACKGROUND: Subcutaneous ports are commonly used for vascular access in patients with cancer undergoing chemotherapy. OBJECTIVES: To determine the incidence of catheter-related infection and to assess the efficacy of catheter salvage in subcutaneous ports. METHODS: We retrospectively reviewed 300 subcutaneous single-lumen chest ports inserted by interventional radiologists in 294 patients between December 1, 1995, and November 15, 1997, at the Cleveland Clinic Foundation, Cleveland, Ohio. The number of days that the catheter remained in situ, infection rate, treatment, and outcome of infection were determined. RESULTS: Two hundred ninety-four patients had a total of 79 748 catheter-days. Vascular access for chemotherapy was the indication for 95% of the subcutaneous ports placed. Seventeen catheters (5.7%) developed 20 episodes of noninfectious complications resulting in the removal of 6 ports. Seventeen patients (5.7%) developed catheter-related infections (2.1/10 000 catheter-days) including 10 episodes of catheter-related bacteremia (1.2/10 000 catheter-days). The most common organism isolated was Staphylococcus aureus. A total of 15 of the 17 infected catheters were removed. Salvage was attempted in 6 patients in whom 4 catheters were eventually removed due to recurrent bacteremia (2 patients) and persistent local infection (2 patients). One of the 10 patients with catheter-related bacteremia developed septic arthritis. There were no complications associated with attempted catheter salvage. CONCLUSIONS: Subcutaneous single-lumen ports inserted by interventional radiologists in patients undergoing chemotherapy have low complication rates but infections remain the leading cause of catheter loss. Antibiotic therapy without catheter removal is unlikely to eradicate catheter-related bacteremia.     

经皮颈内静脉长期导管在老年维持性血液透析患者中的临床应用

目的：探讨经皮颈内静脉长期导管在老年维持性血液透析患者中的应用及其常见并发症的防治。方法对2009年12月至2012年12月在中南大学湘雅医院行经皮颈内静脉长期置管的15例维持性血液透析老年患者的临床资料进行回顾性分析,观察置管术后情况、导管的使用情况、常见并发症的防治、透析充分性评价等。结果（1）实施颈内静脉长期置管18例次,其中3例为重新置管,置管成功率100%。（2）导管相关并发症：2例患者术后1周内出现置管处局部渗血;1例出现导管出口感染,2例发生导管相关性血流感染;3例患者出现导管血栓形成;2例诊断导管纤维鞘形成;1例因人为损坏出现导管破裂。经过相应处理后均使问题得到解决。（3）导管使用期限：本组患者长期导管使用时间为4～41个月,除1例死亡（原因为脑出血）,3例为重新置管,余患者仍继续使用。（4）透析充分性评价：15例患者平均尿素下降率为72%,平均尿素清除指数达1.54。结论对于血管条件差无法建立动静脉内瘘的老年血透患者,使用颈内静脉长期导管行血液透析可以达到充分透析;提高置管及导管护理技术、加强健康宣教,能延长导管使用年限,减少导管并发症。     

Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: a randomized controlled trial

OBJECTIVE: The aim of this study was to assess the efficacy of a disinfectable, needle-free connector in the prophylaxis of catheter-related bloodstream infection. METHODS: A randomized controlled trial was performed in a polyvalent intensive care unit. Patients who needed multilumen central venous catheters were randomly assigned to a study or a control group. All catheters were inserted and manipulated according to the Centers for Disease Control and Prevention (CDC) recommendations. Study group patients were equipped with catheters with disinfectable, needle-free connectors whereas control group patients were equipped with catheters with 3-way stopcocks. Two peripheral blood cultures and a semiquantitative culture of the catheter tip were performed on removal of the catheter. RESULTS: The study included 243 patients, with a total of 278 central venous catheters. The catheters' mean insertion duration was 9.9 days. Both groups were comparable regarding patient and catheter characteristics. Incidence rate of catheter-related bloodstream infection was 0.7 per 1000 days of catheter use in the study group, compared with 5.0 per 1000 days of catheter use in the control group (P=.03). CONCLUSIONS: To add a disinfectable, needle-free connector to the CDC recommendations reduces the incidence of catheter-related bloodstream infection in critically ill patients with central venous catheters.     

Prevention of intravascular catheter-related infections

PURPOSE: To review the literature on prevention of intravascular catheter-related infections. DATA SOURCES: The MEDLINE database, conference proceedings, and bibliographies of review articles and book chapters were searched for relevant articles. Primary authors were contacted directly if data were incomplete. STUDY SELECTION: Studies met the following criteria unless otherwise stated: Trials were prospective and randomized; catheters were inserted into new sites, not into old sites over guidewires; catheter cultures were done by using semi-quantitative or quantitative methods; and, for prospective studies, catheter-related bloodstream infection was confirmed by microbial growth from percutaneously drawn blood cultures that matched catheter cultures. DATA EXTRACTION: Data on population, methods, preventive strategy, and outcome (measured as catheter-related bloodstream infections) were gathered. The quality of the data was graded by using preestablished criteria. DATA SYNTHESIS: The recommended preventive strategies with the strongest supportive evidence are full barrier precautions during central venous catheter insertion; subcutaneous tunneling short-term catheters inserted in the internal jugular or femoral veins when catheters are not used for drawing blood; contamination shields for pulmonary artery catheters; povidone-iodine ointment applied to insertion sites of hemodialysis catheters; specialized nursing teams caring for patients with short-term peripheral venous catheters, especially at institutions with a high incidence of catheter-related infection; no routine replacement of central venous catheters; antiseptic chamberfilled hub or hub-protective antiseptic sponge for central venous catheters; and use of chlorhexidine-silver sulfadiazine-impregnated or minocycline-rifampin-impregnated short-term central venous catheters if the rate of infection is high despite adherence to other strategies that do not incorporate antimicrobial agents (for example, maximal barrier precautions). CONCLUSIONS: Simple interventions can reduce the risk for serious catheter-related infection. Adequately powered randomized trials are needed.     

Prevention of catheter-related infections using a closed hub system in patients with pulmonary arterial hypertension.

BACKGROUND: Most of the patients with pulmonary arterial hypertension (PAH) receiving intravenous epoprostenol have experienced catheter-related infections during long-term treatment. Catheter hub was reported to be the most important source of catheter-related infections. To prevent the catheter-related infections, we have introduced a closed hub system and compared the incidence of catheter-related infections with that in patients using a non-closed hub system. METHODS AND RESULTS: We evaluated the results obtained on 24 occasions in 20 patients with PAH between June 1999 and December 2005. On 11 occasions, a non-closed hub system was used and on 13 cases a closed hub system. We classified the catheter-related infection into a catheter-related bloodstream infection (CRBSI) group or a tunnel infection group based on the pathway of bacteria. The CRBSI rate was 0.89 per 1,000 catheter days in the non-closed hub system group vs 0.10 per 1,000 catheter days in the closed hub system group. Kaplan-Meier analysis showed that the risk of CRBSI significantly decreased in the closed hub system group. None of the patients died as a direct consequence of catheter-related infection during the study period. CONCLUSIONS: We successfully prevented CRBSI by using a closed hub system.     

Use of tunneled femoral catheters to prevent catheter-related infection. A randomized, controlled trial.

BACKGROUND: The risk for catheter-related infection seems higher with femoral catheters than with catheters inserted at other sites. OBJECTIVE: To evaluate the effect of catheter tunneling on femoral catheter-related infection in critically ill patients. DESIGN: Randomized, controlled trial. SETTING: Three intensive care units at academic hospitals in Paris, France. PATIENTS: 345 adult patients requiring a femoral venous catheter for more than 48 hours. INTERVENTION: Tunneled or nontunneled femoral catheters. MEASUREMENTS: Time to occurrence of systemic catheter-related sepsis, catheter-related bloodstream infection, and quantitative catheter tip culture with a cutoff of 10(3) colony-forming units/mL. RESULTS: Of 345 randomly assigned patients, 336 were evaluable. Probable systemic catheter-related sepsis occurred in 15 of 168 patients who received a nontunneled femoral catheter (controls) and in 5 of 168 patients who received a tunneled femoral catheter (estimated absolute risk reduction, 6% [95% CI, 0.9% to 11%]). Time to occurrence of catheter-related bloodstream infection was not significantly modified (relative risk, 0.28 [CI, 0.03 to 1.92]; P = 0.18); 3 events occurred in the control group and 1 event occurred in the tunneled-catheter group. After stratification by treatment center and adjustment for variables that were prognostic (use of broad-spectrum antimicrobial agents at catheter insertion) or imbalanced between both groups (mechanical ventilation at insertion), tunnelized catheterization reduced the proportion of patients who developed systemic catheter-related sepsis (relative risk, 0.25 [CI, 0.09 to 0.72]; P = 0.005) and positive quantitative culture of the catheter tip (relative risk, 0.48 [CI, 0.23 to 0.99]; P = 0.045). CONCLUSION: The incidence of femoral catheter-related infections in critically ill patients can be reduced by using subcutaneous tunneling.     

Triple- vs single-lumen central venous catheters. A prospective study in a critically ill population

To evaluate a new multilumen central venous catheter we prospectively compared the infection rates of 63 single-lumen and 157 triple-lumen catheters in 145 critically ill patients. Using acute physiology scores, severity of illness was shown to be similar in the two patient groups. There were no significant differences in the rate of catheter colonization or catheter-related sepsis comparing single-lumen with triple-lumen catheters. However, the use of total parenteral nutrition or insertion at the femoral vein site significantly increased the rate of colonization. The only factor that was clearly associated with catheter sepsis was the duration of catheterization. Catheter sepsis increased from 1.5% to 10% when the period of catheterization exceeded 6 days. We conclude that the use of triple- and single-lumen central venous catheters in critically ill patients entails similar risks of infection.     

Biofilms and catheter-associated urinary tract infections

Urinary catheter-related infections are commonly seen in several different patient populations and lead to substantial morbidity. The overall health care costs caused by these infections are sizable given how often urinary catheters are used in acute care settings, extended care facilities, and in persons with injured spinal cords. Recent attention has appropriately focused on biofilm development on the catheter surface because biofilm has important implications for the pathogenesis, treatment, and prevention of catheter-related infection. Because the most important risk factor for infection is duration of catheterization, indwelling urethral catheterization should be avoided or at least limited whenever possible. Additional methods to prevent this infection include aseptic insertion and maintenance use of a closed drainage system, anti-infective catheters in patients at high-risk for infection, and systemic antibiotics in select patients. Alternative urinary collection strategies may be appropriate in certain patient groups. Specifically, condom catheters should be considered in men likely to be adherent with this urinary collection method, suprapubic catheters should be considered in patients requiring long-term indwelling drainage, and intermittent catheterization seems appropriate in patients with injured spinal cords. Future research should focus on additional methods for preventing this common infection.     

Effects of a Quality Improvement Program to Reduce Central Venous Catheter-Related Infections in Hemodialysis Patients

BackgroundCentral catheter infections are of concern in patients on hemodialysis because of the high risk of catheter-related bloodstream infections, sepsis, and death. Adequate nursing is critical for the prevention of such infections. This study aimed to use the PDCA (plan-do-check-act) method to reduce the incidence of central venous catheter infection using management in the maintenance of central venous catheter in patients on hemodialysis, compared with routine care.MethodsThis pilot study recruited patients on hemodialysis via central venous catheterization at the Blood Purification Center of Ruijin Hospital between November 2017 and November 2018. The patients were randomized to the routine and PDCA groups. All participants received routine nursing. The PDCA group received central venous catheter management by PDCA. The incidence of central venous catheterization-related infections, nursing satisfaction, and quality of life were compared between the two groups.ResultsA total of 122 participants were enrolled in each group. The incidence of central catheter-related bloodstream infection, as the primary outcome, was 0.8 and 8.8 cases per 1000 catheter days in the PDCA and routine groups, respectively (P < 0.001). In addition, as the secondary outcomes, the scores of nursing satisfaction (health guidance, nursing technology, and therapeutic effects) score and quality of life (physiological, psychological, social, and environmental status) were better in the PDCA group than in the routine group (all P < 0.01).ConclusionsThis pilot study suggests that the PDCA cycle model can effectively reduce the incidence of central venous catheter-related infections and improve satisfaction and quality of life in patients on hemodialysis.     

Central venous catheter (CVC)-related infections in neutropenic patients--guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO)

Catheter-related infections cause considerable morbidity in hospitalised patients. The incidence does not seem to be higher in neutropenic patients than in non- neutropenic patients. Gram-positive bacteria (coagulase-negative staphylococci, Staphylococcus aureus) are the most frequently cultured pathogens, followed by Candida species. In contrast, Gram-negative bacteria play only a minor role in catheter-related infections. Positive blood cultures are the cornerstone in the diagnosis of catheter-related infections, while local signs of infection are only rarely present. However, a definite diagnosis generally requires the removal of the catheter and its microbiological examination. The role plate method with semiquantitative cultures (Maki) has been established as standard in most laboratories. Other standard procedures use quantitative techniques (Sherertz, Brun-Buisson) and are more sensitive. For therapy of catheter-related infections, antibiotics are administered according to the susceptibility of the cultured organism. Routine administration of gylcopepticed antibiotics is not indicated. Removal of the catheter has to be considered in any case of suspected catheter-related infection and is obligatory in Staphylococcus aureus and Candida infections. Tunnel or pocket infection of long-term catheters is always an indication for removal. In the future, the rate of catheter-related infections in neutropenic patients may be reduced by the use of catheters coated with antimicrobial agents.     

Temporary hemodialysis catheters as a long-term vascular access in chronic hemodialysis patients

The objective was to review our experience with temporary, precurved, jugular catheters used for long-term vascular access in chronic hemodialysis patients. Thirty chronic hemodialysis patients, 14 men and 16 women, with an average age of 65.3 +/- 13.5 years (30-90 years), treated by dialysis for 1 month to 30 years (average +/- SD, 6.3 +/- 8.1 years), had single lumen, 'temporary' precurved non-tunneled jugular catheters placed into the right jugular vein as permanent vascular access, with 4% trisodium citrate as a locking solution and mupirocin at the exit site. Hemodialysis catheters were used for vascular access on average for 9.1 +/- 6.5 months, (1-22.7 months), and for a total of 271.7 months (8151 days). Average catheter functioning time was 3.1 +/- 1.9 months (0.5-10 months). The total number of side-effects was 55 (6.7/1000 catheter days), including 26 cases of thrombosis (3.2/1000 catheter days), 9 ruptures of the catheter (1.1/1000 catheter days), 15 catheter malfunctions (1.8/1000 catheter days), 2 exit site infections (0.2/1000 catheter days), 2 bacteremias (0.2/1000 catheter days), 1 avulsion of the catheter (0.1/1000 catheter days), and 2 catheters were removed because an AV fistula was successfully used. In 21 patients single-needle hemodialysis was performed, mean blood flow 251 +/- 16 mL/min (250-300), mean Kt/V 0.96 +/- 0.16 (0.72-1.27) and in 9 patients double-needle hemodialysis was performed (catheter and peripheral vein) with mean blood flow 252 +/- 14 mL/min (200-300), mean Kt/V 1.63 +/- 0.25 (1.21-1.96). 'Temporary' jugular single lumen non-tunneled hemodialysis catheters, with 4% citrate as locking solution and mupirocin ointment at the exit site provided good long-term vascular access with acceptable functioning time and low infection rate. The main reasons for catheter exchange or removal were malfunction and mechanical damage of the catheter.     

Prospective study of infections in indwelling central venous catheters using quantitative blood cultures

PURPOSE: Surgically implanted central venous catheters are widely used in cancer patients in whom there is a need for prolonged venous access for chemotherapy, parenteral nutrition, antibiotics, and blood sampling. This study evaluated catheter infectious complications, including catheter-related sepsis, exit site infection, and tunnel infection. Specifically, an evaluation of the incidence, type, and response to treatment of indwelling catheter infections was performed, and conditions under which the catheter should be removed were delineated. PATIENTS AND METHODS: During the year of this study, 488 central venous catheters were implanted. Records were maintained on demographic variables, date of catheter implantation, surgeon, white blood cell count, absolute neutrophil count, and underlying diagnosis. Blood for both aerobic and anaerobic culture was collected from each patient. For patients in whom infection developed, clinical features, white blood cell count, absolute neutrophil count, and microbiologic data were noted, as were the clinical course and response to treatment. RESULTS: A total of 142 episodes of infectious complications were documented. There were 88 episodes of catheter-related sepsis, and 33 of 54 evaluable episodes (61 percent) were successfully treated with antibiotics. There were 34 episodes of exit site infection, and 20 of the 29 evaluable episodes (69 percent) were successfully treated with antibiotics and local care. Of the 20 tunnel infections, only five (25 percent) were successfully treated with antibiotics, and the other 15 required catheter removal for cure. Twelve of the 15 cases requiring catheter removal were caused by Pseudomonas species. CONCLUSION: On the basis of these results, compulsory removal of the catheter is not required in cases of catheter-related sepsis. Similarly, exit site infections can often be cured by means of antibiotics and local care. However, catheter removal is required to achieve cure in most tunnel infections, particularly if Pseudomonas species are cultured from the exit sites of patients with tunnel infection.     

A prospective study of the mechanisms of infection associated with hemodialysis catheters

Seventy-four subclavian hemodialysis catheters inserted into 53 patients were studied prospectively. Sixteen of 64 assessable catheterization periods were complicated by clinically documented catheter-related sepsis, and 13 had an associated bacteremia. One patient died from catheter-related sepsis, and in two others, sepsis contributed to death. Staphylococci accounted for 11 bacteremias. Semiquantitative culture of the catheters indicated that 28 were significantly colonized. Comparison of these isolates with skin cultures from the insertion site suggested that the origin of the colonizing organisms was the skin (10 cases), intralumenal contamination (16 cases), or both routes (2 cases). Comparison of cultures taken during catheter insertion with those at removal rarely suggested that organisms introduced at insertion caused subsequent colonization. This study has demonstrated that infectious complications from using subclavian hemodialysis catheters exceed reported rates for all other modes of vascular access used for hemodialysis, as well as other indications for central venous catheterization.     

Microbiology difference between colonized catheters and catheter-related bloodstream infections

BACKGROUND/AIMS: Central vein catheters for patients receiving total parenteral nutrition have a high incidence of colonized catheters and catheter-related bloodstream infections. However, the actual incidence and bacterial pattern have not been well studied. This study was undertaken to investigate the difference in bacteriology between colonized catheters and catheter-related bloodstream infections. METHODOLOGY: From January 1997 to March 1998, 354 patients receiving total parenteral nutrition were included in this study. The patients ranged in age from 49 to 80 years, 151 women and 203 men. Colonized catheters and catheter-related bloodstream infections were defined. RESULTS: The culture was performed in 249 catheter tips (249 of 614, 40.6%). Sixty tips were found to have organisms. The organisms cultured from colonized catheters were Gram(+) aerobic bacteria (34, 56.7%), fungi (14, 23.3%), and Gram(-) aerobic bacteria (12, 20%). The organisms cultured from catheter-related bloodstream infections were fungi (16, 64%), Gram(-) aerobic bacteria (5, 20%), and Gram(+) aerobic bacteria (4, 16%). Dermatogenic infection in colonized catheters should be stressed, but systemic fungal infection in catheter-related bloodstream infections should be emphasized. CONCLUSIONS: A striking difference exists in bacterial species between colonized catheters and catheter-related bloodstream infections. Further studies on different treatment strategy for colonized catheters and catheter-related bloodstream infections should be undertaken. The combined approach of a total parenteral nutrition team, sterile protocols, and early diagnosis of fungemia should be advocated for the total parenteral nutrition patients.     

Comparison of Early versus Late Use of Antibiotic Locks in the Treatment of Catheter-Related Bacteremia

Background and objectives: This retrospective study compared the effectiveness of the timing of the antibiotic locks to clear catheter-related bacteremia in children on chronic hemodialysis.Design, setting, participants, & measurements: The early antibiotic lock group received antibiotic locks along with systemic antibiotics from the very beginning of catheter-related bacteremia. The late antibiotic lock group was given only systemic antibiotics initially, and antibiotic locks were used late in the infection if the catheter-related bacteremia could not be cleared after resolution of symptoms.Results: There were 264 catheter-related bacteremias in 79 children during 6 yr of observation. Early antibiotic locks were able to clear catheter-related bacteremia and resolve the symptoms more effectively without the need for catheter exchange when compared with late antibiotic locks. A total of 84 catheter-related bacteremias required wire-guided exchange of the catheters. Late antibiotic locks required wire-guided catheter exchange more frequently than the early antibiotic locks. The post–catheter-related bacteremia infection–free survival of the catheters after wire-guided exchange were significantly longer than those of both antibiotic lock groups. Recurrence of catheter-related bacteremia within 45 d after wire-guided exchange occurred at similar rates compared with the antibiotic lock groups.Conclusion: Antibiotic locks are significantly more effective in clearing catheter-related bacteremia when used early in infection, diminishing the need for catheter exchange. Wire-guided exchange has a late-onset advantage for infection-free survival compared with catheter in situ treatment. The recurrence rates in the first 45 d after catheter-related bacteremia are similar regardless of the treatment strategy.Antibiotic lock solutions (ABL) are high concentration of antibiotic with or without anticoagulant agent that is dwelled (locked) in the catheter lumen, exposing the internal lumen of the catheter to persistent antibacterial action. Biofilms that harbor microorganisms are demonstrated on external and internal surfaces of the indwelling catheters within as early as 24 h after their placement (1,2). The fibrinous-proteinous ultrastructure of the biofilm gives both protection and antimicrobial resistance to the microorganisms. Because the intraluminal concentrations of the systemic antibiotics never reach high enough concentrations above the minimal inhibitory concentration, treatment failure as well as the loss of the catheter becomes inevitable during treatment of catheter-related bacteremias (CRB). Clinical series involving tunneled-cuffed catheters used for hemodialysis or nutrition reported 44 to 100% success rates for clearing CRB with ABL along with systemic antibiotics (3–9). The success of these studies has led to the recommendation of the use of ABL for the management of uncomplicated catheter-related bacteremias from a consensus panel (10).Despite the current recommendations for long-term vascular access in hemodialysis patients being arteriovenous (AV) fistula or AV graft, still in 60% of the newly diagnosed and 30% of the prevalent hemodialysis patients, tunneled cuffed long-term central venous catheters are used as vascular access because of the difficulties in creating and maintaining AV fistulas and grafts (11–17). This is even more prominent for the pediatric ESRD population (18–20). CRB that lead to septic shock and metastatic infections are the most feared complications of long-term catheter use, and systemic antibiotics cannot satisfactorily clear the infected catheters, requiring early catheter exchange, as recommended in the Kidney Disease Outcomes Quality Initiative (K/DOQI) guidelines (11).The aim of this study was to investigate the effect of timing of the use of ABL along with systemic antibiotics for CRB treatment on children who were receiving long-term hemodialysis. The tested hypothesis was that ABL would act synergistically with the systemic antibiotics in eradicating the CRB when used early in the course of CRB rather than when systemic antibiotics fail to control CRB initially. The infection-free outcomes of the two ABL groups were compared with the outcomes of the catheters that were submitted to wire-guided exchange (WGE) as a result of CRB. The WGE catheters did not receive any ABL but only systemic antibiotics. These new catheters had no reason to have intraluminal biofilm formation. The second tested hypothesis was that ABL can successfully clear the intraluminal space of an infected catheter. If so, then post-CRB infection–free survival of the catheters treated in situ should be similar to WGE catheters as a result of CRB. The study was designed as a retrospective chart review protocol.     

Short-term central venous catheter complications in patients with sickle cell disease who undergo apheresis

Patients with sickle cell disease (SCD) are prone to develop thrombosis and infection due to their inflammatory and immune deficiency state. These patients require red cell exchange therapy for treatment or prevention of hemoglobin S associated complications. Owing to vascular access problems, adult patients need central venous catheterization (CVC) for exchange procedures. Procedure related complications have been reported for long-term CVCs in pediatric patients. However, short-term CVC complications in adult patients are not clear. This report represents the results of documented complications of short-term CVCs in patients with SCD who undergo apheresis. A total of 142 non-tunneled catheters with average median diameter of 9 F (range 8–16 F) were implanted for apheresis. The catheters were mainly inserted through the right internal jugular vein (66.2 %). Total days of catheter were 412. Results were reported as a complication rate and event according to 1,000 catheter days and compared to a control group including 37 healthy stem cell donors. In the patient group, 1 (1 %) hematoma and 1 (1 %) infection were observed for internal jugular vein catheterization (3.7 hemorrhages and 3.7 infections according to 1,000 catheter days), whereas four (8.9 %) cases of thrombosis and 1 (2.2 %) infection (27 and 6.9 according to 1,000 catheter days) developed in femoral vein. There was a significant difference in terms of thrombosis (P = 0.009). In the control group, only individual developed thrombosis in internal jugular vein. Short-term CVC inserted through to the internal jugular vein seems to be safer than femoral vein in patients with SCD.     

Risk of infection associated with the use of Broviac and Hickman catheters

A 4-month prospective medical records review was done to investigate the occurrence of central venous catheter-related infections. Nineteen percent of the patients developed a catheter-related infection, either local infection at the insertion site (8.9%) or septicemia (10.0%). There were 7.5 catheter-related infections per 1000 catheter-use days. The infection rate was five times greater in patients with Hickman catheters than in those with Broviac catheters (p = 0.01). Analysis by the life table approach produced a linear curve of catheter-related infection over time, suggesting a constant daily risk of catheter-related infection.     

Percutaneous subclavian vein catheterization for hemodialysis: a report of 57 insertions

The authors report an analysis of 57 subclavian vein catheterizations for hemodialysis. A total of 51 patients (34 men, 17 women) kept the Cobe single- and double-lumen catheters for 1,726 days. The youngest patient was eighteen and the oldest seventy-two years of age. There were no catheter-related deaths. Complications were encountered in 9 patients. The only life-threatening complication was cardiac arrest, which occurred during flushing of the catheter. The patient was successfully revived. The other complications were pneumothorax and hydrothorax in 1 patient, catheter site infection in 5 patients, and arrhythmias in 2 patients, which stopped after readjustment of the catheter tips. Their experience indicates that percutaneous subclavian vein catheterization is safe and provides quick access for hemodialysis with no morbidity and mortality if done correctly, patiently, and meticulously. The authors believe that this should be the first choice in patients with reversible renal failure and in patients with chronic renal failure, who are usually elderly and medically compromised, till a permanent vascular access is ready for use.