Treatment of dialysis catheter infections in 2004

Hemodialysis catheter associated infections are a major source of morbidity and mortality in end stage renal disease patients. There is disagreement about the management of catheter infections, particularly concerning the removal of potentially infected tunneled dialysis catheters. A dialysis catheter should generally be removed when an infection involves a temporary hemodialysis catheter, a septic patient, a patient with a tunnel tract infection, or a patient with evidence of a metastatic infectious complication. In treating stable patients with clinically mild catheter associated bacteremia, parenteral antibiotics alone have a low success rate in eliminating the infection. Antibiotic locks are an emerging strategy for treating these patients, but at present higher rates of success and lower costs are achieved by exchanging the catheter over a guidewire. Antibiotic lock solutions, antibiotic coated catheters, and totally implantable dialysis access systems may play a large role in prevention of catheter associated infections in the future; however, further randomized controlled trials of these strategies are needed. Future efforts should concentrate on limiting the use of traditional tunneled cuffed hemodialysis catheters by early referral to vascular surgery for the creation of an arterio-venous fistula.     

A modified supraclavicular approach for central venous catheterization by manipulation of ventilation in ventilated patients

Background: Because of overuse and multiple implantations of hemodialysis catheters through internal jugular or subclavian vein (SCV) in patients with chronic hemodialysis, these veins often become stenotic or occlude, therefore necessitating alternative access. We introduce a new technique in ventilated patients for placement of tunneled cuffed chronic hemodialysis catheter: modified supraclavicular approach by cease of ventilation. Methods: Patients who received implantation of the tunneled cuffed chronic hemodialysis catheters by supraclavicular approach were collected from February 2003 to July 2005. Right subclavian, right innominate or left SCVs were accessed through the supraclavicular approach for catheter insertion. The procedures were performed by certificated anesthesiologists. The following parameters were recorded: co‐morbidities, laboratory examinations before the procedure, method for catheterization, duration of procedure, complications related to catheterization and long‐term outcome of hemodialysis catheters. Results: Eleven catheters were inserted in nine patients (two patients received twice) by supraclavicular approach during this period. All patients were mechanically ventilated and these catheters (seven at right and four at left) were implanted using the modified supraclavicular approach with lung deflation during venipuncture, advance of guidewire, and insertion of catheter. There were no procedural complications. The average duration of whole procedure was 36.6 minutes (30–45 minutes) and the mean catheter survival days were 62.1 days (13–152 days). The estimated duration was <1 minute of each period of lung deflation. There were no desaturation or pneumothorax during the whole procedure. Conclusion: The modified supraclavicular approach with lung deflation for tunneled cuffed chronic hemodialysis catheter in ventilated patients is at least as effective as traditional approach and can be easily performed by surgeons as well as experienced physicians. Based on the results, this simplified technique using lung deflation may be particularly useful to decrease procedural complications.     

Implantable venous access device

Procedures for long-term angio access have for many years made up a major component of vascular surgical practice. A totally implantable vascular device for chronic venous access developed in the early '80s compares favorably with other methods of angio access. We implanted 76 of these devices in 73 patients on the oncology service of Fairview General Hospital between May 1984 and May 1986. The infusion ports were in place for a total of 14,509 patient days with a 3.9% rate of catheter related sepsis and 6.5% rate of catheter occlusion. Three occlusions resolved with streptokinase. Pocket infection occurred as a late complication in 3 patients. Emphasis is placed on a modified technique for device implantation. Strict adherence to a simplified percutaneous technique for the silastic catheter placement via the subclavian vein, with creation of the reservoir pocket after adequate vascular access is secure, has led to no serious complications during placement. Routine use of fluoroscopy during this procedure helped avoid potential technical complications. The advantages and disadvantages of the implantable systems compared to the dacron cuffed silastic catheters are discussed. Patient acceptance is excellent and improved cost/benefit ratio has been observed when compared to other forms of chronic venous access. Implantable vascular devices can be safely inserted with little morbidity or risk to the patient. They provide a convenient route for drawing blood, administering chemotherapy, hyperalimentation, and intravenous therapy in oncology patients and may represent an advantage over Hickman-Broviac catheters and the attendant catheter related sepsis associated with their use.     

Antibiotic lock technique reduces the incidence of temporary catheter-related infections

BACKGROUND: In the hemodialytic population, infections are the second leading cause of death; access infections account for a large proportion of this mortality. The antibiotic lock technique has been applied to infected tunneled catheters as rescue or prophylaxis medication to reduce infection rates. In addition, application of topical antibiotic ointments to tunneled and non-tunneled catheters also prevents exit site infections. METHODS: 17 patients with 25 catheters participated in our study from March 2004 - February 2005. The catheter lock comprised of mixed cefazolin (5 mg/dl) with heparin (2,500 IU/ml) and mupirocin was topically applied to the area (2 x 2 cm) surrounding the catheter exit site. RESULTS: The catheter infection rate was reduced from 12.7 times/1,000 catheter days to 5.02 times/1,000 catheter days in patients with jugular vein catheters. The total catheter-related infection rate was 14.9 times/1,000 catheter days in the control group and 4.1 times/1,000 catheter days in the study group. The reduction in catheter infections was more evident in a subgroup of non-diabetic patients, and in those with femoral catheters. CONCLUSION: The use of antibiotic lock and topical antibiotics significantly reduces the incidence of temporary catheter-related infections, especially in non-diabetic patients and in those with femoral catheters.     

New tunneled haemodialysis catheter placement preserving the vasculature

Frequent dialysis line insertion can result in central venous occlusions rendering such access of difficult catheterization. New strategies to overcome this difficulty have been reported. This problem also occurs together with accidental loss of tunneled dialysis catheters, periodically observed in chronic hemodialysis patients. We developed a new technique to apply in these situations using the old tunnel. It is exposed close to the vein puncture site and opened to insert the guidewire, advancing the new catheter along it. A new subcutaneous tunnel is performed. We report three cases with successful catheter placement using this technique. Catheters functioned appropriately and no complications were recorded. We conclude that this maneuver can be used to resolve an extruded tunneled hemodialysis catheter while at the same time preserving other vascular access routes.     

Comparison of antimicrobial impregnation with tunneling of long-term central venous catheters: a randomized controlled trial

OBJECTIVE: We sought to compare the impact of antimicrobial impregnation to that of tunneling of long-term central venous catheters on the rates of catheter colonization and catheter-related bloodstream infection. SUMMARY BACKGROUND DATA: Tunneling of catheters constitutes a standard of care for preventing infections associated with long-term vascular access. Although antimicrobial coating of short-term central venous catheters has been demonstrated to protect against catheter-related bloodstream infection, the applicability of this preventive approach to long-term vascular access has not been established. METHODS: A prospective, randomized clinical trial in 7 university-affiliated hospitals of adult patients who required a vascular access for > or = 2 weeks. Patients were randomized to receive a silicone central venous catheter that was either impregnated with minocycline and rifampin or tunneled. The occurrence of catheter colonization and catheter-related bloodstream infection was determined. RESULTS: Of a total of 351 inserted catheters, 346 (186 antimicrobial-impregnated and 160 tunneled) were analyzed for catheter-related bloodstream infection. Clinical characteristics were comparable in the 2 study groups, but the antimicrobial-impregnated catheters remained in place for a shorter period of time (mean, 30.2 versus 43.8 days). Antimicrobial-impregnated catheters were as likely to be colonized as tunneled catheters (7.9 versus 6.3 per 1000 catheter-days). Bloodstream infection was 4 times less likely to originate from antimicrobial-impregnated than from tunneled catheters (0.36 versus 1.43 per 1000 catheter-days). CONCLUSIONS: Antimicrobial impregnation of long-term central venous catheters may help obviate the need for tunneling of catheters.     

Central venous catheters as a vascular access modality for pediatric hemodialysis

Background The use of hemodialysis catheters is an essential component of dialysis practice. Children are particularly likely to require multiple courses of dialysis over their lifetime, hence the repeated need for vascular access. These catheters remain a significant source of morbidity and mortality. Methods All catheters inserted for hemodialysis at the Center of Pediatric Nephrology and Transplantation, Cairo University over a period of 40 months were studied. Patient data as well as data of catheter insertion, dwell, cause of removal and complications were reported. Results A total of 195 uncuffed central venous catheters were used for temporary access in 131 patients for a mean duration of 35.7 days. Of attempted insertions, 87.4% achieved successful access, of which 56% remained for the required period, 8.9% were accidentally dislodged, and 35.1% were removed due to complications—mostly infection. The overall rate of possible catheter-related bacteremia was 9.6 episodes/ 1,000 catheter days. Infection increased with longer catheter dwell. Nineteen cuffed tunneled catheters were surgically inserted and used for up to 11 months (mean 117 days). Loss of these catheters was attributed mainly to infection (ten episodes) and catheter thrombosis (six episodes). During the study, 317 femoral catheters were inserted. Conclusion Uncuffed central venous catheters are both needed and useful for short-term hemodialysis. Vascular access for extended durations may be provided by cuffed tunneled catheters. Infection is the major serious concern with both uncuffed and cuffed catheters.     

Avoiding a cutdown--use of the transcatheter extractor in removal of tunneled dialysis catheters

The purpose of our study was to evaluate the use of a transcatheter extractor (TCE) device in removing cuffed tunneled dialysis catheters without a surgical cutdown. We report eight cases where a TCE was used to successfully remove cuffed tunneled dialysis catheters through the exit site that would have otherwise required a second incision. The cuff was above the clavicle in all cases and varied 3-5 cm from the exit site. The method included inserting the device over the catheter through the exit site and engaging it over the cuff. A to-and-fro motion was then used in the same plane as the catheter to dissect the cuff from the surrounding tissue. Once the cuff was freed, the catheter was removed easily without resistance. The fibrous cuff was removed intact in all cases. We conclude that the use of this device may help avoid a cutdown and minimize trauma to the patient. It is an effective technique to remove tunneled dialysis catheters and is particularly useful in catheters with ingrown cuffs further from the exit site.     

Implantation of permanent jugular catheters in patients on regular dialysis treatment: ten years' experience

Dual-lumen cuffed central venous catheter proved an important alternative vascular access compared to conventional arteriovenous (Cimino-Brescia) shunt in a selected group of patients on regular dialysis treatment. Typically, these catheters are used as bridging access, until fistula or graft is ready for use, or as permanent access when an arteriovenous fistula or graft is not planned (NKF-DOQI). We conducted a prospective study on IJV permanent catheter insertion and its related earlier and long-term complications. From February 1991 to February 2001 we inserted in 124 patients in end stage renal disease 135 cuffed catheters (130 in the right IJV and 5 in the left IJV), 92 of which were Permcath, 27 Vascath, and 16 Ash-Split. We performed the insertion of catheters by puncturing the IJV under ultrasonographic guid-ance in the lower side of the Sedillot triangle and checking the accurate position of the tip by endocavitary electrocardiography (EC-ECG). The duration of catheter use was from 60 to 1460 days, mean 345 days. The actuarial survival rate at 1 year was 82%, at 2 years 56%, at 3 years 42% and at 4 years 20%. The exit site infection and septicemia rates were 5.2 and 2.86 per 1000 catheter days respectively. Catheter sepsis was implicated in the death of three patients, all of whom had multiple medical problems. Several episodes of thrombosis (6% of dialyses) occurred which required urokinase treatment, and catheter replacement in 12 patients (9.6%). In 3 cases the catheters were displaced and correct repositioning was performed. Two catheters (Ash-Split) were replaced due to accidental damage of the external portion of catheters (alcoholic disinfectant). Catheter tip embolism occurred on one occasion during elective catheter exchange over guide-wire. One of the common problems encountered with cuffed tunneled catheters is poor blood flow, most often secondary to the formation of a fibrin sheath around the lumen. Even if we conducted a non-randomized study, in our experience, the higher rate of malfunctioning catheters was in the group with no anticoagulation therapy. Therefore, we suggest anticoagulation treatment in all patients wearing central vascular catheters with no contraindication. Just one year ago, we followed NKF-DOQI clinical practice guidelines for vascular access that indicated that for patients who have a primary AV fistula maturing, but need im-mediate hemodialysis, tunneled cuffed catheters are the access of choice and the preferred insertion site is the right IJV. Considering recent reports of permanent central venous stenosis or occlusion after IJV can-nulation, currently, our first choice is femoral vein cannulation with smooth silicone rubber catheters, tunneled if long-term utilization is needed (more the 3-4 weeks). In our opinion, the right IJV puncture is to be avoided as much as the venipuncture of arm veins suitable for vascular access placement, particularly the cephalic vein of the non-dominant arm. Our data confirm that permanent venous catheters might rep-resent an effective long-term vascular access for chronic hemodialysis, particularly for older patients with cardiovascular disease and for cancer patients.     

Vascular screening prior to placement of tunnelled and cuffed hemodialysis catheters

Purpose: To demonstrate the importance of venous vascular screening before the placement of tunneled and cuffed hemodialysis catheters in patients requiring hemodialysis prior to placement and/or maturation of an arteriovenous fistula (AVF) or graft (AVG). Methods: Between October 1998 and March 2000, all patients requiring hemodialysis access placement were prospectively evaluated with duplex ultrasound for status of upper extremity vessels and central veins prior to selection of a permanent access site. When interim tunneled and cuffed hemodialysis catheters were required, they were placed on the side contralateral to proposed AVF/AVG placement. No catheters were placed without initial vascular screening. The study group was compared to historical controls during a similar period (April 1997 through September 1998) when no vascular screening was performed. Results: During the study period, 234 screening duplex ultrasound examinations were performed in 244 patients. Ten patients required no screening prior to access site placement. Overall, 353 catheters were placed, 243 (69%) on the right side and 110 (31%) on the left side. During the control period, 394 catheters were placed in 255 patients, 306 (78%) right-sided and 88 (22%) left-sided. The increase in left-sided catheters with ultrasound screening and careful planning for future access sites was significant (p<0.01). Conclusion: Vascular-screening-directed catheter placement significantly alters the side of catheter placement when compared to a management protocol without prior screening. Such screening helps identify the side of permanent access placement, while directing interim catheters to the contralateral side such that central veins may be preserved for permanent access.     

Hemodialysis catheters and ports

Percutaneous placement of cuffed tunneled catheters for hemodialysis access has become a firmly established method of providing vascular access to patients with end-stage renal disease. Considerable evidence supports the right internal jugular vein as the preferred site for catheter insertion. The use of real-time imaging using both ultrasound and fluoroscopy permits simple, safe, and effective placement of the catheter for hemodialysis. The use of these imaging techniques has significantly reduced the number of and severity of complications associated with catheter placement. A specific method of placement is described including variations for specific catheter types. The new subcutaneous port as an alternative to the cuffed tunneled catheter appears to provide another option for vascular access; preliminary data suggests higher flow rates and lower infection rates compared with externalized cuffed tunneled catheters. Finally, the criteria for obtaining training and proficiency in placement of cuffed tunneled catheters are outlined.     

X线透视下留置双腔Cuff导管建立血透通路的初步探讨

目的探讨X线透视下留置双腔Cuff导管建立血透通路方法的可行性及优势。方法回顾性分析21例经颈内静脉留置双腔Cuff导管患者的临床资料。结果本组21例均透视下成功留置双腔Cuff导管,成功率100％。置管后隧道出血2例,经压迫均止血;隧道口感染2例,局部加强换药,并口服抗生素治愈。无一例发生气胸、血胸、空气栓塞、静脉撕裂等严重并发症。随访19例,导管使用时间为2—25个月。结论X线透视下操作结合术前彩超评估血管情况及体表定位,可使留置双腔Cuff导管更安全。     

Conversion of temporary hemodialysis catheters to tunneled hemodialysis catheters

PURPOSE: To determine the feasibility and clinical outcomes of conversion of temporary to tunneled hemodialysis catheters using the same venous insertion site. METHODS: Data from 42 patients with existing temporary hemodialysis catheters referred for placement of tunneled hemodialysis catheters were retrospectively reviewed. In these patients, the temporary catheter was exchanged for a peel-away sheath, and a tunneled catheter was inserted using the existing venous access site. Technical success, procedural complications, and clinical outcomes were evaluated. Hemodialysis records were reviewed to assess catheter patency during a 30-day follow-up period. RESULTS: The study group consisted of 20 males and 22 females (mean age: 58 years). All 42 temporary catheters were successfully converted to tunneled hemodialysis catheters without immediate procedure-related complications. Follow-up data were available for 32 patients (total: 3038; median 71 catheter days). Nine catheters were removed for infection, yielding a catheter infection rate of 0.30/100 catheter days; three catheters were removed for blood flow <200 ml/min. 13 patients had catheters removed when catheters were no longer needed. Three patients died with working catheters. The patency rate was 72% at 30 days, with four catheters functioning at the end of the study period. CONCLUSION: Conversion of a temporary hemodialysis catheter to a tunneled hemodialysis catheter using the same venous insertion site is a safe procedure that avoids complications associated with venotomy and allows conservation of other central venous access sites. Patency and infection rates in these catheters are comparable to several studies of catheter exchange and de novo placement of tunneled hemodialysis catheters.     

Conversion of temporary hemodialysis catheters to permanent hemodialysis catheters: a retrospective study of catheter exchange versus classic de novo placement

Many clinicians believe that de novo access is required when converting temporary hemodialysis (HD) catheters to long-term or permanent catheters. However, since vascular access sites are at a premium in the dialysis patient, it is important to preserve existing central venous catheters and conserve future access sites. In this retrospective study, data from 94 patients referred to interventional radiology for placement of long-term, tunneled HD catheters between July 2001 and September 2002 were reviewed. The study group consisted of 42 patients in whom the temporary catheter was exchanged for a peel-away sheath and a tunneled catheter inserted using the existing venous access site. The control group included 52 patients who received traditional de novo placement of permanent catheters. Based on available follow-up data, we report a 100% technical success rate, with 72% patency at 30 days in the study group (n = 32; mean age 58 years). By comparison, de novo catheter placement (n = 35; mean age 59 years) yielded a 100% technical success rate, with 83% patency at 30 days. The overall infection rate was 0.30 per 100 catheter-days (total 3036 catheter-days) and 0.36 per 100 catheter-days (total 3295 catheter-days), respectively (chi2 = 0.64, p > or = 0.05). There was no incidence of exit site infection, tunnel infection, or florid sepsis in either group. Likewise, no stenosis or bleeding complication was noted. Thus conversion of a temporary HD catheter to a tunneled catheter using the same venous insertion site is safe, does not increase the risk of infection, and allows conservation of other central venous access sites.     

Bacterial meningitis--complication from a dialysis catheter

Various infective complications associated with dialysis catheter infection have been reported in the literature previously. We report a case of a hemodialysis patient presented with confusion and dysarthria secondary to Staphylococcus aureus septicemia and meningitis originating from a tunneled catheter used for providing dialysis. Blood cultures from the periphery, central venous catheter and culture of the line tip grew methicillin-sensitive Staphylococcus aureus. Lumbar puncture after CT brain confirmed Staphylococcus aureus. He was treated with high dose of an appropriate parenteral antibiotic and also removal of the infected line. In spite of optimal treatment, he died 15 days following his admission. The ideal option will be to use a definitive access like a fistula or AV graft, but in practice a significant proportion of hemodialysis patients is dialyzed with temporary or tunneled catheters all over the world, and infection poses a serious threat to dialysis patients resulting in significant mortality and morbidity. In patients with dialysis catheter-related sepsis, removal of the infected catheters and appropriate antibiotic treatment will prevent serious metastatic complications. Planning definitive access well ahead in chronic kidney disease patients and minimizing the use of temporary access is the only way forward.     

Vascular access and increased risk of death among hemodialysis patients

BACKGROUND: Hemodialysis with a venous catheter increases the risk of infection. The extent to which venous catheters are associated with an increased risk of death among hemodialysis patients has not been extensively studied. METHODS: We conducted a retrospective cohort study of 7497 prevalent hemodialysis patients to assess the association between dialysis with a venous catheter and risk of death due to all causes and to infection. RESULTS: A tunneled cuffed catheter was used for access in 12% of the patients and non-cuffed, not tunneled catheter in 2%. Younger age (P = 0.0005), black race (P = 0.0022), female gender (P = 0.0004), short duration since starting dialysis (P = 0.0003) and impaired functional status (P = 0.0001) were independently associated with increased use of catheter access. The proportion of patients who died was higher among those who were dialyzed with a non-cuffed (16.8%) or cuffed (15.2%) catheter compared to those dialyzed with either a graft (9.1%) or a fistula (7.3%; P < 0.001). The proportion of deaths due to infection was higher among patients dialyzed with a catheter (3.4%) compared to those dialyzed with either a graft (1.2%) or a fistula (0.8%; P < 0.001). The adjusted odds ratio (95% CI) for all-cause and infection-related death among patients dialyzed with a catheter was 1.4 (1.1, 1.9) and 3.0 (1.4, 6.6), respectively, compared to those with an arteriovenous (AV) fistula. CONCLUSION: Venous catheters are associated with an increased risk of all-cause and infection-related mortality among hemodialysis patients.     

带涤纶套隧道血液透析导管相关感染临床分析

目的回顾性分析带涤纶套隧道血液透析导管相关感染资料,探讨感染发生时间及细菌种类,导管感染发生率,抗生素治疗效果等,为有效防治导管相关感染提供理论依据。方法选择符合导管相关感染诊断标准的患者74例（85例次）,进行抗生素肝素盐水封管及静脉滴注抗生素,有出口感染及隧道感染的还进行局部换药。结果颈内静脉导管相关感染83例次,其中81例次为导管相关血流感染,2例次为皮肤出口及隧道感染;股静脉导管相关感染2例,均为导管相关血流感染。总的导管相关感染发生天数的中位数为368导管日,四分位间距为975导管日。金黄色葡萄球菌占检出细菌总数的32.94%。导管相关感染发生率在1年内为6.5例次/1000导管日,总的导管相关感染发生率为1.29例次/1000导管日。2例患者因基础疾病死亡,其余均临床治愈。结论带涤纶套隧道血液透析导管相关感染的患者,可使用敏感抗生素导管封管及静脉滴注抗生素治疗2-3周,无效者可拔管。检出细菌种类以金黄色葡萄球菌最常见。铜绿假单胞菌较其他菌种抗生素使用时间较长,导管相关感染发生率在1年内最高,带涤纶套隧道血液透析导管相关感染重在预防。     

Outpatient percutaneous central venous access in cancer patients

A 1-year experience of percutaneous subclavian catheterization in outpatients with cancer was reviewed to document reliability, safety, and cost. There were 763 catheter insertions attempted with prospective documentation of complications in 664 consecutive patients. Catheter insertion was successful in 722 attempts (95%). There were only 13 pneumothoraces (2%). Thirty catheters required repositioning (4%). The average catheter duration was 191 days (range: 0 to 892 days). Fifty-six catheters (8%) were removed because of suspected infection. Documented catheter sepsis occurred in 21 patients (3%); catheter site infection occurred in 8 patients (1%). Thus, only 0.22 infections per catheter year occurred during this 382 catheter-year experience. The estimated cost of catheter insertion was $562, which is one-third the estimated cost for tunneled catheters ($1,403) and for reservoir devices ($1,738). In our experience, percutaneous subclavian catheterization is a reliable, cost-effective method compared with tunneled or reservoir devices, with an equivalent incidence of catheter-related infections. The cornerstone of our success with this program is a staff dedicated to catheter care and intensive patient education. In centers where a large number of patients require central venous access, percutaneous catheterization should be the technique of choice.     

Routine replacement of tunneled,cuffed, hemodialysis catheters eliminates paraspinal/vertebral infections in patients with catheter-associated bacteremia

BACKGROUND: Management of tunneled, cuffed, central venous catheters in hemodialysis (HD) patients with bacteremia remains a challenge. Attempts to salvage the catheter with systemic antibiotics alone have been associated with increased risk of metastatic infectious complications. METHODS: Retrospective case series of patients with infectious complications in a chronic dialysis unit, affiliated with a tertiary care university hospital. RESULTS: Between 1996 and 1999, when we treated HD catheter-associated bacteremia with systemic antibiotics alone, we encountered a clustering of 8 cases of paraspinal/vertebral infections in a population of 162 patients. After changing our protocol, i.e., routine catheter exchange over a guide wire at approximately 48 h, while on systemic antibiotic therapy, we did not encounter any new cases of paraspinal/vertebral infections over a 15-month period. CONCLUSION: Our experience suggests that routine exchange of tunneled, cuffed catheters over a guide wire in HD patients presenting with bacteremia may significantly reduce serious infectious complications, e.g., epidural abscess/vertebral osteomyelitis.