Abstract
BackgroundTunnelled central venous dialysis catheter use is significantly limited by the occurrence of catheter-related infections. This randomised controlled trial assessed the efficacy of a 48 hour 70% ethanol lock vs heparin locks in prolonging the time to the first episode of catheter related blood stream infection (CRBSI).MethodsPatients undergoing haemodialysis (HD) via a tunnelled catheter were randomised 1:1 to once per week ethanol locks (with two heparin locks between other dialysis sessions) vs thrice per week heparin locks.ResultsObserved catheter days in the heparin (n=24) and ethanol (n=25) groups were 1814 and 3614 respectively. CRBSI occurred at a rate of 0.85 vs. 0.28 per 1000 catheter days in the heparin vs ethanol group by intention to treat analysis (incident rate ratio (IRR) for ethanol vs. heparin 0.17; 95%CI 0.02-1.63; p=0.12). Flow issues requiring catheter removal occurred at a rate of 1.6 vs 1.4 per 1000 catheter days in the heparin and ethanol groups respectively (IRR 0.85; 95% CI 0.20-3.5 p =0.82 (for ethanol vs heparin).ConclusionsCatheter survival and catheter-related blood stream infection were not significantly different but there was a trend towards a reduced rate of infection in the ethanol group. This study establishes proof of concept and will inform an adequately powered multicentre trial to definitively examine the efficacy and safety of ethanol locks as an alternative to current therapies used in the prevention of catheter-associated blood stream infections in patients dialysing with tunnelled catheters.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12609000493246
Highlights
Tunnelled central venous dialysis catheter use is significantly limited by the occurrence of catheter-related infections
Ethanol is attractive as a prophylactic lock solution as it is bactericidal by protein denaturation, has a broad range of antimicrobial activity [10], is relatively inexpensive, is metabolised by humans, and does not damage catheters by prolonged exposure [11,12]
Catheter-related infections Catheter-related blood stream infections occurred on intention to treat analysis in ethanol vs heparin arms at rates of 0.28 vs 0.85 per 1000 catheter days (IRR 0.17; 0.02-1.63; p=0.12: Table 2)
Summary
Tunnelled central venous dialysis catheter use is significantly limited by the occurrence of catheter-related infections. This randomised controlled trial assessed the efficacy of a 48 hour 70% ethanol lock vs heparin locks in prolonging the time to the first episode of catheter related blood stream infection (CRBSI). There is variation between trials in the concentrations, and length of dwell time with each type of lock study, and these variations in combination with often disparate patient groups and diverse catheter types make conclusions from the limited literature available difficult to reach. Sodium citrate locks were shown in a recent randomised controlled trial to provide no significant protection against catheter-associated infection and to increase the risk of catheter thrombosis [6]. Ethanol is attractive as a prophylactic lock solution as it is bactericidal by protein denaturation, has a broad range of antimicrobial activity [10], is relatively inexpensive, is metabolised by humans, and does not damage catheters by prolonged exposure [11,12]
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