Catheter‐related bacteremia in a pediatric hemodialysis unit

Abstract

Tunneled‐cuffed hemodialysis catheters are frequently used as long‐term vascular access in children due to the technical difficulties in constructing a fistula. Catheter‐related bacteremia (CRB) is still a major complication contributing to patient morbidity and loss of vascular access. Objective: To investigate the microbiological characteristics of CRB in children on hemodialysis. Methods: Chart review of 63 children who received hemodialysis with a tunneled‐cuffed catheter between January 1999 and December 2003 was performed. CRB was diagnosed when positive blood cultures were obtained in patients with symptoms of bacteremia, and without an identifiable source. Results: During the 5 year period, a total of 251 CRB were detected with 313 bacterial and 2 candidal growths in the blood cultures. The distribution of gram positive (Gr+) and gram negative (Gr−) microorganisms and their sensitivity patterns are shown in the table. Coagulase negative Staphylococcus was the most common microorganism, and constituted 62% of all bacterial isolates. All Gr+ microorganisms were sensitive to vancomycin except one isolate of Enterococcus fecalis. Enterobacter cloacae was the most common Gr− microorganism, followed by Klebsiella pneumonia. The sensitivity of Gr− microorganisms to levofloxacin was 100%. The treatment course was complicated by the growth of a second microorganism in subsequent blood cultures in 24% of infections; 54% of these consisted of both Gr+ and Gr− isolates. The etiology of ESRD or the use of immunosuppressive agents had no effect on the occurrence of CRB. The average number of infections were 5.8/1000 catheter days, and the recurrence of CRB was more likely in patients who had two or more CRB in a year. 1999 2000 2001 2002 2003 Gr+ growth 80% 88% 87% 85% 73% Oxacillin resistance 84% 73% 82% 68% 75% Gr− growth 20% 12% 13% 15% 27% Tobramycin resistance 21% 50% 25% 20% 13% Conclusions: Empiric initial treatment for CRB should include both Gr+, and Gr− coverage. Oxacillin and first generation cephalosporins are not good choices due to high incidence of resistance. Levofloxacin is a good alternative for Gr CRB. Novel preventive measures should be sought in patients who have a tendency to have recurrent CRB.