Catheter Exit Site Research Articles

Richter's Hernia at a Tenckhoff Catheter Exit Site

A 60-year-old male presented with a 2-day history of nausea, vomiting, and abdominal pain 3 months after kidney transplantation. No clinical and x-ray signs of small obstruction were present. A CT scan of the abdomen showed incarcerated small bowel loop at the site of the earlier peritoneal dialysis catheter (Tenckhoff) that was removed 2 months before. The hernia was repaired by laparoscopic approach using a biologic mesh. Only a few cases of small bowel obstruction at the Tenckhoff catheter exit site have been reported in the literature but none, to our knowledge, has described a case of partial small obstruction (Richter's hernia). The presentation of Richter's hernia can be very deceiving, especially in transplanted patients because of the masking effects of immunosuppression on symptoms and signs of inflammation and difficult differential diagnosis in these patients.

The importance of peritoneal catheter exit-site care

The risk of peritonitis associated with infections of the peritoneal catheter exit site can be reduced by the use of proper exit-site care, such as the routine administration of prophylactic antibiotics at the exit site. Studies that demonstrate the efficacy of such an approach or similar approaches continue to be published.

Peritonitis in children on chronic peritoneal dialysis; experience from a paediatric nephrology centre

Aim To determine variation in clinical manifestations, antibiotic sensitivity, patterns of causative organisms and the outcomes of bacterial peritonitis in children in our institution. Methods This retrospective study population included all those children who developed chronic peritoneal dialysis (CPD) related peritonitis during October 2005–February 2008 at Children Kidney Centre at UHW, Cardiff. The parameters collected were age, presenting symptoms, presence of exit site infection/tunnel infection, nature of peritoneal effluent (PE) at presentation and at 72 h after treatment, type of organism grown, antibiotics sensitivities, response to treatment and outcome. Results Out of 15 patients who were on CPD during 3 years of the study period, 10 patients developed a total of 15 episodes of peritonitis. Risk factors for peritonitis were presence of gastrostomy, use of diapers and exit site infections. Main presenting features were PE with WBC count >100 (87%), abdominal pain and fever (53%), turbid PE and vomiting (40%). Organisms were grown from PE in 13 (86%) episodes and culture was negative in two. Gram positive (GP) organisms accounted for 47%, gram negative (GN) for 27% of episodes and mixed organisms and candida found in one episode each. 86% of GP organisms were sensitive to a glycopeptide and 75% of GN organisms were sensitive to ceftazidime/gentamicin. 10 episodes showed good response to therapy, four episodes improved following removal of PD catheter and one patient died due to Staphylococcus aureus sepsis. Discussion and Conclusions The children with gram negative peritonitis were younger than those who developed gram positive peritonitis. Abdominal pain was common in peritonitis caused by staph aureus, streptococcus and Gram negative organisms. Fever and turbid PE were more likely with Gram negative peritonitis. With appropriate antibiotic therapy, supportive treatment and PD catheter removal where indicated, good clinical improvement was seen in all patients except one (93%). Peritonitis due to staph aureus, pseudomonas and candida were more likely to need PD catheter removal. Those who ultimately need PD catheter removal are more likely to have associated exit site infection, more symptomatic, are culture (effluent) positive and show unsatisfactory response after 72 h of therapy. Strategies to prevent CPD related peritonitis include early detection and treatment of exit site infection, appropriate care of gastrostomy site, optimum placement of PD catheter and avoiding nappy area for catheter exit site in infants. Early detection and prompt initiation of appropriate therapy is essential for a favourable outcome.

Novel Double Lumen Catheter for Drug Delivery at the Skin- Catheter Interface

This paper shows the technical feasibility of using a modified double lumen catheter for the delivery of fluids at the skin-catheter interface in an in vivo rabbit model. The modified catheter permits the extrusion of suspensions at the site of contact between the skin and the modified catheter (exit site). The modification consisted in the addition of a second lumen, exterior to the original one of the catheter and of shorter length, ending in an extrusion port placed subdermally. An external fluid pump was attached to the catheter and the whole system was tested in vitro in human skin, in a cadaver model and in an in vivo rabbit model. Experiments were performed by delivering solutions of methylene blue in a controlled manner to the subcutaneous area to analyze the skin response to the process. Results indicate that this technique of pumping the material is effective in producing observable epithelial changes in the short term. The modification of the catheter addresses catheter exit site lack of integration of skin and works as a model that can be implemented in a number of percutaneous devices for long-term implantation.

Comparative Analysis of Two-Piece Extended Peritoneal Dialysis Catheters with Remote Exit-Site Locations and Conventional Abdominal Catheters

An alternative peritoneal catheter exit-site location is sometimes needed in patients with obesity, floppy skin folds, intestinal stomas, urinary and fecal incontinence, and chronic yeast intertrigo. Two-piece extended catheters permit remote exit-site locations away from problematic abdominal conditions. The effect on clinical outcomes by remotely locating catheter exit sites to the upper abdomen or chest was compared to conventional lower abdominal sites. In a nonrandomized design, peritoneal access was established with 158 extended catheters and 270 conventional catheters based upon body habitus and special clinical needs. Prospective data collection included patient demographics, infectious and mechanical complications, and catheter survival. Kaplan-Meier survival time until first exit-site infection was longer for extended catheters (p = 0.03). Poisson regression showed no difference in exit site, subcutaneous tunnel, and peritonitis infection rates; however, the proportion of catheters lost during peritonitis episodes was significantly greater for extended catheters (p = 0.007) and appeared to be due primarily to coagulase-negative staphylococcus organisms. Poisson regression showed interactions of body mass index (BMI) and diabetic status in determining catheter loss from peritonitis for both catheter types (p = 0.02). Extended catheter patients had higher BMI and diabetes prevalence (p < 0.0001). Overall extended catheter survival at 1, 2, and 3 years (92%, 80%, 71%) trended lower than conventional devices (93%, 87%, 80%; p = 0.0505). Extended catheters enable peritoneal access for patients in whom conventional catheter placement would be difficult or impossible. Certain patient and extended-catheter characteristics may contribute to loss from peritonitis.

A literature review of central venous catheter dressings: implications for haemodialysis in the tropics

Queensland Health guidelines for central venous catheter (CVC) exit site management recommend using transparent dressings. However, the appropriateness of these dressings in tropical climates has been challenged in a regional haemodialysis unit due to perceived difficulties with moisture accumulation between haemodialysis sessions. This paper aims to reviewthe literature on best dressing practice in reducing incidence of catheter-related infections in patients receiving haemodialysis through a CVC, and will explore the evidence specifically related to tropical climates. Electronic database searches were conducted using the specific search terms: central venous catheter; haemodialysis; tropics; exit site; dressing; transparent; Primapore, IV3000; sepsis. Some 152 articles were initially retrieved. Of these, 135 articles did not specifically relate to exit site dressings, leaving 11 review and six research articles that were included in the literature review. Exit site dressing articles predominantly compared gauze with transparent dressings. The evidence of a causal relationship between transparent dressings and risk of catheter-related bloodstream infections was inconclusive, although transparent dressings may increase the risk of catheter tip colonisation and promote moisture and bacterial proliferation on peripheral cannulation sites. No articles addressed CVC management in the tropics. There was limited evidence to suggest infection rateswere higher using transparent compared with non-transparent (gauze) dressings. No studies were found that investigated the effectiveness of either dressing type, or an appropriate dressing protocol, for the tropics. Further research is required to determine the most effective dressing type for use on haemodialysis CVC exit sites in the tropics.

Vascular Access Devices: A Retrospective Review Amongst Patients Treated at the Ottawa Hospital with Induction Chemotherapy for Acute Leukemia.

Abstract 4521 IntroductionAs part of the care of patients with acute leukemia, central vascular access is important in order to safely and reliably deliver chemotherapy, antibiotics, blood products and nutrition as needed. Two examples of these vascular access devices are peripherally inserted central venous catheters (PICC) and Hickman® catheters (Bard Access Systems, Inc., Salt Lake City, Utah). Each has its set of unique benefits and weaknesses. Some are related to the location where they enter the vascular system but others such as risk of infection, device occlusion or incidence of deep vein thrombosis (DVT) are less clear between devices. MethodsPatients included in this study had a diagnosis of acute leukemia (lymphoblastic [ALL] or myeloid [AML]) between September 1996 and April 2009, had a central venous access device inserted (PICC or a Hickman®), received induction chemotherapy and survived at least 20 days. In that time period, the method of insertion of both devices has changed since January 1st 2007. Prior to this date, a specially trained nurse using palpation inserted the PICC at the patient's bedside into veins located in the antecubital fossa (PICC-palp). After this date, the same nursing team began inserting PICCs using ultrasound guidance and modified seldinger technique into veins proximal to the antecubital fossa (PICC-U/S). Hickman® catheters, previously inserted in the operating room by a surgeon (H-Surg), since January 1st 2007 have been inserted in the angiographic suite by an interventional radiologist (H-IR). The four groups were analyzed for differences in basic demographics. Comparisons between the four devices included the presence of cellulitis at the catheter exit site and whether or not there was an infection accompanied at the site, confirmed bacteremia, the need to administer a thrombolytic agent to unblock the device, a DVT around the device, and whether or not the line had to be removed. The four groups were compared for differences using the Kruskal-Wallis Test for continuous variables and the chi-square test for categorical variables. Results147 patients were identified. 55 had a Hickman® catheter (18 H-Surg and 37 H-IR) and 92 had a PICC (69 PICC-palp and 23 PICC-U/S). The median age (range) within the four groups H-Surg, H-IR, PICC-palp, and PICC-U/S were 54 (20-72), 52 (17-69), 51 (18-73), 56 (19-73), respectively. Males made up 49-56% of each group. ALL ranged between 6 and 9% within each group. The only significant difference between the four groups was whether they were inserted from the right or left side with 89-100% of the Hickman® catheters being inserted on the right vs. 59-74% of the PICCs being inserted on the right (p<0.0001). The most significant improvements from H-Surg to H-IR catheters are the reduction in catheter exit site cellulitis accompanied by exit site infections (27.8% to 5.4%, p=0.04) and in bacteremia counts (72.2% to 27.0%, p=0.01). There were no statistically significant findings from PICC-palp to PICC-U/S; however, the most clinically relevant improvements showed decreases in cellulitis and DVT cases from 60.9% to 39.1% (p=0.07) and 24.6% to 8.7% (p=0.07), respectively. H-IR catheters were shown to outperform PICC-U/S in DVT cases (0.0% vs. 8.7%), and the need to administer a thrombolytic agent (8.1% vs. 69.6%, p<0.0001). upon comparing PICCs vs. Hickman® catheters, the number of catheter exit site cellulitis cases were fewer in the PICC catheters (55.4% vs. 76.4%, p=0.01); however, Hickman® catheters prevailed over PICCs when comparing cases of DVT (0.0% vs. 20.7%) and the need to administer a thrombolytic agent (5.5% vs. 59.8%, p<0.0001). The difference in catheter removal across all four groups was similar ranging from 24-33%. ConclusionDespite small sample groups it appears that both vascular access devices have shown improvements from pre to post 2007 insertion methods. Patients treated at the Ottawa Hospital with intensive chemotherapy for acute leukemia currently appear to demonstrate less complications with Hickman® catheters, inserted by interventional radiologists, compared to PICCs, especially in the most clinically relevant spheres (i.e. bacteremia, incidence of DVT and need for thrombolytic agents to unblock the catheter). This suggests that Hickman® catheters provide a more reliable central vascular access in these patients. A larger sample size or a randomized control trial would be needed to confirm these observations. Disclosures:No relevant conflicts of interest to declare.

Topical Mupirocin/Sodium Hypochlorite Reduces Peritonitis and Exit-Site Infection Rates in Children

Peritoneal dialysis (PD) is a common maintenance renal replacement modality for children with ESRD frequently compromised by infectious peritonitis and catheter exit site and tunnel infections (ESI/TI). The effect of topical mupirocin (Mup) and sodium hypochlorite (NaOCl) solution was evaluated as part of routine daily exit site care on peritonitis and ESI/TI rates, causative microorganisms, and catheter survival rates. Retrospective chart review of children on home continuous cycling PD between April 1, 2001 and June 30, 2007 was performed. Infection rates were examined based on exit site protocol used in two different periods: Mup alone, April 1, 2001 to November 17, 2004; and Mup and NaOCl (Mup+NaOCl), November 18, 2004 to June 30, 2007. Eighty-three patients (mean PD initiation age: 12.1 +/- 5.8 yr) received home PD over 2009 patient months. Annualized rates (ARs) for peritonitis decreased from 1.2 in the Mup period to 0.26 in the Mup+NaOCl period (P < 0.0001). ARs for ESI/TI decreased from 1.36 in the Mup period to 0.33 in the Mup+NaOCl period (P < 0.0001). No infections with Mup-resistant organisms were observed when either Mup or Mup+NaOCl was used for prophylaxis. Gram-negative-organism associated peritonitis decreased from an AR of 0.31 in the Mup period to 0.07 in the Mup+NaOCl period (P < 0.001). Infection-related catheter removal rates decreased from 1 in 38.9 catheter-months in the Mup period to 1 in 94.2 in the Mup+NaOCl period (P = 0.01). Catheter survival rates were longer in the Mup+NaOCl period (Kaplan-Meier, P < 0.009). The combination Mup+NaOCl in daily exit site care was very effective to reduce PD catheter-associated infections and prolong catheter survival in pediatric patients.

Hemodialysis Catheters With Citrate Locking in Critically Ill Patients With Acute Kidney Injury Treated With Intermittent Online Hemofiltration or Hemodialysis

The purpose of the study was to compare the long-term catheter-related complications associated with temporary untunneled hemodialysis catheters, locked with citrate in the interdialysis period, inserted in critically ill patients with acute kidney injury, between different catheter insertion sites (femoral vs. jugular and subclavian) and catheter types (single-lumen [SL] vs. double-lumen [DL]). In a retrospective clinical study, the long-term catheter-related complications in 290 critically ill patients treated with intermittent high-volume online hemofiltration or hemodialysis between December 2004 and January 2008 were analyzed. Among 534 inserted catheters, 493 (92.3%) were femoral, 29 (5.4%) jugular, and 12 (2.3%) subclavian; 304 (56.9%) were SL and 230 (43.1%) were DL. There were 125 (20.3/1000 catheter days [c.d.]) thrombotic complications, while infectious complications were exceptionally rare, that is, only 13 (2.1/1000 c.d.), of which 10 (1.6/1000 c.d.) were possible catheter-related bloodstream infections and 3 (0.5/1000 c.d.) exit-site infections. The incidence rate of all thrombotic complications was significantly lower in all jugular and subclavian vs. all femoral catheters (7.7/1000 c.d. vs. 21.8/1000 c.d., P = 0.01), and in all SL vs. DL catheters (11.4/1000 c.d. vs. 32.2/1000 c.d., P < 0.001). The incidence rate of any possible catheter-related bloodstream and exit-site infections was not significantly different in all jugular and subclavian vs. all femoral catheters, neither in femoral SL vs. DL catheters. The major long-term catheter-related complications were thrombotic, and significantly more frequent in DL vs. SL catheters. Infectious complications were exceptionally rare, most probably due to the strict catheter care protocol, as well as the routine use of a citrate catheter lock and antibiotic ointment at the catheter exit-site.

Catheter-related Chryseobacterium meningosepticum bacteraemia in a haemodialysis patient.

Sir, Chryseobacterium meningosepticum (C. meningosepticum), an unusual opportunistic pathogen resistant to multiple antimicrobial agents, was rarely reported to be a cause of bacteraemia in haemodialysis patients. A 77-year-old female with end-stage renal disease was admitted with fever, chills and tenderness on the insertion site of the femoral double-lumen catheter 2 weeks after the start of haemodialysis. Her body temperature was 38.4°C. Erythema and swelling were present around the exit site of the double-lumen catheter. Laboratory evaluation revealed a haemoglobin of 7.6 g/dL and a C-reactive protein of 7.3 mg/dL. A provisional diagnosis of catheter-related bacteraemia was made. The double-lumen vein catheter was removed along with empiric antimicrobial agents with intravenous vancomycin (2 g/week) plus oral rifampin (450 mg/day). Blood cultures grew C. meningosepticum that was resistant to gentamicin, amikacin and all cephalosporins, but only susceptible to ciprofloxacin and vancomycin. Cultures of the exit site and the tip of catheter also grew C. meningosepticum. Despite 1-week antibiotic therapy, blood cultures still grew the same pathogen. At this time, an echocardiogram was normal. The addition of oral ciprofloxacin (250 mg q12 h) to vancomycin for another 2 weeks achieved uneventful recovery without subsequent growth of this organism. Cultures for tap water and dialysate were also negative for this pathogen. Chryseobacterium spp. are of low virulence but give rise to severe infections in neonate and immunocompromised hosts. C. meningosepticum was the most common species of human pathogens. In neonates, C. meningosepticum meningitis is the most common infection, whereas pneumonia and sepsis were the most common infections in adults with impaired immunity [1]. Patients with uraemia are at a risk for C. meningosepticum infection due to their compromised T- and B-cell immunity. To date, there were only few reports regarding C. meningosepticum infections in uraemic patients on dialysis (Table ​(Table1)1) [2–5]. Among 42 episodes in 41 dialysis patients, a majority (37/42, 88%) of episodes were related to peritoneal dialysis (PD) catheter peritonitis and a minority (5/42, 12%) of episodes had bacteraemia in patients on haemodialysis. Initial antibiotics to eradicate C. meningosepticum infections were usually inappropriate, leading to the necessity of removal of the catheter in most patients. Four (4/41, 10%) patients died from C. meningosepticum infection. In C. meningosepticum bacteraemia, the exact port of entry was unknown in three episodes. C. meningosepticum was isolated from sink water in only one episode. Although C. meningosepticum was not identified in tap, tank and dialysis water, in our patient it was also isolated from the exit site and the tip of the double-lumen catheter, suggesting that the port of entry be the disruption of skin integrity by internal placement of the catheter. Our case is the first report of C. meningosepticum bacteraemia associated with catheter-related infection in a haemodialysis patient. Table 1 Demographic data of the reported patients on dialysis with Chryseobacterium meningosepticum infection Although vancomycin has been previously recommended as the drug of choice for C. meningosepticum infection, recent reports and our case revealed that C. meningosepticum infection failed to respond to vancomycin administration alone [6]. Vancomycin should not be used alone to treat C. meningosepticum infections, especially associated with bacteraemia [6], as shown in the patient. In conclusion, C. meningosepticum should be considered as a causative pathogen of gram-negative bacilli catheter-related bacteremia in haemodialysis patients. Early recognition of this pathogen with appropriate antimicrobial agent administration will avoid the loss of the catheter and even mortality. Conflict of interest statement. None declared.

Interventional Nephrology: Core Curriculum 2009

Interventional Nephrology: Core Curriculum 2009

Application of right Internal jugular cuffed dual lumen catheter in hemodialysis patients

Objective To evaluate the effects of cuffed catheter as the permanent hemodialysis access. Methods The standard Seldinger technique was used for guidewire insertion in right internal jugular. The tan-nel was designed according to the transfer signs of the vein. In choosing the catheter exit site, it was also impor-tant to keep in mind that the final subcutaneous position of the catheter would take on a gentle bend to avoid any kinking of the catheter. Using a standard tunneling device, the cuffed catheter was pulled through subcutaneously up to the entrance of the guidewire, until the Dacron cuff of the catheter was placed subcutaneously at least 2.0 cm beyond the exit site. Soft and hard dilator was then placed over the gnidewire and the cuffed catheter was then inserted through the peel-away sheath. Results The operations were performed in 13 patients. There was one patient died of uremia complication with normal catheter function. Twelve patients were still using the cuffed catheters at the end of the investigation. Conclusion The cuffed catheter hemodialysis access can be kept for u-sing for a relative long time with low rate of infection and thrombosis and is a good choice for the patients who can not use the traditional method to set up vascular access. Key words: Hemodialysis; Hemodialysis access; Cuffed catheter

Complications of Continuous Ambulatory Peritoneal Dialysis

Continuous ambulatory peritoneal dialysis (CAPD) is used to treat end-stage renal failure in an increasing number of patients. CAPD has an advantage over hemodialysis in that it allows patients greater freedom to perform daily activities; it also provides other clinical benefits. However, the long-term effectiveness of CAPD is limited by complications, which have various causes. Complications with an infectious cause include bacterial peritonitis, tuberculous peritonitis, and infections of the catheter exit site and tunnel. Noninfectious complications include catheter dysfunction, dialysate leakage, hernias, and sclerosing encapsulating peritonitis. Many imaging modalities-radiography, ultrasonography, peritoneal scintigraphy, computed tomography (CT), and magnetic resonance (MR) imaging-are useful for characterizing these complications. CT peritoneography and MR peritoneography are techniques specifically suited to this purpose. Imaging plays a critical role in ensuring that complications are detected early and managed appropriately.

The impact of antithrombotic prophylaxis on infectious complications in cancer patients with central venous catheters: an observational study

Infections in cancer patients after implantation of a central venous device (CVD) are not infrequent and are potentially serious. The possibility of limiting this complication with antithrombotic drugs is still debated. For this observational study, we recorded the routine management of CVD in cancer patients in 18 oncology centers in Lombardy (northern Italy), assessing the effect of antithrombotic prophylaxis on catheter-related infections. Out of 1410 patients enrolled, 451 received antithrombotic prophylaxis continuously after implantation of the central line. During a median follow-up of 30 months, 57 catheter-related infections were reported in the 1390 patients seen at least once at follow-up visits (4.1% of the whole series), giving an overall incidence of 0.10 infections per 1000 catheter days. This complication was significantly more frequent among patients with an indwelling central venous catheter, or peripherally inserted catheter, than among those with a port device, and the group not given antithrombotic prophylaxis had 0.14 infective complications/1000 CVD days compared with 0.05/1000 CVD days (odds ratio 2.4; 95% confidence interval 1.7-5.0) for those treated. Antithrombotic prophylaxis protected against infections at the catheter exit site and track but not against systemic infections. Confirming earlier evidence, this study found a reduction in catheter-related infections in patients given antithrombotic prophylaxis. However, this reduction, reflecting local infections, seems unlikely to be one of the mechanisms explaining the lower mortality among our patients treated with anticoagulants.

Clinical effectiveness of different approaches to peritoneal dialysis catheter exit-site care

The main aim of this review is to evaluate and summarise the best available evidence about peritoneal catheter exit site care to minimise the risk of infection. The specific review questions to be addressed are: •What is the most effective approach to managing peritoneal catheter exit sites during the initial post-operative period? •What is the most effective approach to the long term management of peritoneal catheter exit sites? Inclusion Criteria Types of participants Participants of interests are both adults and children (under 18) with chronic renal failure on maintenance peritoneal dialysis. Studies which analyse diabetic patients separately will be considered for inclusion as a subgroup analysis. Types of interventions Interventions of interest are those used to manage peritoneal catheter exit sites, both in the early post-operative period (from 0 to 14 days post insertion of the catheter), and the long term period (15 or more days post insertion). Interventions of interest include: •Dressing of exit sites, including type of dressing, frequency of dressing and technique (aseptic vs. clean) •Exit site skin care, frequency and type of skin care (or product used). •Education of the person with a peritoneal catheter, or a carer, on exit site management. •Prophylactic treatments involving topic antimicrobial agents or antiseptic and devices. Types of outcome measures The outcomes of interest are those related to the effectiveness of peritoneal catheter exit site care. These outcomes will include incidence of exit site infection and peritonitis.Outcome measures: •Incidence of tunnel or exit site infection: Number of patients with infection inside the tunnel or at the exit site. Infection can be defined as the presence of redness, inflammation, exuberant granulation tissue and purulent/bloody exudate associated with erythema and oedema. •Incidence of peritonitis: two positive (post dialysis cell count > 100 cells/ mm³ with >50% of polimorfonuclear leukocytes), peritoneal liquid cultures in an asymptomatic PD catheter carrier or a single positive in a PD catheter carrier with symptoms of peritonitis (such as abdominal pain, fever and cloudy peritoneal liquid). •Reappearance of the peritonitis (after two to four weeks, due to the same microorganism). •Lapse of time to the first episode of peritonitis. •PD Catheter removal. •Readmission rates related to peritonitis. •Failure of the procedure (transfer from PD to haemodialysis). •Death caused by peritonitis

Infecciones asociadas a los catéteres utilizados para la hemodiálisis y la diálisis peritoneal

Las infecciones asociadas a los catéteres utilizados tanto para hemodiálisis como para diálisis peritoneal (DP) constituyen una de las causas de morbimortalidad más importante en pacientes que precisan un tratamiento sustitutivo renal permanente. Staphylococcus aureus en pacientes en hemodiálisis y S. aureus y Pseudomonas aeruginosa en pacientes en DP son los microorganismos más frecuentemente aislados. Actualmente, no están establecidas las pruebas diagnósticas más rentables en infecciones de catéter en pacientes en hemodiálisis, por lo que se utilizan los empleados para las infecciones de los catéteres venosos centrales (CVC) en general. El tratamiento es similar al de otros CVC con algunas recomendaciones especiales. En pacientes en DP la peritonitis es una de las complicaciones más graves. La mejoría de las condiciones higiénicas en la inserción de los catéteres, el tratamiento de los portadores nasales de S. aureus , el tratamiento regular del orificio de salida de los catéteres y el sellado del catéter se han asociado con una disminución en las infecciones asociadas a catéter en pacientes en hemodiálisis y DP. Catheter-related infections in hemodialysis (HD) and peritoneal dialysis (PD) are one of the most common causes of morbidity and mortality in patients with end-stage renal disease. Staphylococcus aureus in HD patients and S. aureus and Pseudomonas aeruginosa in PD patients are the most common causative organisms isolated. Currently, the diagnostic tests with highest yield in suspected catheter-related infection in HD patients have not been established, and tests used for central venous catheters (CVC) in general are applied. Management of the infected HD catheter and the use of antimicrobial therapy are similar to the measures used for other CVCs, with some specific recommendations. Peritonitis is the most severe complication in PD patients. Improving hygiene conditions in catheter insertion, treatment of S. aureus nasal carriers, regular treatment of the catheter's exit site, and antibiotic lock therapy have been associated with a reduction of infectious episodes in HD and PD patients.

Infecciones asociadas a los catéteres utilizados para la hemodiálisis y la diálisis peritoneal

Catheter-related infections in hemodialysis (HD) and peritoneal dialysis (PD) are one of the most common causes of morbidity and mortality in patients with end-stage renal disease. Staphylococcus aureus in HD patients and S. aureus and Pseudomonas aeruginosa in PD patients are the most common causative organisms isolated. Currently, the diagnostic tests with highest yield in suspected catheter-related infection in HD patients have not been established, and tests used for central venous catheters (CVC) in general are applied. Management of the infected HD catheter and the use of antimicrobial therapy are similar to the measures used for other CVCs, with some specific recommendations. Peritonitis is the most severe complication in PD patients. Improving hygiene conditions in catheter insertion, treatment of S. aureus nasal carriers, regular treatment of the catheter's exit site, and antibiotic lock therapy have been associated with a reduction of infectious episodes in HD and PD patients.

Use of prophylactic topical or intraluminal antibiotics for hemodialysis catheters

This Practice Point commentary discusses the findings and limitations of a meta-analysis that evaluated the use of prophylactic antibiotics for hemodialysis catheters. Use of prophylactic topical antibiotics at the catheter exit site was associated with a significant reduction in catheter-related bacteremia, exit-site infections, catheter removals due to secondary complications, hospitalizations for infection, and patient mortality. Use of prophylactic intraluminal antibiotic instillation was associated with a significantly reduced risk of catheter-related bacteremia and need for catheter removal. This commentary highlights the issues that should be considered when interpreting and generalizing these results, including the variability of antibiotic type and catheter type (nontunneled vs tunneled), the use of co-interventions in the various trials, and potential publication bias. The known benefits of prophylactic antibiotic use in patients with hemodialysis catheters are strongly supported by this meta-analysis.

Prévention des infections liées au cathéter en dialyse : validation pharmaceutique de la solution rifampicine–sulfate de protamine

Bacteria from the exit site of dialysis catheter can grow into microcolonies in biofilm. It has been hypothesized that rifampin-protamine combination may have an effect on the biofilm. In hemodialysis centre a combination of rifampin mixed with protamine is commonly used in some centre in order to prevent catheter related infections in hemodialysis patients. Therefore, a pharmaceutical assessment of the rifampin-protamine mixture is clearly mandatory. The aim of this study is to evaluate the stability and the sterility of the rifampin-protamine solution. Five milliliters of protamine (10 mg) was mixed with 10 mL of Rifampin (600 mg). The solution was kept at -20 degrees C temperature for two weeks and subsequently at 4 degrees C for two additional weeks. Stability and sterility were evaluated the first day and two weeks, three weeks and four weeks after the preparation. Concentration of rifampin in the solution was assessed by HPLC. Protamine concentration was evaluated by the effect of the solution on the heparin activity of a heparinized plasma. The solution was cultured on broth media and mannitol agar plate. Areas under curve of rifampin were similar between the four different evaluations. The effect of the solution on the heparin activity was comparable at the four different evaluations. Our results demonstrate the stability and the compatibility of the solution. However, there was biological interference between broth media and the solution. It was, therefore, impossible to make any conclusion after broth culture. Culture on mannitol agar plate did not show any microbiological growth. Based on this finding, we recommend preparing the rifampin-protamine combination in individual conditioning at the time of the utilization.

Nocardia asteroides peritoneal dialysis-related peritonitis: a case of successful treatment and return to peritoneal dialysis

A 66-year-old male from rural Manukau, New Zealand, presented to hospital with 2 weeks of generalized abdominal pain and cloudy PD effluent. He had been on PD for 3 years, with only one previous episode of PD-related peritonitis secondary to Streptococcus oralis a year prior. Other significant co-morbidity included well-controlled Type 2 diabetes mellitus on diet therapy, hypertension, mild chronic obstructive airways disease and quiescent gout. On initial examination, the patient was afebrile with blood pressure of 140/70mmHg. Abdominal examination showed generalized tenderness and normal bowel sounds. The PD catheter exit site was normal. Microscopy of dialysate showed 1600 leucocytes, 86% of which were neutrophils, and no organisms. After initial investigations, antibiotic treatment was commenced for PD-related peritonitis with empirical intraperitoneal cephazolin and gentamicin. His dialysate sample was processed in our microbiology laboratory; this involved inoculation of 10 mL into both BacT/ALERT FA aerobic and FN anaerobic blood culture bottles (bioMerieux, Marcy-l’Etoile, France), with the deposit from 10 mL of centrifuged sample inoculated onto two sheep blood agar plates, incubated in 5% CO2 and anaerobically, and one chocolate agar plate incubated in 5% CO2. After 5 days incubation, the BacT/ALERT FA aerobic bottle was reported as growing a fungus. Since one of the enrichment broths had become positive, the primary agar plates were held longer than the usual 5 days, but remained culture negative after 21 days. The patient was therefore treated as fungal peritonitis with a change in his antibiotic regimen to fluconazole 200 mg orally on alternate days and removal of his PD