Episodes Of Catheter-related Bacteremia Research Articles

POS-013 PROTEIN ENERGY WASTING IN ACUTE KIDNEY INJURY REQUIRING HEMODIALYSIS AND INTRADIALYTIC PARENTERAL NUTRITION

A 78-year-old female with a previous diagnosis of type 2 diabetes mellitus attended to the emergency room after presenting dyspnea of small efforts, chest pain and generalized edema of three days of evolution, as well as a history of decreased food intake from approximately 8 months related to depressive disorder. Upon admission on 12/30/2020, laboratories report serum creatinine 6.70mg/dL (glomerular filtration= 7.2mL/min/1.73m2 by CKD-EPI), urea106.30 mg/dL, potassium 8.01mmol/L, glucose 297 mg/dL; electrocardiographic findings of peaked T waves, widened QRS and supraventricular tachycardia. Admission weight= 44Kg, height= 1.52 m, BMI=19.04 Kg/m2. Nutritional risk was assessed through Malnutrition Universal Screening Tool (MUST) which scored 4 (high risk of malnutrition). The patient was admitted to the hospital with the following diagnoses: Uncontrolled type 2 diabetes mellitus, acute kidney injury KDIGO 3, severe hyperkalemia and protein energy wasting (PEW). Right jugular tunneled vascular access was placed and an urgent hemodialysis session was scheduled at the same day. After three hemodialysis sessions control laboratories were carried out: serum creatinine 3.34mg/dL, urea 53 mg/dL, albumin3.7 mg/dL, potassium4.69 mmol/L. As the patient showed improvement in clinical and biochemical parameters, she was discharged from hospital, and she continued treatment with outpatient hemodialysis two sessions per week. Nutritional counsel was given. During the follow-up, a tendency to decrease in weight prior to hemodialysis sessions was detected, the relatives reported that the patient persisted with low dietary intake (<10kcal /kg ideal weight/day) still related to depressive disorder, so that nutritional status was assessed again founding severe protein energy wasting thus, we decided to start with intradialytic parenteral nutrition (IDPN) on 01/29/2021 in order to increase caloric-protein intake and improve clinical prognosis. It was started with standard emulsion for infusion of 1100 Kcal/986 ml placed in a venous chamber with infusion pump, with good tolerance from the first occasion and continues to be administered during the following 8 sessions. During this period there were no episodes of catheter-related bacteremia, infections or complications associated with treatment; the infusion of parenteral emulsion did not interrupt or complicate the proper functioning of any hemodialysis session. The patient reported a constant increase in her dietary intake evidenced by a desirable increase in dry weight, which is why IDPN was suspended and dialysis doses were progressively decreased until her withdrawal. The patient continues to be followed up and by the last assessment (08/11/2021) her weight increased to 57 Kg without data of water overload, serum creatinine decreased to 1.07mg/dL, urea 47.60mg/dL, and BUN 22.2 mg/dL. The lessons learned from this case are:

Central Venous Catheter-Related Bacteremia in Chronic Hemodialysis Patients: Saudi Single Center Experience

Central vein catheters (CVC) are an important means of delivering hemodialysis (HD) to patients who require immediate initiation of dialysis but are without a mature functioning arterio-venous fistula or graft. The frequency of catheter-related bacteremia (CRB) reported in several large series ranged between 2.5 and 5.5 cases/1,000catheter-days. The aim of the study was to evaluate the incidence, spectrum of infecting organisms, risk factors, and optimal treatment for catheter-related bacteremia.This retrospective study of clinical records was conducted between January 2005 and January 2009 where all episodes of catheter related bacteremia in the preceding 4 years were a subject of our study. Data recorded for each patient included the number of catheter-days, episodes of suspected bacteremia, blood culture results, method of treatment, complications, and outcomes. All patients with CRB were treated with a 21-day course of intravenous antibiotics, with surveillance cultures obtained 1 week after completing the course of antibiotics. The CVC was removed if the patient had uncontrolled sepsis or if other vascular access was ready for use. Once the infection was controlled, catheter salvage was considered successful, leaving the original CVC in place. 93 chronic hemodialysis (HD) patients, 42 male (45.25%) and51 female (54.8%) were included, with median age51.67 years. During this study, there were 37087catheter-days, with 52 episodes of CRB, or 1.4 episodes/1,000 catheterdays. Thirty- five infections (67.3%) were caused by gram-positive cocci only, including Staphylococcus aureus, Staphylococcus simulans, and Staphylococcus haemolyticus. Seventeen infections (32.7%) were caused by gram-negative rods only, including a wide variety of enteric organisms. Five CVCs were removed because of severe uncontrolled sepsis, of the remaining 47 cases; attempted CVC salvage was successful in (90.3%). The only important complication of CRB was endocarditis, occurring in 1 of 52 episodes (1.9%). We conclude that in our study, CRB is relatively near the lower limit of normal range with low incidence of complication and frequently involves gram-positive bacteria. CVC salvage is significantly improved when CVC was treated by antibiotic based on blood culture results.

Outcome of central venous catheter-related bacteraemia according to compliance with guidelines: experience with 91 episodes

Infection is a major complication associated with the use of central venous catheters. Guidelines for medical management of catheter-related bacteraemia have been published, but no study has assessed the appropriateness of physician practices. To assess medical practices in cases of central venous catheter-related bacteraemia (CRB) in a university hospital. Cases were recorded over a period of 12 months and their management was evaluated. All cases of positive blood cultures based on central venous catheter sampling were analysed, and episodes of CRB were determined in this group of patients. Medical management and patient outcome were analysed independently by two physicians. In all, 187 cases of positive blood culture were recorded and 91 cases of CRB were analysed. Systemic antimicrobial therapy was optimal in 56% of the episodes. In 51 episodes, catheter salvage was attempted, for 29 with an indication in agreement with the guidelines but without antibiotic-lock therapy in 20 episodes. The overall medical management was appropriate in 41.8% of the episodes. The overall cure rate was 72.5%. CRB-related death occurred in 5.5% of the episodes. Cure was associated with guideline compliance (P=0.03) and with adaptation of systemic antimicrobial therapy (P<0.01). Conservative treatment success was associated with compliance with the guidelines for the indication (P=0.01). Medical management of CRB did not closely adhere to international guidelines. CRB outcome was associated with the appropriateness of this management, particularly when conservative treatment was attempted.

Arteriovenous Graft Placement in Predialysis Patients: A Potential Catheter-Sparing Strategy

When predialysis patients are deemed unsuitable candidates for an arteriovenous fistula, current guidelines recommend waiting until just before or after initiation of dialysis therapy before placing a graft. This strategy may increase catheter use when these patients start dialysis therapy. We compared the outcomes of patients whose grafts were placed before and after dialysis therapy initiation. Retrospective analysis of a prospective computerized vascular access database. Patients with chronic kidney disease receiving their first arteriovenous graft (n = 248) at a large medical center. Timing of graft placement (before or after initiation of dialysis therapy). Primary graft failure, cumulative graft survival, catheter dependence, and catheter-related bacteremia. The first graft was placed predialysis in 62 patients and postdialysis in 186 patients. Primary graft failure was similar for pre- and postdialysis grafts (20% vs 24%; P = 0.5). Median cumulative graft survival was similar for pre- and postdialysis grafts (365 vs 414 days; HR, 1.22; 95% CI, 0.81-1.98; P = 0.3). Median duration of catheter dependence after graft placement in the postdialysis group was 48 days and was associated with 0.63 (95% CI, 0.48-0.79) episodes of catheter-related bacteremia per patient. Retrospective analysis, single medical center. Grafts placed predialysis have primary failure rates and cumulative survival similar to those placed after starting dialysis therapy. However, postdialysis graft placement is associated with prolonged catheter dependence and frequent bacteremia. Predialysis graft placement may decrease catheter dependence and bacteremia in selected patients.

Central Venous Catheter-Related Bacteremia in Chronic Hemodialysis Patients:Saudi Single Center Experience

Introduction: Central vein catheters (CVC) are an important means of delivering hemodialysis (HD) to patients who require immediate initiation of dialysis but are without a mature functioning arterio-venous fistula or graft. The frequency of catheter-related bacteremia (CRB) reported in several large series ranged between 2.5 and 5.5 cases/1,000 catheter-days. Aim of the study: The aim of the study was to evaluate the incidence, spectrum of infecting organisms, risk factors, and optimal treatment for catheter-related bacteremia. Methodology: This retrospective study of clinical records was conducted between January 2005 and January 2009 where all episodes of catheter related bacteremia in the preceding 4 years were a subject of our study. Data recorded for each patient included the number of catheter-days, episodes of suspected bacteremia, blood culture results, method of treatment, complications, and outcomes. All patients with CRB were treated with a 21-day course of intravenous antibiotics, with surveillance cultures obtained 1 week after completing the course of antibiotics. The CVC was removed if the patient had uncontrolled sepsis or if other vascular access was ready for use. Once the infection was controlled, catheter salvage was considered successful, leaving the original CVC in place. Results: 93 chronic hemodialysis (HD) patients, 42 male (45.25%) and 51 female (54.8%) were included, with median age 51.67 years. During this study, there were 37087catheter-days, with 52 episodes of CRB, or 1.4 episodes/1,000 catheter-days. Thirty- five infections (67.3%) were caused by gram-positive cocci only, including Staphylococcus aureus, Staphylococcus simulans, and Staphylococcus haemolyticus. Seventeen infections (32.7%) were caused by gram-negative rods only, including a wide variety of enteric organisms. Five CVCs were removed because of severe uncontrolled sepsis, of the remaining 47 cases; attempted CVC salvage was successful in (90.3%). The only important complication of CRB was endocarditis, occurring in 1 of 52 episodes (1.9%). Conclusion: We conclude that in our study, CRB is relatively near the lower limit of normal range with low incidence of complication and frequently involves gram-positive bacteria. CVC salvage is significantly improved when CVC was treated by antibiotic based on blood culture results.

Epicardial Cardiac Rhythm Devices for Dialysis Patients: Minimizing the Risk of Infection and Preserving Central Veins

Transvenous leads of cardiac rhythm devices (CRDs) are known to cause central stenosis and are vulnerable to contamination during hemodialysis access-related bacteremia. In this retrospective study, nine consecutive chronic hemodialysis patients with transvenous CRD infection due to dialysis access-related bacteremia and recurrent central stenosis are presented. Four patients with tunneled hemodialysis catheters (TDCs) and three with arteriovenous grafts experienced access-related bacteremia that spread to the transvenous CRD. Two patients required repeated angioplasty procedures (less than 3 months apart) for central venous stenosis. Transvenous CRD was removed and replaced with an epicardial system in all. One patient with TDC switched to peritoneal dialysis and did not experience infection of the epicardial system despite two episodes of peritonitis. The remaining TDC (n=3) and graft patients (n=3) received a new TDC after the resolution of bacteremia. While all six experienced on average 1.5 episodes of catheter-related bacteremia (average follow-up = 14.5 months), none developed infection of the epicardial system. The patients with central stenosis have required only one angioplasty each for the past 8 and 6 months. To the best of our knowledge this is the first study to suggest that an epicardial approach might be a preferred method over transvenous leads for chronic hemodialysis patients.

Catheter-Related Bacteremia in Hemodialysis: Which Preventive Measures to Take?

Background: The use of tunneled hemodialysis catheters as definitive vascular access is becoming increasingly more widespread, reaching 25% of all dialysis patients in some countries. The rate of infectious morbidity and mortality is much higher when catheters are used than when patients are dialyzed through grafts or native fistulas, and it is generally agreed that implementing appropriate preventive measures would do more to lower its incidence. Methods: A prospective, randomized, open-label, long-term follow-up clinical trial was conducted to compare the efficacy of dressing the exit site with antibiotic ointment (AO) versus catheter antimicrobial locking (AL) in preventing catheter-related bacteremia (CRB), both associated with strict standard precautions and appropriate catheter care. A total of 141 tunneled catheters, newly implanted in 116 consecutive patients, were followed during a 2-year period. Patients were randomly distributed into one of three arms, with group A receiving AO prophylaxis, group B treated with a heparin + gentamicin (5.2 mg/ml) lock (AL) and group C receiving both AO and AL prophylaxis. Results: Group A had a significantly lower infection-free time survival curve (p < 0.02, Kaplan-Meier) with a catheter survival of 103.9 days and a significantly higher number of CRB (9 episodes, p < 0.02, χ²). Group B had 130.7 mean infection-free days and 1 episode of CRB. Group C had 127.3 mean infection-free days and 5 episodes of CRB. No toxicity or other adverse events were observed during this 2-year period, and the efficacy of the preventive measures remained stable throughout. Conclusion: Antimicrobial lock is superior to AO as a CRB preventive measure. The use of lock and ointment in the same catheter was not associated with additive effects.

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Hub qualitative blood culture is useful for diagnosis of catheter-related infections in critically ill patients

To assess clinical safety and accuracy of qualitative blood culture drawn through the hub for ruling out catheter-related infection (CRI). Prospective observational study in a surgical intensive care unit. All patients with sepsis of unknown origin and possibly due to a CRI. Blood culture drawn through a central venous catheter (CVC) just before the catheter was cultured. In 126 patients we investigated 135 cases of sepsis of unknown origin. Using a clinical and bacteriological approach as the reference, the performance of the CVC blood culture was evaluated by the calculation of sensitivity, specificity, and positive and negative predictive values. When CVC blood culture was positive, the time to positivity was considered. Using standard definitions, seven CRIs were diagnosed. CVC blood culture identified five CRIs including the three episodes of catheter-related bacteremia. The method missed two coagulase-negative staphylococcus CRIs without bacteremia. Thirteen false-positive results occurred, including seven bacteremias from a distant source. The CVC blood culture had a sensitivity of 71% (CI 30-95%), specificity of 90% (CI 83-94%), negative predictive value of 98% (CI 93-100%), and positive predictive value of 28% (CI 11-54%). In cases of catheter-related bacteremia the time to positivity of CVC blood culture was 24 h or less. Negative CVC blood culture at 24 h seems useful for management of CVC in selected critically ill surgical patients developing a clinical sepsis. The subsequent risk of catheter-related bacteremia cannot be excluded advocating for an uninterrupted clinical and bacteriological survey.

Recurrent bacteraemia by 2 different Bacillus cereus strains related to 2 distinct central venous catheters

A 14-y-old girl with osteosarcoma developed 3 episodes of catheter-related bacteraemia by Bacillus cereus. After removal of the first and insertion of a second Hickman catheter, further episodes of B. cereus bacteraemia occurred. PFGE analysis revealed that bacteraemic episodes related to each catheter were caused by a distinct B. cereus strain.

Dialysis catheter-related bacteremia: Treatment and prophylaxis

Dialysis catheter-related bacteremia: Treatment and prophylaxis

Treatment of catheter-related bacteraemia with an antibiotic lock protocol: effect of bacterial pathogen.

The standard therapy of dialysis catheter-related bacteraemia involves both systemic antibiotics and catheter replacement. We reported recently that instillation of an antibiotic lock (highly concentrated antibiotic solution) into the catheter lumen after dialysis sessions, in conjunction with systemic antibiotics, can successfully treat many episodes of catheter-related bacteraemia without requiring catheter removal. The present study evaluated whether the likelihood of achieving a cure with this protocol depends on the type of pathogen. This was a historically controlled interventional study of an antibiotic lock protocol for the treatment of catheter-related bacteraemia. We analysed prospectively the likelihood of clinical cure (fever resolution and negative surveillance cultures) with an antibiotic lock protocol among patients with dialysis catheter-related bacteraemia. In addition, infection-free catheter survival was evaluated for up to 150 days, and compared with that observed among patients managed with routine catheter replacement. Overall, the antibiotic lock protocol was successful in 33 of 47 infected patients (70%) with catheter-related bacteraemia. The likelihood of a clinical cure was 87% for Gram-negative infections, 75% for Staphylococcus epidermidis infections, and only 40% for Staphylococcus aureus infections (P = 0.04). The median infection-free catheter survival with the antibiotic lock protocol was longer than that observed among patients with routine catheter replacement (154 vs 71 days, P = 0.02). The clinical success of an antibiotic lock protocol in eradicating catheter-related bacteraemia while salvaging the catheter is highly dependent on the bacterial pathogen. Thus, the overall success rate in an individual dialysis programme will depend on the relative frequencies of different bacterial pathogens.