Exit-site Tunnel Infection Research Articles

A Randomized Controlled Trial of Comparative Efficacy between Sodium Bicarbonate and Heparin as A Locking Solution for Tunneled Central Venous Catheters Among Patients Requiring Maintenance Hemodialysis.

Background:Sodium bicarbonate (NaHCO3) is one of the promising solutions that has good safety profile and theoretical advantages regarding antimicrobial and antithrombotic properties but there are still limited reports.Objective:To compare the efficacy in lowering rate of catheter loss due to catheter-related thrombosis (CRT) or catheter-related blood stream infection (CRBSI) between sodium bicarbonate and heparin lock in prevalent chronic hemodialysis (HD) patients.Design:A multicenter, randomized, open-label studySetting:In a developing country, ThailandPatients:Chronic HD patients with tunneled central venous catheterMeasurements:Catheter loss rate, rate of catheter-related blood stream infection, catheter-related thrombosis, and exit site or tunnel infectionMethods:The prospective multicenter randomized controlled trial was conducted, we randomly assigned 118 patients undergoing HD with tunneled central venous catheter to receive a catheter locking solution of sodium bicarbonate or heparin. The primary outcome was a catheter loss rate due to CRT or CRBSI, while the secondary outcome was a composite outcome of CRT, CRBSI, or exit site/tunnel infection (ESI/TI).Results:The present study was stopped early due to an excess of catheter-related thrombosis in the sodium bicarbonate group. From the first 6 weeks of follow-up, there were no catheter losses due to CRT or CRBSI in both groups. The sodium bicarbonate group had a significantly higher rate of the secondary composite outcomes and this was entirely caused by CRT with the median time to thrombosis of 23.6 days. Every CRT event could be successfully rescued by using a single dose of recombinant tissue plasminogen activator (rt-PA).Limitations:Short follow-up period.Conclusions:In prevalent HD patients with tunneled CVCs, use of a sodium bicarbonate locking solution for prevention of CRT is inferior to heparin and is associated with a high rate of catheter-related thrombosis.Trial registration:The study was registered with the Thai Clinical Trials Registry TCTR 20200610003

Impact of peritoneal catheter intramural design on dialysis discontinuation rate.

Catheter dislocation is an important cause of technique failure for peritoneal dialysis (PD). Aim of this study is to evaluate the effect of intramural trait configuration on this outcome. We considered 240 swan neck, double-cuffed catheters positioned in adult patients in our Centre with mini-laparotomy technique partitioned, according with the intramural segment design, in a standard technique group (ST) (n. 199): oblique passage of the catheter through the rectus sheath in the craniocaudal direction, and in a modified technique group (MT) (n. 41): anterior fascia lanced 3 cm cranially to the deep cuff to let catheter out. The primary end-point was dialysis failure due to tip migration. Secondary end-points were any other causes of catheter removal. Incidence of catheter removal for non-responsive tip migration was 14.3% in MT and 6.1% in ST. Neither this difference nor the catheter survival rate for this outcome was statistically significant. PD interruption for refractory exit site/tunnel infection (ESI) was in favour of ST (4% ST, 35.7% MT; P < .01) whereas ESI catheter survival rate was only marginally significant (292.8 days in MT vs 743.6 in ST, P = .045). No other recorded cause of PD discontinuation was significantly different. Modified technique group is associated with a major ESI risk but, given the average survival, it seems to be due more to exit site management than to the specific surgical procedure. MT is not superior to ST to prevent catheter dislocation nevertheless, considering its simplicity and rapidity it can be deemed as first-choice option.

P134410 YEARS EXPERIENCE WITH HEMODIALYSIS TUNNELED CATHETERS

Abstract Background and Aims A well functioning vascular access ( VA) is vital for hemodialysis (HD) patients. To date a native arteriovenous fistula ( NAVF) remains the gold standard but patients vascular characteristics are often not optimal for vascular surgery. A tunneled central venous catheter (tCVC) are becoming increasingly used as permanent dialysis access and are also competitive to NAVF for the easy and safe insertion tecnique. Our retrospective study observe, during a 10 years period, infection rate of tCVC, bacteriologic analysis and cause of removal. Method From January 2010 to December 2019, 176 tCVC were placed in 158 patients ( mean age 74 +/- 18) . All tCVC were inserted by nephrologist in internal giugular vein (IGV), subclavian vein (SV) and femoral vein (FV) using ultasonographic guide. Standards protocols, according to European Renal Best Practice (2010) detailing all aspects of preventive care were used. Each tCVC was followed until it was removed or until the end of the study. 62110 days was the follow up period. 143 tCVC wew placed in IGV ( 81,5%), 22 in FV ( 11,5 %) and 11 in SV (7%). The diagnosis of infection was based on clinical evidence and positive blood culture or positive exit site swab, with no sign of other infection site. We considered a tCVC disfunction in case of blood flow less than 250 ml/m'. Event rates were calculated per 1000 catheters days. Results Mean tCVC duration was 353 days. We observed a progressive increment in CVC prevalence during the observational period ( from 15% in 2010 to 39% in 2019). Catheter replacement recurred in 19 patients and the main cause of replacement was loss of patency ( 0,3 per 1000 catheter days). We observed 63 catheter related bloodstream infection (CRBI) and 71 exit site/tunnel infection (ESI/TI). Incidence for CRBI was 1 per 1000 catheter days and ESI/TI was 1,14 per 1000 catheter days. In CRBI the most common organism isolated were MRSA (40%) and MSSA (26%) . In ESI/TI the most common organism isolated was Staphilococcus epidermidis (39.5%) . We used systemic antibiotics, local therapy and lock therapy with a 93% resolution without removal. 12 tCVC were removed for recurrent CRBI ( 0,19 per 1000 catheter days). At the end of the observation 25 tCVC were still in use. Conclusion Our data showed an high survival rate of tCVC in hemodialysis patients. We observed CRBI and ESI/TI rates at the lower limits of the data reported in the literature. Infections were successfully treated conservately in most cases. Careful nursing protocol may reduced the frequency of infection and an early diagnosis can facilitate the rescue of the tCVC with systemic/lock therapy or local therapy. We consider in an elderly population with many comorbidities the use on tCVC recommended especially in patients with poor native peripheral vessels, in patients with steal syndrome high risk and also with a low life expectancy.

Peritoneal dialysis catheter infections and peritonitis in children: a report of the North American Pediatric Renal Transplant Cooperative Study.

Peritonitis and catheter-related infections remain the two most-common causes of peritoneal dialysis (PD) treatment failure. To define the frequency and risks associated with exit site/tunnel infections (ESI/TI), as well as peritonitis, in pediatric patients on PD, we undertook a retrospective cohort study of patients initiated on PD in the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). We examined demographic data and PD catheter characteristics of 1,258 patients, aged < or = 21 years, initiated on PD from 1992 to 1997. We examined the frequency and complications of ESI/TI occurring within 30 days, 6 months, and 1 year of follow-up. For peritonitis episodes, we examined patient risk factors for peritonitis. Almost 11% of patients had an ESI/TI at 30 days, 26% between 30 days and 6 months, and 30% between 6 months and 1 year of follow-up. There was no increased risk of ESI/TI associated with patient age, race, or catheter characteristics. Peritonitis occurred in dialysis patients at a rate of 1 episode per 13.2 patient months. Proportional hazards regression analysis demonstrated that black race, single-cuffed catheters, and upward pointing exit sites were independent risk factors for peritonitis in the pediatric PD population. Patients with ESI/TI had twice the risk of those without these infections of developing peritonitis or needing access revision, and an almost threefold increased risk of hospitalization for access complications/malfunction. ESI/TI occurs commonly in pediatric PD patients. These infections cause significant morbidity, through risk of peritonitis, access revision, and hospitalization for catheter complications. Further study of potentially modifiable risk factors for ESI/TI in pediatric end-stage renal disease patients is warranted.

Outpatient CAPD catheter salvage for persistent exit-site/tunnel infection

Partial replantation (i.e. replacement of the extraperitoneal portion of the catheter with creation of a new subcutaneous tunnel) has been suggested to avoid catheter removal in patients with persistent exit-site/tunnel infection (ESTI). However, published experience with this technique is limited. Partial replantation was performed on an outpatient basis under local anesthesia for seven patients with persistent ESTI of >3 months duration. All patients resumed CAPD immediately following surgery. One patient had dialysate leakage less than 1 week after surgery that required catheter removal. The other patients had no complications and mean catheter survival following surgery was 7. 7 months (range 3.5-13 months). There was no recurrence of ESTI after surgery, although two patients presented with exit-site infection unrelated to the initial episode (i.e. different organism, long latency). Three other patients presented with episodes of peritonitis unrelated to surgery (i.e. delay >1 month) or ESTI (i.e. different organism). Partial replantation allows significant prolongation of catheter survival without major complications or interruption of CAPD. This novel procedure appears to be an appropriate alternative to catheter removal for the management of persistent ESTI. However, further studies are needed to prospectively compare partial replantation with catheter removal.

Exit Site Tunnelinfection Rate in Tenckhoff Catheter with a 2.3 Diameter Exit Site Tunnel Section

Exit Site Tunnelinfection Rate in Tenckhoff Catheter with a 2.3 Diameter Exit Site Tunnel Section

Special Studies from the NIH USA CAPD Registry

Recent studies from the USA CAPD Registry include: cohort studies related to year of training, the impact of center size, the impact of descriptive characteristics of therapy that were not previously available, and identification of additional risk factors that predispose to transfer. The results indicate decreasing rates of peritonitis, exit site tunnel infection, and hospitalization for CAPD complications in the more recently trained patients. Center size has no major impact on outcomes. There may be a reduced risk of peritonitis with the addition of insulin to peritoneal dialysis solutions. Factors such as training year, distance from center, use of a partner, activity status, visual status, exchange volume, exchange frequency and exchange type, may influence outcomes and must be considered in studies of complication rates.