Harborview Medical Center Guidelines

Hemodialysis Central Venous Catheter Infections

Overview

HD-catheter associated bloodstream infections (HD-CABSI) are a crucial problem for hemodialysis patients in the inpatient and outpatient venues.

  • Morbidity (admission, line replacement, site damage, discomfort, temporary access, abx toxicity, infection sequelae including potential mortality, damage to future vascular access sites, missed dialysis with consequences of uremia, acid/base/electrolyte abnormalities, volume overload etc).
  • Expense (increased length of stay, resources needed to replace lines, drug acquisition costs, etc.).

The appropriate definition, prevention, diagnosis, and management of HD-CABSI remain topics of debate in the medical literature and at UW Medicine.  However, guidelines are now published by the Infectious Diseases Society of America (IDSA) on CABSI, and by the National Kidney Foundation’s Kidney Diseases Outcomes Quality Initiative (NKF KDOQI) specifically on HD-CABSI.2    A multi-disciplinary working group has been formed to study the feasibility and appropriateness of implementing these guidelines at UWMC.

Long-Range Goals

  • To reduce the incidence of HD-CABSI at UWMedicine sites,
  • To improve the outcomes of our patients who develop HD-CABSI in spite of those preventive efforts, and
  • To publish our experiences with this process.

Mid-Range Goal

Achieve consensus among stakeholders regarding best evidence-based practices for the management of patients who are diagnosed with HD-CABSI, and implement those practices.

Short-Range Goals / Next Steps

  • Meet with other draft readers to discuss proposed changes, so that we may then
  • Arrange for introduction of the revised proposal to the broader stakeholder group.

Stakeholders

  • Patients
  • UW Medicine
  • Nephrology
  • Interventional Radiology
  • Internal Medicine
  • Infectious Diseases
  • Infection Control / Abx Stewardship
  • Lab Medicine / Medical Microbiology
  • Center for Clinical Excellence
  • Risk Management

Proposal for Management Of HD-CABSI at UWMC

Definitions of HD-CABSI-related conditions

Catheter-Related Infection Subtypes

  • Exit Site Infection: Physical exam findings distal / superficial to the cuff suggestive of inflammation (including localized erythema, fluctuance, tenderness, and purulent discharge from the exit site).  This is a clinical diagnosis, and can be made before culture results are reported from blood or from subcutaneous exudates.
  • Tunnel Infection: Physical exam findings proximal / deep to the cuff suggestive of inflammation (including track erythema, fluctuance, tenderness, and purulent discharge, purulent discharge from the exit site on squeezing of cuff).  This is a clinical diagnosis, and can be made before culture results are reported from blood or from subcutaneous exudates.
  • Lumen Infection: Positive blood cultures drawn from one or more line lumens, in the absence of obvious alternate sources.  Lumen infections may be suspected clinically, but can only be confirmed by laboratory work.  Lumen infections may co-exist with exit site or tunnel infections.  

Classification of Infection

  • Definite: The same organism from a semiquantitative culture of the catheter tip (>15 colony-forming units per catheter segment) and from a peripheral or catheter blood sample in a symptomatic patient with no other apparent source of infection.
  • Probable: Defervescence after antibiotic therapy with or without removal of catheter, in the setting in which blood cultures confirm infection, but catheter tip does not (or catheter tip does, but blood cultures do not) in a symptomatic patient with no other apparent source of infection.
  • Possible: Defervescence after antibiotic treatment or after removal of catheter in the absence of laboratory confirmation of bloodstream infection in a symptomatic patient with no other apparent source of infection.

Diagnosis

  • H&P:
    • Assess for presence of SIRS or sepsis syndrome, and
    • Assess for presence of exit site or tunnel infection.
  • Laboratory Values:
    • Optimal: Obtain paired, simultaneous quantitative blood cultures from both HD catheter lumens and from a fresh peripheral stick, being careful to label each specimen by origin (line infection if ≥5x increased colony count from HD catheter vs. peripheral stick), or
    • Practical: Obtain paired, simultaneous quantitative blood cultures from both HD catheter lumens, being careful to label each specimen by origin (>102 colonies from either sample indicates probable line infection). 

Management of HD-CABSI

Suspected Exit Site Infection (Cuff not Involved), Clinically Stable Patient:

Figure 1: Algorithm for Suspected Exit Site Infections

Figure 1: Algorithm for Suspected Exit Site Infections

  1. Draw blood cultures as described above to rule out concurrent lumen infection.
  2. Culture exudate at exit site, if present.
  3. Use topical antibiotic therapy (triple antibiotic cream or mupirocin). Consider empiric trimethoprim/sulfamethoxazole 1 DS tablet PO Q 24 hours (NOTE: if already on TMP/SMX or immunosuppressed, consider parenteral therapy with vancomycin).  If patient is unable to take PO or is sulfa allergic, consider vancomycin   No need to re-check vancomycin levels once patient has achieved steady-state.
  4. If lumen infection is diagnosed by blood culture, proceed to “Lumen Infection, clinically stable patient” below.
  5. Tailor antibiotics based upon culture results:
    • For MRSA, continue oral TMP/SMX if infection is minor and patient is responding; or if infection is severe or patient fails to improve clinically within first 48 hours use vancomycin 15 mg/kg x 1, and check level before next dialysis session (target level = 10-20 mcg/mL).
    • For MSSA switch to cephalexin 500 mg PO Q 12 hours; or if infection is severe or patient fails to improve clinically within first 48 hours use cefazolin 2 gm IV following HD or 3 gm IV following weekend HD.
    • For CoNS or gram-negatives, switch antibiotics based on susceptibility pattern.  Duration of therapy is typically 5-10 days, or less if patient is clinically cured sooner.
    • Retain HD access unless patient becomes hemodynamically unstable, or infection fails to improve clinically after 48-72 hours of antibiotics, or infection clinically progresses proximal to cuff at any time. 

Suspected Tunnel or Cuff Infection, Clinically Stable Patient:

Figure 2: Algorithm for Suspected Track Infections

Figure 2: Algorithm for Suspected Track Infections

  1. Draw blood cultures as described above to rule out concurrent lumen infection and assist in identification of offending pathogen.
  2. Culture exudate at entry site, if present.
  3. Remove HD catheter within 24 hours, in order to facilitate cure of tunnel infection.
  4. Establish peripheral IV access (not PICC).
  5. Chronic HD patients: Empiric Vancomycin 15 mg/kg IV plus either ceftazidime 1gm IV x 1 or tobramycin 2 mg/kg IV x 1 post-HD loading dose, followed by 1 mg/kg IV post-HD until susceptibility patterns established and tobramycin can be switched to a safer class of medication in consultation with ID.  It is essential to monitor tobramycin levels in collaboration with clinical pharmacists in order to minimize risk of tobramycin ototoxicity and vestibular toxicity.  For patients who remain on tobramycin, audiograms are required within 48 hours of initiating therapy.  Consider N-acetylcysteine 600mg PO BID during tobramycin therapy, which may reduce risk of ototoxicity.
  6. Acute HD patients: Empiric Vancomycin 15 mg/kg IV plus ceftazidime 1 gm IV x 1.
  7. Await blood cultures.  If negative consider trimethoprim/sulfamethoxazole 1 DS tablet PO Q 24 hours.  If patient is unable to take PO or is sulfa allergic, consider vancomycin 15 mg/kg x 1, and check level before next dialysis session (target level = 10-20 mcg/mL).  No need to re-check vancomycin levels once patient has achieved steady-state.
  8. Tailor antibiotics based upon culture results: for MRSA, continue oral TMP/SMX; for MSSA switch to cephalexin 500 mg PO Q 12 hours; for CoNS or gram-negatives, switch based on susceptibility pattern.  Duration of therapy is typically 5-10 days, or less if patient is clinically cured sooner.
  9. If feasible, placement of new permanent HD access at a new site is advisable once the patient has been treated with antibiotics for at least 48 hours and has negative cultures at 48 hours of incubation.  If initial blood cultures are positive, they should be re-drawn daily until negative at 48 hours incubation.  Because the patient is receiving antibiotics, line placement can proceed once a single set of blood cultures are negative at 48 hours of incubation, regardless of whether subsequent sets of blood cultures are still in process at that time.

Suspected Lumen Infection, tunnel & exit sites normal, clinically stable patient:

Figure 3: Algorithm for Suspected Lumen Infections

Figure 3: Algorithm for Suspected Lumen Infections

  1. Draw blood cultures as described above to confirm diagnosis and identify offending pathogen.  Consider ID consultation and echocardiogram.
  2. Chronic HD patients: Empiric Vancomycin 15 mg/kg IV plus either ceftazidime 1gm IV x 1 or tobramycin 2 mg/kg IV x 1 post-HD loading dose, followed by 1 mg/kg IV post-HD until susceptibility patterns established and tobramycin can be switched to a safer class of medication in consultation with ID.  It is essential to monitor tobramycin levels in collaboration with clinical pharmacists in order to minimize risk of tobramycin ototoxicity and vestibular toxicity.  For patients who remain on tobramycin, audiograms are required within 48 hours of initiating therapy.  Consider N-acetylcysteine 600mg PO BID during tobramycin therapy, which may reduce risk of ototoxicity.3
  3. Acute HD patients: Empiric Vancomycin 15 mg/kg IV plus ceftazidime 1 gm IV x 1.
  4. Tailor continued antibiotics based on culture & sensitivity results:  for MRSA or CoNS, continue IV vancomycin by checking levels before next dialysis session (target level = 10-20 mcg/mL), usual dose 500mg after dialysis.  Check vancomycin levels once patient has achieved steady-state (approximately 1x/week).  For MSSA switch to cefazolin 2 gm IV on HD days, 3 gm if > 48 hours anticipated before next dialysis session (pre-weekend); for gram-negatives, continue tobramycin or alternative in consultation with inpatient clinical pharmacist, or switch to alternative agent if susceptibility patterns allow.   Regardless of organism or drug chosen, duration of therapy is typically 21 days. It is essential to monitor tobramycin levels in collaboration with clinical pharmacists in order to minimize risk of tobramycin ototoxicity and vestibular toxicity.  For patients who remain on tobramycin, audiograms are required within 48 hours of initiating therapy.
  5. Because of the high failure rate of simply “treating through” the lumen with intermittent doses of antibiotics4, this practice is not recommended.
  6. Per NKF / KDOQI guidelines, attempt site salvage by exchanging catheter over a guidewire once patient has gotten at least 24 hours of appropriate antibiotics.*,† Documenting clearance of cultures is not required for catheter exchange.
  7. Continue antibiotics, and continue to draw daily blood cultures as described above via new tunneled catheter.  If blood cultures fail to clear within 72 hours of exchange, then consider placing peripheral IV access (not PICC), removing catheter, and awaiting negative blood cultures at 48 hours of incubation before placing new tunneled access.

* Rationale: Protect the site—which is precious—rather than the line—which is expendable. Evidence: The majority of patients treated in this manner as described in the literature have achieved clearance of their bacteremia without untoward effects. Significant cost savings versus conservative therapy is an additional benefit. Many infectious diseases specialists believe that patients who have lumen infections due to Staph aureus, yeast, and mycobacteria are unlikely to clear their infections without catheter removal.  Thus, when these species are detected, the infectious diseases consultants will generally recommend catheter exchange. Downsides: Resource utilization in interventional radiology, and risk of injury to the patient during the exchange procedure.

† NOTE: NKF / KDOQI guidelines also address catheter salvage attempts by combining systemic antibiotics with antibiotic lock technique.  In this approach, highly-concentrated solutions of antibiotics and anticoagulants instilled precisely to the volume of the affected lumen(s) may achieve MIC’s far in excess of those required to overcome the relative antibiotic resistance provided by biofilms.  This approach avoids inconvenience associated with guidewire exchange.  Success rates with this approach reported in the literature approach those of catheter exchange.  In the absence of a head-to-head RCT comparing catheter exchange with antibiotic lock or catheter removal, the NKF / KDOQI Guidelines do not endorse one approach over the other.  However, significant downsides prohibit us from putting this into practice at UW and NWKC, including frequency of changing the locks, lack of nursing expertise / QC, and risk of harm from inadvertent infusion of concentrated anticoagulants, and lack of reliability for organisms such as Staph aureus, yeast, and mycobacteria.

Septic or hemodynamically-unstable patient with no other apparent source of infection:

  1. Admit to MICU. Recommend immediate ID consultation and echocardiogram.
  2. Draw blood cultures as described above.
  3. Chronic HD patients: Empiric Vancomycin 15 mg/kg IV plus either ceftazidime 1gm IV x 1 or tobramycin 2 mg/kg IV x 1 post-HD loading dose, followed by 1 mg/kg IV post-HD until susceptibility patterns established and tobramycin can be switched to a safer class of medication in consultation with ID.  It is essential to monitor tobramycin levels in collaboration with clinical pharmacists in order to minimize risk of tobramycin ototoxicity and vestibular toxicity.  For patients who remain on tobramycin, audiograms are required within 48 hours of initiating therapy.  Consider N-acetylcysteine 600mg PO BID during tobramycin therapy, which may reduce risk of ototoxicity.3For continued antibiotic dosing regimens, consult ID service and inpatient clinical pharmacist. 
  4. Acute HD patients: Empiric Vancomycin 15 mg/kg IV plus ceftazidime 1 gm IV x 1.
  5. Establish peripheral IV access (not PICC) and consult IR service.  IR will remove HD catheter as soon as feasible (within no more than 12-24 hours of consultation), in order to accelerate clearance of bacteremia and improve odds of survival in these critically ill patients.  
  6. Tailor antibiotic coverage once culture & sensitivity data are available.  For MRSA, continue vancomycin (no need to re-check vancomycin levels once patient has achieved steady-state); for MSSA switch to cefazolin 2 gm IV on HD days, 3 gm if > 48 hours anticipated before next dialysis session; for gram-negatives, continue tobramycin in consultation with inpatient clinical pharmacist, or switch to alternative agent if susceptibility patterns allow.   Infectious Diseases consultation is recommended. 
  7. Regardless of offending organism, usual minimum duration of antibiotic therapy is 21 days following HD catheter removal.  If cultures are persistently positive, or if organism is identified as Staph aureus or Candida, strongly consider evaluating for possible metastatic endovascular infection (possibly via TTE, ophthalmological exam, or CT imaging).  
  8. Placement of new permanent HD access is advisable once the patient is afebrile and clinically stable, has been treated with appropriate antibiotics for at least 48 hours, and has blood cultures that are negative for growth at 48 hours of incubation.  If HD access is required before patients meet these criteria, then placement of a temporary HD catheter may be necessary.

References

  1. Mermel LA, Farr BM, Sheretz RJ, et al.  Guidelines for the management of intravascular catheter-related infections.  Clin Infect Dis 2001: 32 1249-1272.
  2. National Kidney Foundation 2006.  http://www.kidney.org/professionals/KDOQI/guideline_upHD_PD_VA/va_guide7.htm
  3. Feldman L, Efrati S, Eviatar E, et al.  Gentamicin-induced ototoxicity in hemodialysis patients is ameliorated by N-acetylcysteine.  Kidney Int 2007: 72, 359-363.
  4. Marr KA, Sexton DJ, Conlon PJ, et al.  Catheter-related bacteremia and outcome of attempted catheter salvage in patients undergoing hemodialysis. Ann Intern Med 1997: 127:275-280.
  5. Robinson D, Suhocki P, Schwab PJ.  Treatment of infected tunneled venous access hemodialysis catheters with guidewire exchange.  Kidney Int 1998: 53: 1792-94.
  6. Beathard GA.   Management of bacteremia associated with tunneled-cuffed hemodialysis catheters. J Am Soc Nephrol  1999: 10:1045-1049.
  7. Shaffer D.  Catheter-related sepsis complicating long-term, tunnelled central venous dialysis catheters: Management by guidewire exchange. Am J Kidney Dis 1995: 25:593-596.
  8. Saad TF.  Bacteremia associated with tunneled, cuffed hemodialysis catheters. Am J Kidney Dis 1999:  34:1114-1124.
  9. Mokrzycki MH, Singhal A.  Cost-effectiveness of three strategies of managing tunnelled, cuffed haemodialysis catheters in clinically mild or asymptomatic bacteraemias. Nephrol Dial Transplant 2002: 17:2196-2203.
  10. Boorgu R, Dubrow AJ, Levin NW, et al.  Adjunctive antibiotic/anticoagulant lock therapy in the treatment of bacteremia associated with the use of a subcutaneously implanted hemodialysis access device. ASAIO J 2000: 46:767-770.
  11. Capdevila JA, Segarra A, Planes AM, et al.  Successful treatment of haemodialysis catheter-related sepsis without catheter removal.  Nephrol Dial Transplant 1993: 8:231-234.
  12. Krishnasami Z, Carlton D, Bimbo L, et al.  Management of hemodialysis catheter-related bacteremia with an adjunctive antibiotic lock solution.  Kidney Int 2002: 61:1136-1142.
  13. Poole CV, Carlton D, Bimbo L, Allon M: Treatment of catheter-related bacteraemia with an antibiotic lock protocol: Effect of bacterial pathogen. Nephrol Dial Transplant 2004: 19:1237-1244.
  14. Maya ID, Carlton D, Estrada E, Allon M.  Treatment of dialysis catheter-related Staphylococcus aureus bacteremia with an antibiotic lock: a quality improvement report.  Am J Kidney Dis 2007: 50 (6): 289-95.

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