Dialysis Catheter Infection

[waterski232002]

Do all dialysis catheters need to be removed in cases of confirmed line sepsis?

---

Members don't see this ad.

 

[elwademd]

i think that any line (triple lumen, dialysis catheter, port a cath, etc.) that is confirmed to be the source of infection should be removed. the timing of this removal depends on the type of catheter, since a typical triple lumen catheter can be removed easily at the bedside; whereas a tunneled/cuffed catheter may require going to the o.r.

idsociety.org / clinical infectious diseases on management of intravascular catheter associated infections:
http://www.journals.uchicago.edu/CID/journal/issues/v32n9/001689/001689.html

 

[ChildNeuro]

Do all dialysis catheters need to be removed in cases of confirmed line sepsis?

I would agree with above that any line, in the case of line sepsis when confirmed to be the source of the sepsis should be removed, as antibiotics will not clear the bacterial collection/infection in the catheter AND it will continue to seed infection. To go one step further, a big red flag when you wrote *dialysis* catheter, dialysis patients, I believe, are immunosupressed and can get severe sepsis and die very easily, so SIRS i.e. such as a low grade fever is taken much much more seriously in these patients, and if a line was suspected to be the source it would be removed asap. If you delayed removing an infected line in a dialysis patient especially that would be very very bad medicine.

 

[waterski232002]

Uptodate suggests that you can salvage tunneled/cuffed catheters even in confirmed line sepsis. This is a consideration particularly in situations where alternative access sites are problematic.

However, they must meet the following criteria: HD stable, no associated cellulitis/abscess/tunnel infection, no fevers & no +BCx 48 hours from first round of antibiotic administration, blood cultures do not grow out pseudomonas or candida.

I'm just curious if using salvage antibiotics is actually practiced, or if most nephrologists tend to just change out the dialysis cath any time a blood culture turns positive.

 

[lurkerboy]

In patients with difficult access, and suspected line infection, I have had several cases of ports and tunneled lines where I've treated through. There are even protocols for doing antibiotic flushes (eg: heparin + vanco). If you are sure the line is infected (eg: the patient has fevers/chills every time you use the line) I've never seen this work.

(By difficult access, I mean patients who have clots/stenosis of their IJ's and subclavians and are walking around with a crazy tunneled line in their groin or something)

Uptodate suggests that you can salvage tunneled/cuffed catheters even in confirmed line sepsis. This is a consideration particularly in situations where alternative access sites are problematic.

However, they must meet the following criteria: HD stable, no associated cellulitis/abscess/tunnel infection, no fevers & no +BCx 48 hours from first round of antibiotic administration, blood cultures do not grow out pseudomonas or candida.

I'm just curious if using salvage antibiotics is actually practiced, or if most nephrologists tend to just change out the dialysis cath any time a blood culture turns positive.

 

[f_w]

I'm just curious if using salvage antibiotics is actually practiced, or if most nephrologists tend to just change out the dialysis cath any time a blood culture turns positive.

In my experience, most exchanges happen after a failed course of antibiotics and TPA (I only saw the failures, never the ones where it works, so I can't tell you how the odds are).

You have a limited number of access sites for large diameter tunneled catheters. Once you are talking translumbars, you have to get a bit less orthodox than the ID guys want you to be.

 

[ChildNeuro]

Uptodate suggests that you can salvage tunneled/cuffed catheters even in confirmed line sepsis. This is a consideration particularly in situations where alternative access sites are problematic.

However, they must meet the following criteria: HD stable, no associated cellulitis/abscess/tunnel infection, no fevers & no +BCx 48 hours from first round of antibiotic administration, blood cultures do not grow out pseudomonas or candida.

I'm just curious if using salvage antibiotics is actually practiced, or if most nephrologists tend to just change out the dialysis cath any time a blood culture turns positive.

There are some small trials showing that an antibiotic-heparin lock can be used in tunneled catheters in hemodialysis patients with very close monitoring of the patients, maybe there is a larger trial out there, I am not sure. I would be really afraid if I had a patient who I was waiting on blood cultures for in deciding on whether or not to take out the catheter, you would have to be an expert in recognizing failure of empiric treatment in the case of line sepsis in the hemodialysis patient. Couldn't a line infection be a source of sepsis as often times in sepsis the blood cultures are negative? It seems unclear from the trial in 2002 whether or not you define success as clinical improvement and return to baseline in the face of continued positive bacteriologic blood cultures, who knows what the risk is to the patient then, they will maybe need to do much larger studies. Personally, I think they need to develope catheters that have some sort of biologic tissue which would be resistant to colonization or even a biofilm of an engineered non-pathogenic bacteria that the catheters is pre-soaked in. . . if such a thing exists, I bet 50 years from now all the "tubes" we put into patients will be biologics.

 

[augmel]

practically speaking, the organism kind of matters too. I've seen ID docs and nephrologists hesitate to pull a line for some organisms, but never for others, such as staph aureus.