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

Abstract

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.

Effect of Catheter-Lock Solutions on Catheter-Related Infection and Inflammatory Syndrome in Hemodialysis Patients: Heparin versus Citrate 46% versus Heparin/Gentamicin

“…Some authors proposed antibiotic or antiseptic ointments at the exit site. Antibiotic ointment at the exit site was compared in one randomized study to gentamicin CLS (5 mg/ml) [20] . CRI was less frequent in the gentamicin CLS group.…”

Efficacy of preventing hemodialysis catheter infections with citrate lock

“…Another opinion review reported conflicting results of trials made by different authors with different citrate concentrations and for sure with different clinical management practices, which in our opinion are not comparable. In our hands, topical antimicrobial ointments had a significantly higher number of CRB episodes compared to gentamicin lock and the addition of topical antimicrobial ointments to gentamicin lock did not decrease the incidence of CRB . So our experience with Lok's recommendation of prophylactic topical antimicrobial ointments at the catheter exit site had no utility.…”

“…No additive effect was observed when joining both methods in the same patients. The number of CRB episodes was three times lower in the low‐dose gentamicin lock group and five times lower when compared to our historical controls . Most popular locks use either gentamicin or citrate.…”

“…In our hands, topical antimicrobial ointments had a significantly higher number of CRB episodes compared to gentamicin lock and the addition of topical antimicrobial ointments to gentamicin lock did not decrease the incidence of CRB. 13 So our experience with Lok's recommendation of prophylactic topical antimicrobial ointments at the catheter exit site had no utility. Nowadays, CRB is fortunately an increasingly rare event because of better catheter management.…”

“…The number of CRB episodes was three times lower in the low-dose gentamicin lock group and five times lower when compared to our historical controls. 13 Most popular locks use either gentamicin or citrate. Citrate has a proven anti biofilm activity, 14 probably does not lead to bacterial resistance, has a low industrial cost and easy manipulation, all relevant advantages over the in-unit prepared low-dose gentamicin lock, previously in use in our units.…”