Comparative Effectiveness of Two Catheter Locking Solutions to Reduce Catheter-Related Bloodstream Infection in Hemodialysis Patients

Abstract

Background and objectives Infection is the second leading cause of death in hemodialysis patients. Catheterrelated bloodstream infection and infection-related mortality have not improved in this population over the past two decades. This study evaluated the impact of a prophylactic antibiotic lock solution on the incidence of catheter-related bloodstream infection and mortality.Design, setting, participants, & measurements This prospective, multicenter, observational cohort study compared the effectiveness of two catheter locking solutions (gentamicin/citrate versus heparin) in 555 hemodialysis patients dialyzing with a tunneled cuffed catheter between 2008 and 2011. The groups were not mutually exclusive. Rates of catheter-related bloodstream infection and mortality hazards were compared between groups.Results The study population (n=555 and 1350 catheters) had a median age of 62 years (interquartile range=41-83 years), with 50% men and 71% black. There were 427 patients evaluable in the heparin period (84,326 days) and 322 patients evaluable in the antibiotic lock period (71,192 days). Catheter-related bloodstream infection in the antibiotic lock period (0.45/1000 catheter days) was 73% lower than the heparin period (1.68/1000 catheter days; P=0.001). Antibiotic lock use was associated with a decreased risk of catheter-related bloodstream infection compared with heparin (risk ratio, 0.23; 95% confidence interval, 0.13 to 0.38 after multivariate adjustment). Cox proportional hazards modeling found that antibiotic lock was associated with a reduction in mortality (hazard ratio, 0.36; 95% confidence interval, 0.22 to 0.58 in unadjusted analyses; hazard ratio, 0.32; 95% confidence interval, 0.14 to 0.75 after multivariate adjustment). The rate of gentamicin-resistant organisms decreased (0.40/1000 person-years to 0.22/1000 person-years) in the antibiotic lock period (P=0.01). ConclusionsThe results of this study show that the use of a prophylactic, gentamicin/citrate lock was associated with a substantial reduction in catheter-related bloodstream infection and is the first to report a survival advantage of antibiotic lock in a population at high risk of infection-related morbidity and mortality.

Prevention of catheter-related bloodstream infections in patients on hemodialysis: challenges and management strategies

“…43 A prospective, observational cohort study in 555 patients conducted over a 3-year period showed a 73% reduction in CRBSI after a gentamicin citrate locking solution was instituted. 47 A unique feature of this study was the decrease in mortality after AML was initiated with an adjusted hazard ratio of 0.32 (CI 0.14-0.75). The rate of gentamicin-resistant organisms actually decreased over the course of the study.…”

Effectiveness of heparin versus 0.9% saline solution in maintaining the permeability of central venous catheters: a systematic review

“…Despite the potential benefits of saline solution, the change in clinical practice for a normal saline solution has not been widely suggested in the literature for the whole typology of patients and CVC. A possible explanation for this may be attributed to the long period of time that CVC remains in the patient (25)(26)(27) , complications associated with maintaining CVC (28)(29)(30)(31) , type of infusion used (medicinal, solutions…) (32) ; if the purpose of the CVC is hemodialysis (9)(10)(11)(12)(13)(14) and institutional procedures for locking and flushing can strengthen medical belief about heparin effectiveness (10) , thus ultimately leading to exploiting the effectiveness of other solutions (33) (i.e. citrate).…”

Reducing Catheter-Related Infections in Hemodialysis Patients

“…In this issue of CJASN, Moore et al try to answer these questions (20). The authors conducted a prospective, multicenter, observational cohort study in a metropolitan area to compare the effectiveness of a gentamicin-citrate lock versus heparin in 555 hemodialysis patients undergoing dialysis with a tunneled central venous catheter between 2008 and 2011.…”