Preventing haemodialysis catheter-related bacteraemia with an antimicrobial lock solution: a meta-analysis of prospective randomized trials

Abstract

Background. Catheter-related bacteraemia (CRB) is a major cause of morbidity and mortality in haemodialysis patients. Interdialytic locking of catheters with antimicrobial agents has recently been investigated for the prevention of CRB. We performed a meta-analysis of randomized controlled trials (RCT) to determine the efficacy of antimicrobial lock solutions (ALS) in the prevention of CRB in haemodialysis patients. Methods. We collected from Medline, Web of Science, the Cochrane Library and major nephrology journals, all relevant references (January 1990-March 2007. We selected RCT comparing an ALS to a standard heparin lock in CRB prevention. We extracted data concerning study quality, patient characteristics and CRB incidence. The relative risk (RR) of CRB was calculated as Ln (CRB incidence control/CRB incidence experimental) using both a fixed-and a random-effects model. Results. Eight studies were included, involving 829 patients, 882 catheters and 90 191 catheter-days. The use of an ALS significantly decreased the risk of CRB (RR 0.32; 95% CI 0.10-0.42). Borderline heterogeneity was observed in the fixed-effects model (Q = 14.42; P = 0.071). Despite the under-representation of small negative studies, the high number of additional trials necessary to reverse the final effect strengthens the confidence in the overall results. Subgroup analyses stratified by the presence of diabetes, duration of follow-up, biochemical markers, proportion of tunnelled cuffed catheters, intranasal mupirocin use and citrate use in the ALS did not show significant differences, except a higher efficacy of gentamicin-containing lock solutions (P = 0.003). Conclusions. The use of ALS reduces by about a factor 3 the risk of CRB in haemodialysis patients. The achieved absolute incidence is similar to the best-published figures (presumably related to stricter hygienic measures). The limited follow-up of the studies does not exclude the onset of Correspondence and offprint requests to: Michel Jadoul, Department of Nephrology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Avenue Hippocrate 10, B 1200 Brussels, Belgium. Tel: +32-2-764-18-52; Fax: +32-2-764-28-36; E-mail: jadoul@nefr.ucl.ac.be adverse events or bacterial resistance with longer use of ALS.

Prevention of catheter-related bacteremia in children on hemodialysis: time for action

“…James et al reported that the use of intraluminal antibiotics in 11 trials reduced the rate of catheter removal due to complication by 63% [79]. The meta-analysis of Labriola et al of nine trials documented that the use of AMLs in TCCs reduced the incidence of CRB by about a factor of three [80]. However, the achieved incidence of CRB in the ALS groups is similar to published reports from units with low CRB incidence (and presumably stricter hygienic measures) [80].…”

“…The meta-analysis of Labriola et al of nine trials documented that the use of AMLs in TCCs reduced the incidence of CRB by about a factor of three [80]. However, the achieved incidence of CRB in the ALS groups is similar to published reports from units with low CRB incidence (and presumably stricter hygienic measures) [80]. Similarly, the meta-analysis of 11 studies by Yahav et al showed that the treatment of four patients with AMLs prevented one CRB [81].…”

“…It is encouraging that the recent meta-analysis studies do not provide evidence for the development of resistance with the use of AML [81]. Unfortunately, the limited follow-up of patients included in these studies does not exclude the onset of adverse events or bacterial resistance with longer use of ALS [80]. Actually, there is some evidence that this possibility might occur.…”

Reducing Catheter-Related Infections in Hemodialysis Patients

“…Boyce recently reviewed all antimicrobial lock studies (antibiotic-and non-antibiotic-based) performed from 1999 to 2012 and concluded that antimicrobial locks should be used for CRBSI prevention in all hemodialysis units (11). In addition, five meta-analyses or systematic reviews (12)(13)(14)(15)(16) published during this time period indicate significant reductions in CRBSI; in particular, two meta-analyses reported a number needed to treat to prevent one CRBSI of 3 to 4 (12,13). Most of the included studies compared an antimicrobial lock with heparin as the control and used different protocols for general catheter care, such that infection rates in the control groups were approximately 3 per 1000 catheter-days.…”

Emergence of Gentamicin-Resistant Bacteremia in Hemodialysis Patients Receiving Gentamicin Lock Catheter Prophylaxis

“…Numerous randomized, controlled trials (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20), as well as meta-analyses of these studies (21)(22)(23)(24)(25), have been performed during the past decade to evaluate the benefit of anti-microbial lock solutions in chronic hemodialysis patients with TCCs. These studies have been heterogeneous in nature and used different antibiotics (gentamicin, minocycline, cefazolin, cefotaxime, vancomycin) and nonantibiotic (citrate, taurolidine, EDTA) anti-microbial lock solutions; however, they have all shown a significant decline of 50 to 100% in CRIs compared with standard heparin lock without antibiotics or other sterilizing solutions (3).…”