Tunneled catheters' outcome optimization among diabetics on dialysis through antibiotic-lock placement

Saxena, Anil Kumar; Panhotra, B. R.; Sundaram, D.S.; Al-Hafiz, A.; Naguib, Mohammed; Venkateshappa, C.; Abu-Oun, B.A.; Hussain, Sultana Monira; Ghamdi, Abdullah M Al

doi:10.1038/sj.ki.5001776

Cited by 61 publications

(58 citation statements)

References 25 publications

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“…The results are comparable to the outcomes reported in earlier trials involving antimicrobial locking solutions for the prevention of CRBSI among hemodialysis (HD) patients [6][7][8][9][10][11][12] (Fig. 1).…”

supporting

confidence: 79%

Editorial: The Issues Related to Hemodialysis Catheter Lock Prophylaxis with Recombinant Tissue Plasminogen Activator

Saxena¹

2011

TOUNJ

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Arteriovenous fistulas (AVF) are the most preferred and promoted form of dialysis access due to their lowest complication rates. However, the changing demographic profile of end-stage renal disease (ESRD) with an increasing elderly and diabetic population having relatively poor vasculature, relative lack of prudent pre-ESRD planning for AV fistula creation, late referrals, and comparatively lower fistula maturation rates, are essentially the factors accountable for our continued dependence upon central venous catheters (CVCs) [1][2][3]. Moreover, CVCs remain the only means to provide instant access to the circulation during emergency situations arising from the unpredictable course of chronic kidney disease.Virchow's described three broad categories of factors that contribute to thrombus formation -hypercoagulability, stasis and vascular endothelial injury. The placement of this relatively large foreign body traumatizes the host vessel and significantly alters hemodynamics fulfilling Virchow's triad for thrombus formation and provides a nidus for bacterial entry into the circulation. However, catheter malfunction limits the life span of CVCs. Inadequate blood flow and catheter-related bloodstream infections (CRBSI) are common causes of recurrent use of thrombolytic therapy, antibiotics and often result in catheter removal. Generally, standard heparin (5000 U/ mL) is used to lock the CVCs to maintain catheter patency during the interdialytic period. Locking with heparin however, does not prevent bacterial colonization and subsequent development of CRBSI. Moreover, in vitro studies have shown that heparin may induce biofilm formation [4].Replacing heparin with recombinant tissue plasminogen activator (rt-PA) once a week, as a dialysis catheter locking solution significantly reduced the incidence of catheter malfunction and CRBSI in a well conducted multicenter, double-blind, randomized controlled trial from Canada by Hemmelgarn and colleagues [5]. The authors were able to decrease the rates of catheter malfunction by 50% and

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confidence: 79%

Editorial: The Issues Related to Hemodialysis Catheter Lock Prophylaxis with Recombinant Tissue Plasminogen Activator

Saxena¹

2011

TOUNJ

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“…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). None of the aforementioned studies have reported anti-microbial resistance or loss of anti-microbial lock solution efficacy, but the longest follow-up period has only been 547 days in one study (13). Therefore, the emergence of bacterial antibiotic resistance from anti-microbial lock solutions and its potential complications remain to be determined.…”

mentioning

confidence: 91%

“…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).…”

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confidence: 99%

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

Landry

Braden

Gobeille

et al. 2010

Clinical Journal of the American Society of Nephrology

137

105

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Results: Within the first year of the GHL protocol, our CRI rate decreased from 17 to 0.83 events per 1000 catheter-days. Beginning 6 months after initiation of the GHL protocol, febrile episodes occurred in 13 patients with coagulase-negative Staphylococcus bacteremia resistant to gentamicin. Over the 4 years of GHL use, an additional 10 patients developed 11 episodes of gentamicin-resistant CRI (including 7 with Enterococcus faecalis), in which there were 4 deaths, 2 cases of septic shock requiring intensive care unit admission, and 4 cases of endocarditis. Because of these events, the GHL protocol was discontinued at the end of 2006.Conclusions: Although the use of GHL effectively lowered the CRI rate in our dialysis population, gentamicin-resistant CRIs emerged within 6 months. Gentamicin-resistant infections are a serious complication of the long-term use of GHLs. Alternative nonantibiotic catheter locks may be preferable to decrease the incidence of CRIs without inducing resistant pathogens.

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“…Furthermore, two small randomized, controlled trials showed a reduction in mortality on crude analysis by use of a prophylactic antimicrobial lock solution (16,17). However, this approach has not been widely adopted.…”

Section: Introductionmentioning

confidence: 99%

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

Moore

Besarab

Ajluni

et al. 2014

Clinical Journal of the American Society of Nephrology

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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.

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Tunneled catheters' outcome optimization among diabetics on dialysis through antibiotic-lock placement

Cited by 61 publications

References 25 publications

Editorial: The Issues Related to Hemodialysis Catheter Lock Prophylaxis with Recombinant Tissue Plasminogen Activator

Editorial: The Issues Related to Hemodialysis Catheter Lock Prophylaxis with Recombinant Tissue Plasminogen Activator

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

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

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