Infecciones asociadas a los catéteres utilizados para la hemodiálisis y la diálisis peritoneal

Nueva alternativa para evitar la retirada del catéter de hemodiálisis. Caso clínico

Una de las mayores complicaciones de la utilización de los catéteres venosos tunelizados para hemodiálisis son las infecciones, de las cuales las “tunelitis” o infección del túnel subcutáneo, en general conllevan la retirada del catéter. Presentamos en el siguiente caso a una paciente de 81 años, pluripatológica y graves problemas de accesos vasculares en la que produjo una infección recurrente del túnel subcutáneo del catéter (tunelitis). Para evitar recambiar ese catéter, dado su buen funcionamiento y la enorme dificultad para conseguir un nuevo acceso vascular, se aplicó un tratamiento específico consistente en instilar en el túnel subcutáneo 500 mg de Vancomicina disuelta en suero salino mediante un Abbocath® nº 26, con el fin de impregnar los componentes del catéter. Un año después de este episodio el catéter se mantuvo funcionante sin signos de infección.

Spanish Clinical Guidelines on Vascular Access for Haemodialysis

Vascular access for haemodialysis is key in renal patients both due to its associated morbidity and mortality and due to its impact on quality of life. The process, from the creation and maintenance of vascular access to the treatment of its complications, represents a challenge when it comes to decision-making, due to the complexity of the existing disease and the diversity of the specialities involved. With a view to finding a common approach, the Spanish Multidisciplinary Group on Vascular Access (GEMAV), which includes experts from the five scientific societies involved (nephrology [S.E.N.], vascular surgery [SEACV], vascular and interventional radiology [SERAM-SERVEI], infectious diseases [SEIMC] and nephrology nursing [SEDEN]), along with the methodological support of the Cochrane Center, has updated the Guidelines on Vascular Access for Haemodialysis, published in 2005. These guidelines maintain a similar structure, in that they review the evidence without compromising the educational aspects. However, on one hand, they provide an update to methodology development following the guidelines of the GRADE system in order to translate this systematic review of evidence into recommendations that facilitate decision-making in routine clinical practice, and, on the other hand, the guidelines establish quality indicators which make it possible to monitor the quality of healthcare.

[Colonization management of methicillin resistant Staphylococcus aureus in patients and health professional in the haemodialysis unit in a situation of high risk of endemic disease: looking for zero nasal carriers?]

AIMS

To describe the dynamics of colonization by methicillin resistant Staphylococcus aureus (MRSA) detected in the Haemodialysis Unit (UHD) of the Hospital San Pedro de Alcantara of Caceres due to the detection of catheter-associated infections. Additionally, we attempt to evaluate the effectiveness of preventive strategies introduced.

METHODS

Nasal swab tests were performed in order to detect MRSA colonization in patients and health professionals from August 2008 to January 2009, according to the Consensus GEIH-SEIMC Y SEMPSPH Consensus. An active surveillance was performed with treatment and control of the carriers until negative results were achieved. A consensus document was drawn up in the UHD with registered preventive measures and work systems were reviewed. Prevalence, cumulative incidence, colonization pressure (carrier ratio per day/total patients or experts per day) were calculated. A chi-square test was performed, as well as a Z test for the comparison ratio.

RESULTS

The nasal swabs of 54 acute and chronic patients on haemodialysis showed an initial carrier prevalence of 29.6%; cumulative incidence in patients of 42.6%. Nasal swabs of 48 professionals had a cumulative incidence of 39.5%. There was a parallel decrease in colonization pressure in patients and specialists. After five months A smear was performed 5 months later on 40 patients and 26 specialists, which showed no carriers among the patients, and one among the health professionals.

CONCLUSION

We detected a high number of MRSA carriers among patients and Health professionals from the Haemodialysis Unit. Screening and treatment measures were effective for the decolonization of this population. It is important to adopt long-term strategies for active surveillance for the rapid detection of alert situations.