Modified Exchange Technique for Management of Dysfunctional Tunneled Hemodialysis Catheters in the Presence of Exit-Site Infection: A Quality Improvement Report

Definition and clinical management of haemodialysis central venous catheter local infections (exit site and tunnel infection): An international consensus assessment

AIM

To evaluate the relevance of signs and symptoms for the clinical identification of ESI and TI in HD-CVC, by means of international expert consensus, and to reach a consensus on a definition and clinical management (CM) for these infections.

BACKGROUND

A recent systematic review showed a high heterogeneity in the signs/symptoms used for determining exit site infection (ESI) and tunnel infection (TI) of haemodialysis central venous catheter (HD-CVC).

DESIGN

A modified Delphi ranking process was carried out between November 2020 and March 2021, consisting of four rounds using an online questionnaire with a panel of 26 experts from 12 countries.

METHODS

Experts responded on the level of relevance for the identification of ESI and TI, based on a list of 22 signs/symptoms obtained from a previous systematic review, using a 4-point Likert-type scale. After reaching consensus on the signs/symptoms, they followed the same method to reach consensus on the CM. The STROBE Checklist was used to report this study.

RESULTS

A high degree of consensus was reached to identify the presence of ESI based on nine signs/symptoms: presence of pain at the exit site (ES) during interdialysis period, with fever ≥38°C do not suspect other cause, local signs at the ES (inflammation, induration, swelling, hyperemia/erythema ≥2 cm from ES) and obvious abscess or purulent exudate at ES; and of TI. Likewise, 5 cm were agreed upon.

CONCLUSION

This Delphi study provides international expert consensus definitions of ESI and TI in HD-CVC, laying the groundwork for the validation of an HD-CVC ES clinical assessment scale for early identification of ESI.

RELEVANCE TO CLINICAL PRACTICE

In addition, this study provides a series of attitudes to consensual clinics regarding signs/symptoms of local infections in HD-CVC, which may be useful as expert opinion in clinical practice guidelines, when there is insufficient scientific evidence.

Early identification of local infections in central venous catheters for hemodialysis: A systematic review

BACKGROUND

The use of central venous catheters (CVC) is associated with higher morbidity and mortality, related to infectious complications, contributing to poorer clinical outcomes and increased healthcare costs. According to the literature, the incidence of local infections related to CVC for hemodialysis is highly variable. This variability is related to differences in definitions of catheter-related infections.

OBJECTIVE

To identify signs and symptoms for determining local infections (exit site and tunnel tract infections) used in the literature in tunnelled and nontunnelled CVC for hemodialysis.

DESIGN

Systematic review METHODS: Structured electronic searches were conducted in five electronic databases, from 1 January 2000-31 August 2022, using key words and specific vocabulary, as well as manual searches in several journals. Additionally, vascular access clinical guidelines and infection control clinical guidelines were reviewed.

RESULTS

After validity analysis, we selected 40 studies and seven clinical guidelines. The definitions of exit site infection and tunnel infection used in the different studies were heterogeneous. Among the studies, seven (17,5 %) used the definitions of exit site and tunnel infection based on a clinical practice guideline. Three of the studies (7.5 %) used the Twardowski scale definition of exit site infection or a modification. The remaining 30 studies (75 %) used different combinations of signs and symptoms.

CONCLUSIONS

Definitions of local CVC infections are highly heterogeneous in the revised literature. It is necessary to establish a consensus regarding the definitions of hemodialysis CVC exit site and tunnel infections.

REGISTRATION

PROSPERO (CRD42022351097).