Effect of antimicrobial locks for tunneled hemodialysis catheters on bloodstream infection and bacterial resistance: a quality improvement report

Advances in the prevention and management of central-line-associated bloodstream infections: The role of chelator-based catheter locks

The proper functioning of central lines is imperative for the management of patients with cancer or on hemodialysis. However, these lifelines can become infected and can malfunction.Chelators such as citrate and EDTA have been widely studied alone or in combination with other antimicrobial agents in catheter lock solutions to prevent catheter-related bloodstream infections and to maintain catheter patency. Given their anticoagulation, antiplatelet aggregation, antibiofilm, antimicrobial activity, safety profile, as well as their low cost, chelators have long been considered alternatives to heparin and a vital component of catheter lock solutions. In this review, we present a detailed summary of the properties of chelators and in vitro and in vivo studies of chelator-containing lock solutions.

Which Type of Temporary Hemodialysis Catheter Should Be Used for the Right Internal Jugular Vein? Prospective Observational Study of Straight vs. Precurved Catheters

Weak evidence is present for choosing amongst different temporary hemodialysis catheter (THC) designs with regards to the risk of venous thrombosis, therefore two THC designs for the right internal jugular vein (RIJV) were compared. Patients aged ≥18 years who needed THC insertion into the RIJV for acute hemodialysis due to either acute or chronic renal failure were included. The type of THC (precurved/straight) was dependent on the date of hospital admission. Clinical and ultrasonographic surveillance was conducted prospectively. Thrombosis of the RIJV was the primary objective. Precurved and straight catheters were inserted into 32 and 23 patients (mean age 63 ± 15 years, females 28), respectively. The baseline characteristics and catheter dwell-times were similar in both groups. Partial and total thrombosis of the RIJV during catheter dwell-time developed at a higher rate in the straight group (52% vs. 9.3%, P = 0.000; 47.8% vs. 9.3%, P = 0.001, respectively). At least 2 weeks after catheter removal, total thrombosis was found in 43.4% vs. 9.6% (P = 0.004) of patients with straight and precurved THCs, respectively. The hazard ratios for total thrombosis was 0.161 (P = 0.006) during catheter dwell-time and 0.190 (P = 0.012) after catheter removal. Catheter dysfunction did not occur and only one catheter-related bloodstream infection (CRBI) was seen. Thrombosis rates of the RIJV were higher with straight vs. precurved THCs, both during catheter dwell-time and after catheter removal. Catheter dysfunction was not noted in any group and the rate of CRBI was extremely low.

Prevention of hemodialysis catheter infections: Ointments, dressings, locks, and catheter hub devices

Tunneled central venous catheters used for the provision of hemodialysis are associated with excess morbidity and mortality. Catheter related exit site and blood stream infections are major risks of their use. Although catheter-avoidance is the best strategy to reduce infections and mortality in the hemodialysis population, the use of catheters remains unacceptably high. In this review, the existing clinical practice guidelines for the prevention of hemodialysis catheter associated infections are outlined, and a comprehensive evidenced-based summary of interventions is provided. This includes details about the use of topical antimicrobial ointments and dressings, intranasal ointment application, prophylactic use of antibiotic and non-antibiotic catheter lock solutions, and catheter hub devices for the prevention of catheter blood stream infections.

An ethanol/sodium citrate locking solution compared to heparin to prevent hemodialysis catheter-related infections: a randomized pilot study

PURPOSE

The objective of this study was to compare the initial safety and efficacy of a novel 30% ethanol/4% sodium citrate catheter-locking solution to heparin in a hemodialysis population.

METHODS

This was a prospective, randomized, pilot study of 40 hemodialysis patients randomized to a 30% ethanol/4% sodium citrate or heparin 1000 units/mL locking solution. The primary outcome was identification of any serious adverse events over the study duration. Secondary outcomes included the rate per 1000 catheter days for catheter-related bloodstream infections (CRBSI), alteplase use, catheter dysfunction, and catheter removal.

RESULTS

Three serious adverse events were reported as possibly related to the catheter solutions. Only one CRBSI was observed during the study in the heparin arm. The rate of alteplase use was 1.5/1000 catheter days in the heparin arm compared to 2.8/1000 catheter days in the ethanol/citrate arm (rate ratio = 1.85, 90% CI 0.48, 7.07, p value = 0.45), while the rate of catheter dysfunction was 6.8/1000 catheter days in the heparin arm compared to 1.9/1000 catheter days in the ethanol citrate arm (rate ratio = 0.27, 90% CI 0.10, 0.74, p value = 0.04). Catheter survival to first catheter outcome was longer in the ethanol/citrate group compared to heparin and there were no catheter removals due to bacteremia or thrombosis.

CONCLUSIONS

The ethanol/sodium citrate locking solution was safely used in this study. It appears to prevent CRBSI and may improve catheter survival compared to heparin.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01394458.

Effects of Prolonged Ethanol Lock Exposure to Carbothane- and Silicone-based Hemodialysis Catheters: A 26-week Study

Purpose

Antibiotic locks in catheter-dependent chronic hemodialysis patients reduce the rate of catheter-related bloodstream infections (CRBSIs), but may be associated with the development of resistant bacteria. Ethanol-based catheter locks may provide a better alternative; however, there are limited data on the long-term integrity of dialysis catheters exposed to ethanol.

Methods

We performed in vitro testing of two types of hemodialysis catheters—silicone (SLC) and carbothane (CBT) based—with a 70% ethanol lock (EL) versus heparin lock (HL) for 26 weeks. Lock solutions were changed thrice weekly to mimic a conventional hemodialysis schedule. We tested mechanical properties of the catheters at 0, 13 and 26 weeks by examining stress/strain relationships (SS400%) and modulus of elasticity (ME). Electron microscopy was performed to examine catheter ultrastructure at 0 and 26 weeks.

Results

Catheter integrity for HL versus EL in SLC (SS400%: 4.5 vs. 4.5 MPa, p = NS; ME: 4.6 vs. 4.7 MPa, p = NS) or CBT-based catheters (SS400%: 7.6 vs. 8.9 MPa, p = NS; ME: 9.6 vs. 12.2 MPa, p = NS) were all similar at 13 and 26 weeks. Scanning electron microscopy revealed no structural changes in the central and luminal wall internal surfaces of EL- versus HL-treated catheters.

Conclusions

There were no significant differences in catheter integrity between SLC or CBT catheters exposed to a 70% EL for 26 weeks. Given its low cost, potential to avoid antibiotic resistance and structural integrity after 6 months of high-dose ethanol, ELs should be studied prospectively against antibiotic locks to assess the efficacy and safety in hemodialysis patients.

Prevention of hemodialysis catheter-related blood stream infections using a cotrimoxazole-lock technique

ABSTRACT 

Background & aim: This trial assessed the efficacy of cotrimoxazole lock solution in reducing catheter-related blood stream infections (CRBSIs) among hemodialysis (HD) patients who were dialyzed using tunneled catheters. Method: Patients randomly received either heparin (2500 U/ml) (control group) or a mixture of 10 mg/ml cotrimoxazole (based on trimethoprim) and 2500 U/ml heparin (antibiotic group) as catheters lock solution. Results: Compared with the control group, CRBSIs rates per 1000 catheter-days was significantly lower (0.58 vs 4.4 events; p = 0.002) and cumulative infection-free catheter survival was significantly higher (log rank statistic 5.88; p = 0.015) in the antibiotic group. There were no statistical differences regarding incidences of catheter removal (8.7% in the antibiotic group vs 22% in the control group; p = 0.116) or thrombosis (2.2% in the antibiotic group vs 9.8% in the control group; p = 0.129) between the two groups. Conclusion: cotrimoxazole containing catheter lock solution is effective in reducing CRBSIs incidence and prolonging dialysis catheter survival in HD patients.

Prevention of Central Line–Associated Bloodstream Infections in Hemodialysis Patients

An increasing proportion of central line-associated bloodstream infections (CLABSIs) are seen in outpatient settings. Many of such infections are due to hemodialysis catheters (HD-CLABSIs). Such infections are associated with substantial morbidity, mortality, and excess healthcare costs. Patients who receive dialysis through a catheter are 2–3 times more likely to be hospitalized for infection and to die of septic complications than dialysis patients with grafts or fistulas. Prevention measures include minimizing the use of hemodialysis catheters, use of CLABSI prevention bundles for line insertion and maintenance, and application of antimicrobial ointment to the catheter exit site. Instillation into dialysis catheters of antimicrobial solutions that remain in the catheter lumen between dialyses (antimicrobial lock solutions) has been studied, but it is not yet standard practice in some dialysis units. At least 34 studies have evaluated the impact of antimicrobial lock solutions on HD-CLABSI rates. Thirty-two (94%) of the 34 studies demonstrated reductions in HD-CLABSI rates among patients treated with antimicrobial lock solutions. Recent multicenter randomized controlled trials demonstrated that the use of such solutions resulted in significantly lower HD-CLABSI rates, even though such rates were low in control groups. The available evidence supports more routine use of antimicrobial lock solutions as an HD-CLABSI prevention measure in hemodialysis units.

Antibiotic lock therapy: review of technique and logistical challenges

Antibiotic lock therapy (ALT) for the prevention and treatment of catheter-related bloodstream infections is a simple strategy in theory, yet its real-world application may be delayed or avoided due to technical questions and/or logistical challenges. This review focuses on these latter aspects of ALT, including preparation information for a variety of antibiotic lock solutions (ie, aminoglycosides, beta-lactams, fluoroquinolones, folate antagonists, glycopeptides, glycylcyclines, lipopeptides, oxazolidinones, polymyxins, and tetracyclines) and common clinical issues surrounding ALT administration. Detailed data regarding concentrations, additives, stability/compatibility, and dwell times are summarized. Logistical challenges such as lock preparation procedures, use of additives (eg, heparin, citrate, or ethylenediaminetetraacetic acid), timing of initiation and therapy duration, optimal dwell time and catheter accessibility, and risks of ALT are also described. Development of local protocols is recommended in order to avoid these potential barriers and encourage utilization of ALT where appropriate.

Systematic review and meta-analysis on management of hemodialysis catheter-related bacteremia

Hemodialysis catheter-related bacteremia is a common clinical problem with several management options. We performed a systematic review and meta-analysis to determine cure proportions with systemic antibiotics, antibiotic lock solution, and guidewire exchange. We searched databases and registries; conference proceedings from relevant medical societies; and article reference lists. Data regarding management approach, cure, follow-up, recurrence, complications, and microbiology were abstracted and pooled from 28 selected publications. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated from a mixed effects logistic regression model. In total, 1596 patients with tunneled hemodialysis catheter-related bacteremia were divided into groups on the basis of treatment with systemic antibiotics (n=697), antibiotic lock solution (n=546), or guidewire exchange (n=353). Antibiotic lock solution and guidewire exchange had similar cure proportions that were superior to systemic antibiotics alone (OR, 2.08; 95% CI, 1.25 to 3.45; P<0.01 for antibiotic lock solution; OR, 2.88; 95% CI, 1.82 to 4.55; P<0.001 for guidewire exchange versus systemic antibiotics). Cure proportions were highest for coagulase-negative staphylococci followed by gram-negative rods and Staphylococcus aureus. Among S. aureus infections, guidewire exchange led to a higher cure proportion than systemic antibiotics or antibiotic lock solution (OR, 3.33; 95% CI, 1.17 to 9.46; P=0.02; OR, 4.72; 95% CI, 1.79 to 12.46; P=0.002, respectively). Thus, results of this study suggest that tunneled hemodialysis catheter-related bacteremia should be treated with either guidewire exchange or antibiotic lock solution. Future studies should address prospectively whether one strategy is better than the other overall and for specific pathogens.

Heparin versus 0.9% sodium chloride intermittent flushing for prevention of occlusion in central venous catheters in adults

BACKGROUND

Heparin intermittent flushing is a standard practice in the maintenance of patency in central venous catheters. However, we could find no systematic review examining its effectiveness and safety.

OBJECTIVES

To assess the effectiveness of intermittent flushing with heparin versus 0.9% sodium chloride (normal saline) solution in adults with central venous catheters in terms of prevention of occlusion and overall benefits versus harms.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched December 2013) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 11). Searches were also carried out in MEDLINE, EMBASE, CINAHL and clinical trials databases (December 2013).

SELECTION CRITERIA

Randomised controlled trials (RCTs) in adults 18 years of age and older with a central venous catheter (CVC) in which intermittent flushing with heparin (any dose with or without other drugs) was compared with 0.9% normal saline were included. No restriction on language was applied.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed trial quality and extracted data. Trial authors were contacted to retrieve additional information, when necessary.

MAIN RESULTS

Six eligible studies with a total of 1433 participants were included. The heparin concentrations used in these studies were very different (10-5000 IU/mL), and follow-up varied from 20 days to 180 days. The overall risk of bias in the studies was low. The quality of the evidence ranged from very low to moderate for the main outcomes (occlusion of CVC, duration of catheter patency, CVC-related sepsis, mortality and haemorrhage at any site).Combined findings from three trials in which the unit of analysis was the catheter suggest that heparin was associated with reduced CVC occlusion rates (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.29 to 0.94). However, no clear evidence of a similar effect was found when the results of two studies in which the unit of analysis was the participant were combined (RR 0.21, 95% CI 0.03 to 1.70), nor when findings were derived from one study, which considered total line accesses (RR 1.08, 95% CI 0.84 to 1.40). Furthermore, results for other estimated effects were found to be imprecise and compatible with benefit and harm: catheter duration in days (mean difference (MD) 0.41, 95% CI -1.29 to 2.12), CVC-related thrombosis (RR 1.22, 95% CI 0.74 to 1.99), CVC-related sepsis (RR 1.02, 95% CI 0.34 to 3.03), mortality (RR 0.77, 95% CI 0.45 to 1.32) and haemorrhage at any site (RR 1.37, 95% CI 0.49 to 3.85).

AUTHORS' CONCLUSIONS

We found no conclusive evidence of important differences when heparin intermittent flushing was compared with 0.9% normal saline flushing for central venous catheter maintenance in terms of efficacy or safety. As heparin is more expensive than normal saline, our findings challenge its continued use in CVC flushing outside the context of clinical trials.

A randomised controlled trial of Heparin versus EthAnol Lock THerapY for the prevention of Catheter Associated infecTion in Haemodialysis patients--the HEALTHY-CATH trial

Background

Tunnelled central venous dialysis catheter use is significantly limited by the occurrence of catheter-related infections. This randomised controlled trial assessed the efficacy of a 48 hour 70% ethanol lock vs heparin locks in prolonging the time to the first episode of catheter related blood stream infection (CRBSI).

Methods

Patients undergoing haemodialysis (HD) via a tunnelled catheter were randomised 1:1 to once per week ethanol locks (with two heparin locks between other dialysis sessions) vs thrice per week heparin locks.

Results

Observed catheter days in the heparin (n=24) and ethanol (n=25) groups were 1814 and 3614 respectively. CRBSI occurred at a rate of 0.85 vs. 0.28 per 1000 catheter days in the heparin vs ethanol group by intention to treat analysis (incident rate ratio (IRR) for ethanol vs. heparin 0.17; 95%CI 0.02-1.63; p=0.12). Flow issues requiring catheter removal occurred at a rate of 1.6 vs 1.4 per 1000 catheter days in the heparin and ethanol groups respectively (IRR 0.85; 95% CI 0.20-3.5 p =0.82 (for ethanol vs heparin).

Conclusions

Catheter survival and catheter-related blood stream infection were not significantly different but there was a trend towards a reduced rate of infection in the ethanol group. This study establishes proof of concept and will inform an adequately powered multicentre trial to definitively examine the efficacy and safety of ethanol locks as an alternative to current therapies used in the prevention of catheter-associated blood stream infections in patients dialysing with tunnelled catheters.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12609000493246

Antibiotic lock solutions allow less systemic antibiotic exposure and less catheter malfunction without adversely affecting antimicrobial resistance patterns

There are current concerns that antibiotic lock solutions (ABL) can induce antimicrobial resistance in long-term hemodialysis patients. Retrospective chart review of 157 children on hemodialysis between January 1997 and June 2006 was performed. In ERA I, only systemic antibiotics were used. In ERA II, ABL were added to systemic antibiotics when needed. In ERA III, ABL were used for treatment of all cases of catheter-related bacteremia (CRB) and for CRB prophylaxis in high-risk patients. The study includes 111,325 catheter days. The CRB incidence was 3.9 CRB/1000 catheter days. There was significant decrease for the total systemic antibiotic exposure (P = 0.0484) and the percentage of catheters lost to malfunction (P = 0.001) in ERA III. Protocol ABL exposure was associated with a trend to increased tobramycin-gentamicin resistance for gram-positive CRBs (P = 0.2586) but with improved tobramycin-gentamicin resistance for gram-negative (P = 0.0949) and polymicrobial CRBs (P = 0.1776) and improved vancomycin resistance for gram-positive CRBs (P = 0.0985). This retrospective analysis does not support the premise that ABL use will promote antimicrobial resistance in the hemodialysis population. The decreased exposure to systemic antibiotics by vigorous ABL use may even improve the antimicrobial resistance patterns in this population in the long term.

Prevention of central line-associated bloodstream infections: a journey toward eliminating preventable harm

Central line-associated blood stream infections (CLABSI) are among the most common, lethal, and costly health care-associated infections. Recent large collaborative quality improvement efforts have achieved unprecedented and sustained reductions in CLABSI rates and demonstrate that these infections are largely preventable, even for exceedingly ill patients. The broad acceptance that zero CLABSI rates are an achievable goal has motivated and stimulated diverse groups of stakeholders, including public and private groups to develop policy tools and to mobilize their local constituents toward achieving this goal. Nevertheless, attributing reductions in CLABSI rates achieved by multifaceted quality improvement efforts solely to the use of checklists to ensure adherence with appropriate infection control practices is an easily made but crucial mistake. National CLABSI prevention is a shared responsibility and creating novel partnerships between government agencies, health care industry, and consumers is critical to making and sustaining progress in achieving the goals toward eliminating CLABSI.

Minocycline-EDTA lock solution prevents catheter-related bacteremia in hemodialysis

There is growing concern about the development of antibacterial resistance with the use of antibiotics in catheter lock solutions. The use of an antibiotic that is not usually used to treat other serious infections may be an alternative that may reduce the clinical impact should resistance develop. We conducted a randomized controlled trial to compare a solution of minocycline and EDTA with the conventional unfractionated heparin for the prevention of catheter-related bacteremia in hemodialysis patients during a period of 90 d. The study included 204 incident catheters (27.8% tunneled); 14 catheters were excluded because of early dysfunction and 3 because of protocol violations. We observed catheter-related bacteremia in 19 patients in the heparin group (4.3 per 1000 catheter-days) and in 5 patients in the minocycline-EDTA group (1.1 per 1000 catheter-days; P = 0.005). We did not detect a significant difference in the rate of catheter removal for dysfunction. Catheter-related bacteremia-free survival was significantly higher in the minocycline-EDTA group than in the heparin group (P = 0.005). In conclusion, a minocycline-EDTA catheter lock solution is effective in the prevention of catheter-related bacteremia in hemodialysis patients.

A novel antimicrobial and antithrombotic lock solution for hemodialysis catheters: a multi-center, controlled, randomized trial

BACKGROUND AND PURPOSE

Catheter-related bloodstream infection is the greatest threat to the safety of patients on hemodialysis. Catheter lock solutions containing heparin have been linked to an increased risk of hemorrhage and thrombocytopenia.

OBJECTIVES

To ascertain the safety and efficacy for prevention of catheter-related bloodstream infection and catheter loss from patency failure of a novel catheter lock solution with antimicrobial and antithrombotic activity containing 0.24 M (7.0%) sodium citrate, 0.15% methylene blue, 0.15% methylparaben, and 0.015% propylparaben (C-MB-P), compared with heparin.

DESIGN

Multicenter, prospective, randomized, open-label trial with patients studied for up to 6 months. An independent clinical evaluation committee assessing trial outcomes was blinded to patients' treatment assignments.

SETTING

Twenty-five outpatient hemodialysis units.

PATIENTS

Patients with end-stage renal disease receiving maintenance hemodialysis through a percutaneous cuffed and tunneled internal jugular hemodialysis catheters.

INTERVENTIONS

Participants' catheters were locked between hemodialysis sessions with the C-MB-P lock solution or sterile saline containing 5000 units of unfractionated heparin (control).

MEASUREMENTS AND MAIN RESULTS

We recorded and evaluated catheter-related bloodstream infections, catheter loss attributable to luminal thrombosis, and adverse events. A total of 407 patients participated in the trial (49,565 catheter days), 201 in the C-MB-P group and 206 in the heparin group. Patients in the two lock solution groups were comparable for risk factors predisposing to catheter-related bloodstream infection. Catheters locked with C-MB-P were significantly less likely to cause catheter-related bloodstream infection (0.24 vs. 0.82 per 1000 catheter days; relative risk, 0.29; 95% confidence interval, 0.12-0.70; p = .005) and were less likely to be lost because of patency failure (0 vs. 4; log rank, p = .04).

CONCLUSIONS

The novel C-MB-P lock solution is well tolerated, significantly reduces the risk of catheter-related bloodstream infection, and provides protection comparable to heparin against patency failure.

Emergence of gentamicin-resistant bacteremia in hemodialysis patients receiving gentamicin lock catheter prophylaxis

BACKGROUND AND OBJECTIVES

Antibiotic locks in catheter-dependent chronic hemodialysis patients reduce the rate of catheter-related blood stream infections (CRIs), but there are no data regarding the long-term consequences of this practice.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Over a 4-year period, from October 1, 2002, to September 30, 2006, we initiated a gentamicin and heparin lock (GHL) protocol in 1410 chronic hemodialysis patients receiving dialysis through a tunneled catheter in eight outpatient units.

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.

Epidemiology, surveillance, and prevention of bloodstream infections in hemodialysis patients

Infections cause significant morbidity and mortality in patients undergoing hemodialysis. Bloodstream infections (BSIs) are particularly problematic, accounting for a substantial number of hospitalizations in these patients. Hospitalizations for BSI and other vascular access infections appear to have increased dramatically in hemodialysis patients since 1993. These infections frequently are related to central venous catheter (CVC) use for dialysis access. Regional initiatives that have shown successful decreases in catheter-related BSIs in hospitalized patients have generated interest in replicating this success in outpatient hemodialysis populations. Several interventions have been effective in preventing BSIs in the hemodialysis setting. Avoiding the use of CVCs in favor of access types with lower associated BSI risk is among the most important. When CVCs are used, adherence to evidence-based catheter insertion and maintenance practices can positively influence BSI rates. In addition, facility-level surveillance to detect BSIs and stimulate examination of vascular access use and care practices is essential to a comprehensive approach to prevention. This article describes the current epidemiology of BSIs in hemodialysis patients and effective prevention strategies to decrease the incidence of these devastating infections.

Rationale and design of the HEALTHY-CATH trial: a randomised controlled trial of Heparin versus EthAnol Lock THerapY for the prevention of Catheter Associated infecTion in Haemodialysis patients

BACKGROUND

Catheter-related bacteraemias (CRBs) contribute significantly to morbidity, mortality and health care costs in dialysis populations. Despite international guidelines recommending avoidance of catheters for haemodialysis access, hospital admissions for CRBs have doubled in the last decade. The primary aim of the study is to determine whether weekly instillation of 70% ethanol prevents CRBs compared with standard heparin saline.

METHODS/DESIGN

The study will follow a prospective, open-label, randomized controlled design. Inclusion criteria are adult patients with incident or prevalent tunneled intravenous dialysis catheters on three times weekly haemodialysis, with no current evidence of catheter infection and no personal, cultural or religious objection to ethanol use, who are on adequate contraception and are able to give informed consent. Patients will be randomized 1:1 to receive 3 mL of intravenous-grade 70% ethanol into each lumen of the catheter once a week and standard heparin locks for other dialysis days, or to receive heparin locks only. The primary outcome measure will be time to the first episode of CRB, which will be defined using standard objective criteria. Secondary outcomes will include adverse reactions, incidence of CRB caused by different pathogens, time to infection-related catheter removal, time to exit site infections and costs. Prospective power calculations indicate that the study will have 80% statistical power to detect a clinically significant increase in median infection-free survival from 200 days to 400 days if 56 patients are recruited into each arm.

DISCUSSION

This investigator-initiated study has been designed to provide evidence to help nephrologists reduce the incidence of CRBs in haemodialysis patients with tunnelled intravenous catheters.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Number: ACTRN12609000493246.