Catheter-related bacteraemia in haemodialysis patients with HIV infection

Impact of risk factors on the incidence of tunneled dialysis catheter infections: a systematic review and meta-analysis

INTRODUCTION

Tunneled dialysis catheters (TDCs) are important for hemodialysis in patients awaiting a permanent surgical solution, kidney transplantation or without feasible surgical access. Infection of a TDC is a common and severe complication, which often requires removal of the TDC and causes high morbidity and mortality. To date, several risk factors for TDC infections have been reported. This systematic review and meta-analysis aim to provide an overview of currently known risk factors.

METHODS

A systematic literature search was conducted, including all studies describing patient-, catheter-, and dialysis-related risk factors for TDC infections. In case sufficient data was available for a risk factor, a meta-analysis with random effects model was performed.

RESULTS

Out of 1273 studies, 30 were included describing a total of 71 risk factors. A meta-analysis was conducted for 26 risk factors. The average incidence of TDC infections was 1.16 ± 0.70/1000 catheter days. Diabetes (odds ratio, OR 1.96), coronary artery disease (OR 2.16), peripheral artery disease (OR 2.28), history of sepsis (OR 2.79), and the number of prior TDCs (OR 1.24) were the most significant risk factors for infection.

CONCLUSION

Several risk factors are associated with increased TDC infection rates. Most of these risk factors are also linked with infection in other populations and most likely reflect the general frailty of hemodialysis patients. The association between many risk factors and TDC infections was often unclear due to the low number of studies available. Additional large cohort studies are necessary to demonstrate the relevance of these risk factors.

Re-hospital admission, morbidity and mortality rate in patients undergoing tunnelled catheter implantation for haemodialysis

OBJECTIVE

Despite the effort to increase the proportion of patients starting dialysis on native accesses, many of them are still dialyzed on tunnelled catheter. Catheter-related complications are often serious and responsible for re-hospital admission, high morbidity and mortality. Several multicenter trials have reported results in the use of tunnelled dialysis catheter (TDC). However, few single-center studies have been published to verify the outcome from real-world experience. This study presents our center's experience in managing such patients in the context of relevant literature.

METHODS

Demographics and operative data were retrospectively collected from medical charts. A prospective follow-up was performed to investigate complications, number of re-hospitalizations and mortality. Kaplan-Meier estimate was used to evaluate catheter primary patency and patients' overall survival.

RESULTS

Among a total 298 haemodialysis accesses interventions, 105 patients (56 men, 53.3% and 49 women, 46.7%) with a median age of 65 years (range 32-88 years) were included in the study. All insertions were successful with an optimal blood flow achieved during the first session of dialysis in all cases. A catheter-related complication was detected in 33.3% (n=35) patients (48.6% infections; 28.6% TDC dysfunction; 14.3% local complications; 5.7% accidental catheter retractions; 2.8% catheter migrations). At a median follow-up of 10.5±8.5 months, a total of 85 patients (80.9%) was re-hospitalized, in 28 cases (26.7%) for a catheter-related cause. The median catheter patency rate was 122 days. At the last follow-up, 39 patients (37.1%) were still dialyzed on catheter, 30(28.6%) were dialyzed on an arteriovenous fistula and 7(6.7%) received a kidney transplantation. Two patients (2%) were transferred to peritoneal dialysis and two patients (2%) recover from renal insufficiency. Mortality rate was 23.8% (25 patients). Causes of death were myocardial infarction (n=13, 52%), sepsis (n=9, 36%); one patient (4%) died from pneumonia, one (4%) from uremic encephalopathy and one (4%) from massive hematemesis.

CONCLUSION

TDCs may represent the only possible access in some patients, however they are burned with a high rate of complications, re-hospital admission and mortality. Results from this institutional experience are in line with previously published literature data in terms of morbidity and mortality. The present results reiterate once more that TDC must be regarded as a temporary solution while permanent access creation should be prioritized. Strict surveillance should be held in patients having TDC for the early identification of complications allowing the prompt treatment and modifying the catheter insertion site whenever needed.

Current Concepts in Hemodialysis Vascular Access Infections

Infection-related causes are second only to cardiovascular events for mortality among end-stage renal disease patients. This review will provide an overview of hemodialysis catheter-, graft-, and fistula-related infections with emphasis on diagnosis and management in specific settings. Use of catheters at the initiation of dialysis has remained unchanged at 80%. Of all access-related bloodstream infections (BSIs), 70% occur in patients with catheters. The risk factors for BSIs in tunneled, cuffed catheters include the duration of the catheter, past catheter-related bacteremia, left-sided internal jugular vein catheters, hypoalbuminemia, and immunosuppression. Surprisingly, human immunodeficiency virus infection has not been associated with a higher risk of catheter-related bacteremia. Catheter-related bloodstream infection is a clinical definition that requires specific laboratory testing to identify the catheter as the source of the BSI. A central line-associated bloodstream infection is a primary BSI in a patient who had a catheter within the 48-h period before the development of the BSI with no other identifiable source. Guidewire exchange of catheter is a viable alternative in select patients to aid in preserving venous access sites. Catheter lock therapy can decrease infectious complications and mortality. Arteriovenous graft infections are prevalent with significant morbidity. Studies evaluating the impact of stent use in infection risks of the arteriovenous graft are sorely needed.

Prevalence and outcomes of central venous catheter-related bacteraemia in HIV-infected versus non-HIV-infected patients undergoing haemodialysis treatment for end-stage kidney disease

Background

Central venous catheter (CVC) haemodialysis (HD) to implement renal replacement therapy is the preferred choice in the urgent setting. Unfortunately, CVC placement is associated with multiple complications including nosocomial bloodstream infections. There is a paucity of data on the prevalence and pattern of pathogenic organisms in haemodialysed HIV-infected versus non-HIV-infected patients with end-stage kidney disease.

Method and results

We undertook a retrospective study of 228 patients who were dialysed using a CVC at a tertiary referral hospital in KwaZulu-Natal, South Africa. Seventy-eight patients (34.2%) complicated with bacteraemia and sepsis requiring antibiotics. Removal of the catheter was necessary in 58 patients (74.0%). The most common organisms isolated were Staphylococcus aureus (30.8%), Staphylococcus epidermidis (24.4%) and Klebsiella pneumoniae (15.4%). There was no statistically significant difference between HIV-infected and non-infected patients with regards to infection rate, time interval from insertion of CVC to infection and final outcome. However, HIV-infected patients took longer to recover; 54.3% of non-infected patients versus 10.3% HIV-infected patients had their sepsis controlled within one week. Acidosis, hypotension, line malfunction and line discharge were infrequent signs of sepsis. Fever, rigors and raised white cell count occurred in over 80.0% of patients.

Conclusion

The infection rate in CVC HD is not more frequent in HIV-infected patients, provided that CD4+ count is ≥ 200 cells/µL and the patient is virologically suppressed. Outcomes following intravenous antibiotic and removal of the CVC are similar in HIV-infected and non-infected patients but response to treatment is slower in HIV-infected patients. A high index of suspicion is needed in detecting CVC-related bacteraemia.

Prognostic Factors of Human Immunodeficiency Virus-Infected Patients on Chronic Hemodialysis

BACKGROUND/AIMS

The number of human immunodeficiency virus (HIV)-infected patients on hemodialysis (HD) have increased, and their prognostic factors are still poorly clarified. The study aimed to identify factors that can influence the survival of HIV-infected patients on HD.

METHODS

We performed a retrospective cohort study of 44 HIV-infected patients on HD.

RESULTS

A total of 17 patients (39%) died. Median survival on HD was 30.8 months and the survival rate at 1 and 5 years was 82.5 and 62.9%, respectively. Male (relative risk [RR] 3.1, p = 0.040) and blacks (RR 2.5, p = 0.037) had higher risk of death. The patients who died had a shorter duration of HIV infection (p = 0.028), had a higher viral load (p = 0.044), more opportunistic infections (p = 0.013), and a lower serum albumin (p = 0.009). Lower serum albumin, nonsexual HIV transmission, viral load, opportunistic infections, and usage of catheters were associated with lower survival.

CONCLUSION

Several demographic, viral, and dialysis variables may help to predict survival of this population. The intervention in these factors could improve their prognosis.

Management of severe non-TB bacterial infection in HIV-infected adults

Despite widespread antiretroviral therapy use, severe bacterial infections (SBI) in HIV-infected adults continue to cause significant morbidity and mortality globally. Four main pathogens account for the majority of documented SBI: Streptococcus pneumoniae, non-typhoidal strains of Salmonella enterica, Escherichia coli and Staphylococcus aureus. The epidemiology of SBI is dynamic, both in developing countries where, despite dramatic successes in antiretroviral therapy, coverage is far from complete, and in settings in both resource-poor and resource-rich countries where antiretroviral therapy failure is becoming increasingly common. Throughout the world, this complexity is further compounded by rapidly emerging antimicrobial resistance, making management of SBI very challenging in these vulnerable patients. We review the causes and treatment of SBI in HIV-infected people and discuss future developments in this field.

Clinical practice guideline for the management of chronic kidney disease in patients infected with HIV: 2014 update by the HIV Medicine Association of the Infectious Diseases Society of America

It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Subphrenic abscess as a complication of hemodialysis catheter-related infection

We describe an unusual case of subphrenic abscess complicating a central venous catheter infection caused by Pseudomonas aeruginosa in a 59-year-old woman undergoing hemodialysis. The diagnosis was made through computed tomography, and Pseudomonas aeruginosa was isolated from the purulent drainage of the subphrenic abscess, the catheter tip and exit site, and the blood culture samples. A transesophageal echocardiography showed a large tubular thrombus in superior vena cava, extending to the right atrium, but no evidence of endocarditis or other metastatic infectious foci. Catheter removal, percutaneous abscess drainage, anticoagulation, and antibiotics resulted in a favourable outcome.

Renal and urologic emergencies in the HIV-infected patient

Antiretroviral therapy has revolutionized the care of individuals infected with the human immunodeficiency virus (HIV) and has fundamentally altered the scope of the disease. Acute renal failure and chronic kidney disease from medication toxicity and comorbid noninfectious illnesses are just as likely today as end-organ injury from the virus itself. Chronic immunosuppression renders HIV-infected patients vulnerable to any of several unique urological infections not frequently seen in immunocompetent patients. A deeper understanding of renal and urological emergencies in the context of the HIV-infected patient will better prepare the emergency physician to render optimal care to this rapidly expanding and aging patient population.