Taurolidine-citrate-heparin catheter lock solution reduces staphylococcal bacteraemia rates in haemodialysis patients

Taurolidine and Heparin as Catheter Lock Solution for Central Venous Catheters in Hemodialysis

BACKGROUND

Chronic kidney disease can lead to end-stage renal disease, and the prevalence is increasing. Many patients starting hemodialysis require central venous catheters (CVCs). Catheter-related bloodstream infections (CRBSIs) are a common complication and lead to significant morbidity and mortality. Interventions to prevent CRBSI include antimicrobial lock therapy but concern for the development of antimicrobial resistance and adverse effects. Nonantimicrobial antiseptics as catheter lock solutions have also been used. Taurolidine and heparin catheter lock solution is first approved by the Food and Drug Administration for the prevention of CRBSI in patients on hemodialysis. Taurolidine has a unique mechanism of action and favorable safety profile.

MECHANISM OF ACTION, PHARMACODYNAMICS, AND PHARMACOKINETICS

Taurolidine and heparin catheter lock solution have both antimicrobial and anticoagulant properties. Taurolidine is derivative of the amino acid taurine, and heparin is derived from porcine intestinal mucosa. Taurolidine not only damages microbial cell walls but also prevents the adherence of microorganisms to biological surfaces, preventing biofilm formation. Taurolidine and heparin catheter lock solution is intended to be used intraluminally within the catheter and should be aspirated. Because it is used locally, limited pharmacokinetic and pharmacodynamic data are available.

CLINICAL TRIALS

The LOCK-IT-100 trial is a randomized, double-blind, phase 3 study, which included 795 end-stage renal disease patients on hemodialysis with CVC. Taurolidine and heparin was compared with the control heparin alone. The results of the study showed a 71% risk reduction in CRBSI for taurolidine and heparin arm (95% confident interval, 38%-86%, P = 0.0006). Other studies have also shown that taurolidine lock solution leads to decreased CRBSI episodes. Several systematic reviews and meta-analysis consisted of taurolidine in adult, and pediatric populations also showed reduction in the incidence of CRBSIs.

THERAPEUTIC ADVANCE

Taurolidine and heparin lock solution represents a novel preventive strategy for those undergoing hemodialysis through a CVC by reducing the risk of CRBSI. This is significant progress because there are no other similar options available for patients for whom catheters are the only options for their life-saving treatment.

Taurolidine/Heparin Lock Solution and Catheter-Related Bloodstream Infection in Hemodialysis: A Randomized, Double-Blind, Active-Control, Phase 3 Study

BACKGROUND

Catheter-related bloodstream infections (CRBSIs) are one of the most prevalent, fatal, and costly complications of hemodialysis with a central venous catheter (CVC). The LOCK IT-100 trial compared the efficacy and safety of a taurolidine/heparin catheter lock solution that combines taurolidine 13.5 mg/ml and heparin (1000 units/ml) versus heparin in preventing CRBSIs in participants receiving hemodialysis via CVC.

METHODS

LOCK IT-100 was a randomized, double-blind, active-control, multicenter, phase 3 study that enrolled adults with kidney failure undergoing maintenance hemodialysis via CVC from 70 US sites. Participants were randomized 1:1 to taurolidine/heparin catheter lock solution or heparin control catheter lock solution (1000 units/ml). The primary end point was time to CRBSI as assessed by a blinded Clinical Adjudication Committee. Secondary end points were catheter removal for any reason and loss of catheter patency. On the basis of a prespecified interim analysis, the Data and Safety Monitoring Board recommended terminating the trial early for efficacy with no safety concerns.

RESULTS

In the full analysis population ( N =795), nine participants in the taurolidine/heparin arm ( n =397; 2%) and 32 participants in the heparin arm ( n =398; 8%) had a CRBSI. Event rates per 1000 catheter days were 0.13 and 0.46, respectively, with the difference in time to CRBSI being statistically significant, favoring taurolidine/heparin ( P < 0.001). The hazard ratio was 0.29 (95% confidence interval, 0.14 to 0.62), corresponding to a 71% reduction in risk of CRBSIs with taurolidine/heparin versus heparin. There were no significant differences between study arms in time to catheter removal for any reason or loss of catheter patency. The safety of taurolidine/heparin was comparable with that of heparin, and most treatment-emergent adverse events were mild or moderate.

CONCLUSIONS

Taurolidine/heparin reduced the risk of developing a CRBSI in study participants receiving hemodialysis via CVC compared with heparin with a comparable safety profile.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Study Assessing Safety & Effectiveness of a Catheter Lock Solution in Dialysis Patients to Prevent Bloodstream Infection, NCT02651428 .

The efficacy of taurolidine containing lock solutions for the prevention of central-venous-catheter-related bloodstream infections: a systematic review and meta-analysis

The incidence of central venous catheter (CVC)-related bloodstream infections is high in patients requiring a long-term CVC. Therefore, infection prevention is of the utmost importance. The aim of this study was to provide an updated overview of randomized controlled trials (RCTs) comparing the efficacy of taurolidine containing lock solutions (TL) to other lock solutions for the prevention of CVC-related bloodstream infections in all patient populations. On 15^th February 2021, PubMed, Embase and The Cochrane Library were searched for RCTs comparing the efficacy of TLs for the prevention of CVC-related bloodstream infections with other lock solutions. Exclusion criteria were non-RCTs, studies describing <10 patients and studies using TLs as treatment. Risk of bias was evaluated using the Cochrane Risk of Bias 2 tool. A random effects model was used to pool individual study incidence rate ratios (IRRs). Subgroup analyses were performed based on the following factors: CVC indication, comparator lock and bacterial isolates cultured. A total of 14 articles were included in the qualitative synthesis describing 1219 haemodialysis, total parenteral nutrition and oncology patients. The pooled IRR estimated for all patient groups together (nine studies; 918 patients) was 0.30 (95% confidence interval 0.19-0.46), favouring the TLs. Adverse events (10 studies; 867 patients) were mild and scarce. The quality of the evidence was limited due to a high risk of bias and indirectness of evidence. The use of TLs might be promising for the prevention of CVC-related bloodstream infections. Large-scale RCTs are needed to draw firm conclusions on the efficacy of TLs.

The best solution down the line: an observational study on taurolidine- versus citrate-based lock solutions for central venous catheters in hemodialysis patients

INTRODUCTION

To prevent infection and thrombosis of central venous catheters (CVCs) in hemodialysis patients, different CVC lock solutions are available. Taurolidine-based solutions and citrate in different concentrations are frequently used, but no definite conclusions with regard to superiority have been drawn.

METHODS

In this retrospective, observational, multicenter study, we aimed to assess the risk for removal of CVC due to infection or catheter malfunction in hemodialysis patients with CVC access for different lock solutions: taurolidine, high-concentrated citrate (46.7%) and low-concentrated citrate (4 or 30%). A multivariable Cox-regression model was used to calculate hazard ratio's (HR).

RESULTS

We identified 1514 patients (median age 65 years, 59% male). In 96 (6%) taurolidine-based lock solutions were used. In 1418 (94%) citrate-based lock solutions were used (high-concentrated 73%, low-concentrated 20%). Taurolidine-based lock solutions were associated with a significantly lower hazard for removal of CVC due to infection or malfunction combined (HR 0.34, 95% CI 0.19-0.64), and for removal of CVC due to infection or malfunction separately (HR 0.36, 95% CI 0.15-0.88 and HR0.33, 95% CI 0.14-0.79). High-concentrated citrate lock solutions were not associated with a decreased hazard for our outcomes, compared to low-concentrated citrate lock solutions.

CONCLUSION

Removal of CVC due to infection or catheter malfunction occurred less often with taurolidine-based lock solutions. We present the largest cohort comparing taurolidine- and citrate-based lock solutions yet. However, due to the retrospective observational nature of this study, conclusions with regard to superiority should be drawn with caution.

Low Concentration Trisodium Citrate as a Non-inferior Locking Agent for Non-tunneled Dialysis Catheters in the Asian Setting

Introduction

Unfractionated heparin is the commonly used catheter lock solution in patients with temporary dialysis catheters as hemodialysis access. The effectiveness of trisodium citrate as an alternate catheter lock agent has not been studied in Asian population.

Methods

In this prospective quasi-experimental study, which included 180 patients with central venous dialysis catheter, patients were randomly allotted to citrate 4.67% and heparin 5000 units/ml arms in the ratio of 2:1. Baseline demographic and dialysis related data, incidence of catheter-related bloodstream infections, and mean catheter days in both the study cohorts were collected and compared. Formal cost analysis for citrate 4.67% use as catheter lock was done.

Results

The mean age of the total study population was 50.49 ± 14.87 years. Sixty-six females (36.7%) and 80 (44.4%) diabetic patients were included in the study. The overall incidence of catheter-related bloodstream infection (CRBSI) was 11.11%. The majority had nontunneled dialysis catheters (95%; n = 114). On analyzing the data of patients with nontunneled catheters, it was found that the total number of catheter days for the citrate and heparin groups were 4,795 and 2,419 days, respectively. The number of CRBSI episodes per 1,000 catheter days for the citrate and heparin groups were 2.711 and 2.89, respectively. Citrate catheter lock cost only 6% of that of heparin lock.

Conclusions

The incidence of catheter related bloodstream infections was comparable between the heparin and citrate 4.67% lock cohorts. The use of low concentration citrate as catheter lock was cost-effective when compared with heparin.

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.

Taurolidine as adjuvant treatment of relapsing peritonitis in peritoneal dialysis patients

Relapsing peritonitis in peritoneal dialysis patients is one of the complications that jeopardizes the continuity of the technique. It is often associated with the formation of biofilm in the lumen of the catheter. To date, its removal remains the only recommended attitude. Due to its antimicrobial and antifungal properties, taurolidine has been previously used for the sealing of central line catheters and hemodialysis. Despite the good results obtained, there is no evidence available regarding its utility in peritoneal dialysis. This case report describes the use of taurolidine (TauroLock™HEP500) in 5 patients with relapsing peritonitis after antibiotic treatment completion. Mean follow-up for the detection of recurrences was 13.4 months. In 4 patients with infections caused by Staphylococcus epidermidis, eradication was achieved. In the remaining case, caused by Staphylococcus aureus, the taurolidine seal was ineffective and the removal of the catheter was required.

Cefazolin-gentamicin versus taurolidine-citrate for the prevention of infection in tunneled central catheters in hemodialysis patients: A quasi-experimental trial

BACKGROUND

Catheter-related bloodstream infection (CR-BSI) is one of various complications related to hemodialysis (HD). As a result of the high rate of infection, the use of lock solutions for the prevention of CR-BSI has been studied. However, adverse effects of lock solution, such as increased emergence of strains resistant to antibiotics, which is an important concern, need to be investigated further. The aim of this study was to compare the efficacy of lock solution using a combination of cefazolin and gentamicin versus taurolidine and citrate in reducing CR-BSI in patients undergoing HD and to identify any adverse effects.

METHODS

A prospective observational study was performed at two dialysis centers. Patients using new tunneled central venous catheters (CVC) for HD were included. Patients with a tunneled CVC were assigned to receive either antibiotic lock solution (group 1: gentamicin 7mg/ml+cefazolin 12mg/ml+heparin 3500IU/ml) or lock solution with TauroLock-Hep500 (group 2: taurolidine citrate 4%+heparin 500 IU/ml) during the inter-dialysis period. The patients were allocated to these groups according to the hemodialysis center they were attending.

RESULTS

A total of 145 CVCs were implanted in 127 patients and were followed for 15 months: 77 CVCs (65 patients) were placed in group 1 and 68 CVCs (62 patients) in group 2. There was no difference between the two groups with regard to CR-BSI (events per 1000 catheter-days: group 1=0.79, group 2=1.10; p=0.18) or exit site infection rates (events per 1000 catheter-days: group 1=2.45, group 2=1.83; p=0.37). The groups differed in ESI pathogens, with gram-positive oxacillin-resistant pathogens more frequent in group 1 (31.8% vs. 5.0%; p=0.003). The two groups were similar in mechanical complications. In the Cox regression analysis, the internal jugular vein site was a protective factor for all catheter removal complications (hazard ratio (HR) 0.41, 95% confidence interval (CI) 0.19-0.91) and mechanical complications (HR 0.16, 95% CI 0.065-0.41); only ESI was a risk factor for all catheter removal complications (HR 1.79, 95% CI 1.04-3.07) and mechanical complications (HR 5.64, 95% CI 1.65-19.3).

CONCLUSIONS

The efficacy of both lock solutions was similar in preventing infections related to tunneled CVCs for HD. However, there were more oxacillin-resistant strains in patients who received antibiotic lock solution. Further studies are required to determine the optimal drug regimen and concentrations for lock solution and the associated adverse effects.

In Vitro and In Vivo Activity of a Novel Catheter Lock Solution against Bacterial and Fungal Biofilms

Central-line-associated bloodstream infections are increasingly recognized to be associated with intraluminal microbial biofilms, and effective measures for the prevention and treatment of bloodstream infections remain lacking. This report evaluates a new commercially developed antimicrobial catheter lock solution (ACL), containing trimethoprim (5 mg/ml), ethanol (25%), and calcium EDTA (Ca-EDTA) (3%), for activity against bacterial and fungal biofilms, using in vitro and in vivo (rabbit) catheter biofilm models. Biofilms were formed by bacterial (seven different species, including vancomycin-resistant Enterococcus [VRE]) or fungal (Candida albicans) species on catheter materials. Biofilm formation was evaluated by quantitative culture (CFU) and scanning electron microscopy (SEM). Treatment with ACL inhibited the growth of adhesion-phase biofilms in vitro after 60 min (VRE) or 15 min (all others), while mature biofilms were completely inhibited after exposure for 2 or 4 h, compared to control. Similar results were observed for drug-resistant bacteria. Compared to the heparinized saline controls, ACL lock therapy significantly reduced the catheter bacterial (3.49 ± 0.75 versus 0.03 ± 0.06 log CFU/catheter; P = 0.016) and fungal (2.48 ± 1.60 versus 0.55 ± 1.19 log CFU/catheter segment; P = 0.013) burdens in the catheterized rabbit model. SEM also demonstrated eradication of bacterial and fungal biofilms in vivo on catheters exposed to ACL, while vigorous biofilms were observed on untreated control catheters. Our results demonstrated that ACL was efficacious against both adhesion-phase and mature biofilms formed by bacteria and fungi in vitro and in vivo.

Taurolidine-citrate-heparin lock reduces catheter-related bloodstream infections in intestinal failure patients dependent on home parenteral support: a randomized, placebo-controlled trial

Background: In patients with intestinal failure who are receiving home parenteral support (HPS), catheter-related bloodstream infections (CRBSIs) inflict health impairment and high costs.Objective: This study investigates the efficacy and safety of the antimicrobial catheter lock solution, taurolidine-citrate-heparin, compared with heparin 100 IE/mL on CRBSI occurrence.Design: Forty-one high-risk patients receiving HPS followed in a tertiary HPS unit were randomly assigned in a double-blinded, placebo-controlled trial. External, stratified randomization was performed according to age, sex, and prior CRBSI incidence. The prior CRBSI incidence in the study population was 2.4 episodes/1000 central venous catheter (CVC) days [95% Poisson confidence limits (CLs): 2.12, 2.71 episodes/1000 CVC days]. The maximum treatment period was 2 y or until occurrence of a CRBSI or right-censoring because of CVC removal. The exact permutation tests were used to calculate P values for the log-rank tests.Results: Twenty patients received the taurolidine-citrate-heparin lock and 21 received the heparin lock, with 9622 and 6956 treatment days, respectively. In the taurolidine-citrate-heparin arm, no CRBSIs occurred, whereas 7 CRBSIs occurred in the heparin arm, with an incidence of 1.0/1000 CVC days (95% Poisson CLs: 0.4, 2.07/1000 CVC days; P = 0.005). The CVC removal rates were 0.52/1000 CVC days (95% Poisson CLs: 0.17, 1.21/1000 CVC days) and 1.72/1000 CVC days (95% Poisson CLs: 0.89, 3.0/1000 CVC days) in the taurolidine-citrate-heparin and heparin arm, respectively, tending to prolong CVC survival in the taurolidine arm (P = 0.06). Costs per treatment year were lower in the taurolidine arm (€2348) than in the heparin arm (€6744) owing to fewer admission days related to treating CVC-related complications (P = 0.02).Conclusions: In patients with intestinal failure who are life dependent on HPS, the taurolidine-citrate-heparin catheter lock demonstrates a clinically substantial and cost-beneficial reduction of CRBSI occurrence in a high-risk population compared with heparin. This trial was registered at clinicaltrials.gov as NCT01948245.

Catheter-related bloodstream infection in end-stage kidney disease: a Canadian narrative review

Purpose of the review

Patients with end-stage renal disease (ESRD) are at a high risk of bacterial infection. We reviewed publications on risk factors, prevention, and treatment paradigms, as well as outcomes associated with bacterial infection in end-stage kidney disease. We focused in particular on studies conducted in Canada where rates of haemodialysis catheter use are high.

Sources of information

We included original research articles in English text identified from MEDLINE using search terms ‘chronic kidney failure’, ‘renal dialysis’, or ‘chronic renal insufficiency’, and ‘bacterial infection’. We focused on articles with Canadian study populations and included comparisons to international standards and outcomes where possible.

Findings

Bacterial infections in this setting are most commonly due to Gram-positive skin flora, particularly Staphylococcus, with methicillin-resistant Staphylococcus aureus (MRSA) carrying a poorer prognosis. Interventions that may decrease mortality from sepsis include a collaborative care model that includes a nephrology team, an infectious disease specialist, and use of standardized care bundles that adhere to proven quality-of-care indicators. Decreased infectious mortality may be achieved by ensuring appropriate antibiotic selection and dosing as well as avoiding catheter salvage attempts. Reduction in bloodstream infection (BSI) incidence has been observed with the use of tPA catheter-locking solutions and the use of mupirocin or polysporin as a topical agent at the catheter exit site, as well as implementing standarized hygiene protocols during catheter use.

Limitations

There has been a paucity of randomized controlled trials of prevention and treatment strategies for catheter-related BSIs in haemodialysis. Some past trials have been limited by lack of blinding and short duration of follow-up. Microbiological epidemiology, although well characterized, may vary by region and treatment centre.

Implications

With the high prevalence of catheter use in Canadian haemodialysis units, further studies on long-term treatment and preventative strategies for BSI are warranted.

Prevention of catheter-related bloodstream infections in patients on hemodialysis: challenges and management strategies

Catheter-related bloodstream infections are a significant source of morbidity and mortality in the end-stage renal disease population. Although alternative accesses to undergoing renal replacement therapy exist, many patients begin hemodialysis with a dialysis catheter due to logistic and physiologic factors involved in arteriovenous fistula creation and maturation. Colonization of catheters via skin flora leads to the production of biofilm, which acts as a reservoir for virulent bacteria. Preventative therapies center on appropriate catheter maintenance, infection control measures, and early removal of devices as patients transition to other access. Despite best efforts, when conservative measures fail to prevent infections in a high-risk population, antimicrobial lock therapy should be considered as an option to combat catheter-related bloodstream infections.