Complications of Hemodialysis Catheter Bloodstream Infections: Impact of Infecting Organism

Central venous catheter-related bloodstream infections: Epidemiology and risk factors for hematogenous complications

BACKGROUND

Central catheter-related bloodstream infections (CRBIs) can lead to severe complications, including suppurative thrombophlebitis, endocarditis, and metastatic infections. While complications due to CRBIs caused by Staphylococcus aureus (SA) are well-known, there are limited data regarding CRBIs caused by other bacteria.

METHODS

This 2-year retrospective single-center study of patients with CRBIs from a tertiary care hospital examined the hematogenous complications associated with CRBIs according to patient characteristics, central venous catheter (CVC) types, and causative bacteria.

RESULTS

All in all, 254 patients with confirmed CRBIs were included; 285 bacteria types were isolated, mainly Enterobacteriaceae (n = 94), coagulase-negative Staphylococci (CNS, n = 82), SA (n = 45), and non-fermenting Gram-negative bacteria (NGB, n = 45). Among the patients, 35 developed at least one hematogenous complication (14 %), including suppurative thrombophlebitis (n = 15), endocarditis (n = 7) and metastatic infections (n = 16). In multivariate analysis, hemodialysis, persistent bacteremia for at least 3 days, and CRBIs caused by SA were associated with increased risk for hematogenous complications, while previous curative anticoagulant treatment was associated with reduced risk. Diabetes, CVC maintenance, and hematogenous complications were associated with increased 3-month mortality.

CONCLUSION

A thorough investigation of hematogenous complications should be envisioned in patients with persistent bacteremia, particularly those with SA infections and those on hemodialysis.

Clinical presentation and outcome of hemodialysis tunneled catheter-related bloodstream infection in older persons

BACKGROUND

The use of a tunneled catheter as the primary vascular access among old hemodialysis patients is frequent. Catheter-related bloodstream infection (CRBSI) is a common complication, associated with increased mortality. Data regarding the clinical presentation and outcomes of CRBSI among old hemodialysis patients is limited.

METHODS

All chronic hemodialysis patients hospitalized between 2010 and 2022 with CRBSI were included. Patients were classified into two groups: old adults (≥ 75) and younger patients. Clinical, microbiological, and outcome data were collected and analyzed.

RESULTS

One hundred and fifty-four patients with CRBSI were identified. Fifty-seven were aged ≥ 75 years. Mean age in the older and younger groups was 81.2 ± 5 and 59.7 ± 12.7, respectively. Male gender was predominant (64%). Charlson comorbidity score and Pitt bacteremia score were comparable among both groups. Norton score < 14 was more common among old persons (n = 24, 67% versus n = 21, 31%, p < 0.001), as well as nursing-home residence. Gram-negative pathogens and Staphylococcus aureus were common in both groups. The frequency of inappropriate empirical antimicrobial treatment was higher among older persons. Overall, in-hospital and 90-day mortality was high (age ≥ 75, 36.8%, age < 75, 24.7%, p = 0.14). Age was not significantly associated with mortality after adjustment for low Norton score, residence, and inappropriate antimicrobial therapy as well as resistance patterns of bloodstream isolates [OR = 1.2 (95% CI 0.4-3.3), p = 0.76].

CONCLUSIONS

Clinical characteristics and outcomes of CRBSI were comparable among old and young hemodialysis patients. However, the high mortality rate in this cohort suggests that the use of tunneled catheters as a permanent vascular access should be discouraged in both patient groups.

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 .

Fulminant ruptured septic aneurysm complicating the catheter related blood stream infection in a patient on maintenance hemodialysis: A case report

Metastatic infections can complicate catheter-related blood stream infections (CRBSI) in dialysis dependent patients. However, an infected/septic aneurysm involving the aorta or its branches as a direct complication of CRBSI without an underlying infective endocarditis is not reported so far in the literature. We report a 43-year female, who presented with CRBSI 2 weeks following a tunneled dialysis catheter (TDC) insertion. Due to the lack of defervescence after 72 h of antibiotics given as per the culture sensitivity reports, the TDC was removed. Blood cultures grew Pseudomonas aeruginosa. After a catheter free interval of 4 days, a TDC was reinserted, an antibiotic course was completed, and she was discharged in stable condition. Five days later, she presented with acute abdominal pain and fever. A tender, firm, and pulsatile mass was noted in the hypogastrium with a bruit. Contrast-enhanced CT revealed a pseudoaneurysm of the aorta, and left common iliac artery at the site of origin. She was started on IV antibiotics and planned for an endovascular prosthesis but had a sudden collapse during her hospital stay due to a ruptured aneurysm. CRBSI due to certain pathogens such as Pseudomonas might require prolonged and dual antibiotic therapy to prevent fulminant complications.

Catheter-Related Bloodstream Infections among patients on maintenance haemodialysis: a cross-sectional study at a tertiary hospital in Ghana

BACKGROUND

Catheter-Related Bloodstream Infections (CRBSIs) are notable complications among patients receiving maintenance haemodialysis. However, data on the prevalence of CRBSIs is lacking. This study was conducted to determine the prevalence and factors associated with CRBSIs among patients receiving haemodialysis in the renal unit of the largest tertiary hospital in Ghana.

METHODS

A hospital-based cross-sectional study was conducted on patients receiving maintenance haemodialysis via central venous catheters (CVC) between September 2021 and April 2022. Multivariate analysis using logistic regression was used to determine the risk factors that were predictive of CRBSI. Analysis was performed using SPSS version 23 and a p-value<0.05 was statistically significant.

RESULTS

The prevalence of CRBSI was 34.2% (52/152). Of these, more than half of them (53.9%(28/52)) had Possible CRBSI while 11.5% (6/52) had Definite CRBSI. Among the positive cultures, 62% (21/34) were from catheter sites whilst the rest were from peripheral blood. Gram-negative cultures made up 53% (18/34) of positive cultures with the rest being Gram positive cultures. Acinetobacter baumannii (33.3% (6/18)) was the commonest organism isolated among Gram-negative cultures whilst Coagulase negative Staphylococci (43.7% (7/16)) was the commonest organism isolated among Gram-positve cultures. Gram-negative bacilli were more predominant in this study making up 52.9% of the total bacteria cultured. Sex, duration of maintenance dialysis, underlying cause of End-stage kidney disease, mean corpuscular haemoglobin (MCH), neutrophil count and lymphocyte count were significantly predictive of CRBSI status (p<0.05).

CONCLUSION

There was a high prevalence of CRBSI among patients undergoing haemodialysis. The commonest causative agent was Coagulase negative Staphylococci, however there was a predominance of Gram-negative bacilli as compared to Gram positive cocci. There is a need to set up infection surveillance unit in the renal unit to track CRBSI and put in place measures to reduce these CRBSI.

Staphylococcus epidermidis bloodstream infections are a cause of septic shock in intensive care unit patients

OBJECTIVES

Staphylococcus epidermidis (SE) is a supposedly low-virulence agent, which may cause proven bloodstream infections (BSIs), with little-known consequences on intensive care unit (ICU) patients. We aimed at studying ICU patients diagnosed with BSIs caused by SE (SE-BSIs).

METHODS

We constituted a retrospective cohort in two medical ICUs. SE-BSIs were defined by two or more independent SE-positive blood cultures of the same strain, within 48 hours, without concurrent infection.

RESULTS

We included 59 patients; 58% were men (n = 34), with median age of 67 (interquartile range 60-74) years and a simplified acute physiology score II of 59 (36-74) points, and 56% were immunocompromised (n = 33). Among the 37 (63%) patients requiring norepinephrine initiation or increase at the onset of SE-BSI versus patients not requiring vasopressors (37%; n = 22), concomitant arterial lactate levels reached 2.8 (1.9-5.8) versus 1.5 (1.3-2.2) mmol/l (P <0.01), whereas the mean blood pressure was 49 (42-54) versus 61 (56-65) mm Hg (P = 0.01) and the mortality was 46% (n = 17) vs 14% (n = 3) at day 28 (P = 0.01), respectively. Regarding antibiotics, the susceptibility rates toward linezolid and vancomycin were 71% (n = 41/58) and 100% (n = 54/54), respectively. At the time of SE-BSI, all but one patient had a central venous access device.

CONCLUSION

This work highlights SE-BSIs as a cause of septic shock, mostly in immunocompromised ICU patients, with increasing concerns about resistance to antibiotics and central line management.

Effects of a More Selective Arteriovenous Fistula Strategy on Vascular Access Outcomes

SIGNIFICANCE STATEMENT

The optimal choice of vascular access for patients undergoing hemodialysis-arteriovenous fistula (AVF) or arteriovenous graft (AVG)-remains controversial. In a pragmatic observational study of 692 patients, the authors found that among patients who initiated hemodialysis with a central vein catheter (CVC), a strategy that maximized AVF placement resulted in a higher frequency of access procedures and greater access management costs for patients who initially received an AVF than an AVG. A more selective policy that avoided AVF placement if an AVF was predicted to be at high risk of failure resulted in a lower frequency of access procedures and access costs in patients receiving an AVF versus an AVG. These findings suggest that clinicians should be more selective in placing AVFs because this approach improves vascular access outcomes.

BACKGROUND

The optimal choice of initial vascular access-arteriovenous fistula (AVF) or graft (AVG)-remains controversial, particularly in patients initiating hemodialysis with a central venous catheter (CVC).

METHODS

In a pragmatic observational study of patients who initiated hemodialysis with a CVC and subsequently received an AVF or AVG, we compared a less selective vascular access strategy of maximizing AVF creation (period 1; 408 patients in 2004 through 2012) with a more selective policy of avoiding AVF creation if failure was likely (period 2; 284 patients in 2013 through 2019). Prespecified end points included frequency of vascular access procedures, access management costs, and duration of catheter dependence. We also compared access outcomes in all patients with an initial AVF or AVG in the two periods.

RESULTS

An initial AVG placement was significantly more common in period 2 (41%) versus period 1 (28%). Frequency of all access procedures per 100 patient-years was significantly higher in patients with an initial AVF than an AVG in period 1 and lower in period 2. Median annual access management costs were significantly higher among patients with AVF ($10,642) versus patients with AVG ($6810) in period 1 but significantly lower in period 2 ($5481 versus $8253, respectively). Years of catheter dependence per 100 patient-years was three-fold higher in patients with AVF versus patients with AVG in period 1 (23.3 versus 8.1, respectively), but only 30% higher in period 2 (20.8 versus 16.0, respectively). When all patients were aggregated, the median annual access management cost was significantly lower in period 2 ($6757) than in period 1 ($9781).

CONCLUSIONS

A more selective approach to AVF placement reduces frequency of vascular access procedures and cost of access management.

Haemodialysis vascular catheter-related blood stream infection: Organism types and clinical outcomes

Catheter-related bloodstream infection (CRBI) is an important complication of catheter use for haemodialysis, but it remains unclear whether clinical outcomes following CRBI are influenced by organism type. This study aims to compare clinical outcomes following CRBI from Gram-positive and non-Gram-positive organisms. This was a retrospective cohort study of patients with kidney failure receiving haemodialysis (HD) via vascular catheters who had a documented episode of CRBI in Western Australia between 2005 and 2018. The associations between organism type, likelihood of hospitalization, catheter removal and death from CRBI were examined using adjusted logistic regression models. There were 111 episodes of CRBI in 99 patients (6.1 episodes per 1000-catheter-days at risk). Of the study cohort, 53 (48%) were male and 38 (34%) identified as Aboriginal or Torres Strait Islander. Gram-positive organisms were identified in 73 (66%) CRBI episodes, most commonly Staphylococcus aureus. Of those with non-Gram-positive CRBI, 9 (24%) were attributed to Pseudomonas aeruginosa. One-hundred and two (92%) episodes of CRBI required hospitalization and 15 (13%) patients died from CRBI. Compared with non-Gram-positive CRBI, Gram-positive CRBI was associated with an increased risk of hospitalization and catheter removal, with adjusted odds ratio of 9.34 (95% CI 1.28-68.03) and 3.47 (95% CI 1.25-9.67), respectively. There was no association between organism type and death from CRBI. Staphylococcus aureus remains the most common organism causing CRBI in HD patients. CRBI is associated with substantial morbidity, particularly CRBI attributed to Gram-positive organisms.

Vancomycin use for haemodialysis patients-Development of a new dosing protocol

AIM

To develop a dosing and monitoring protocol to achieve therapeutic vancomycin levels on intermittent haemodialysis.

METHODS

We identified 15 vancomycin treatment courses received by patients on intermittent haemodialysis at a district health board in Auckland, New Zealand. Demographic, biochemical and clinical parameters were gathered from their health records. We subsequently devised and implemented a new vancomycin protocol consisting of weight-based loading dose, and subsequent dose titration according to same-day measured pre-dialysis levels. We then re-audited 16 vancomycin treatment courses to assess the performance of the protocol.

RESULTS

A significantly higher proportion of vancomycin levels were within the target range (15-20 mg/L) following the implementation of protocol, from 23% to 46% (p < .005). Additionally, a greater proportion of treatment courses had >50% of pre-dialysis levels within the target range, rising from 13% to 56% (p < .01). In the pre-protocol group, 19 out of 117 doses of vancomycin were withheld during treatment, compared to 1 out of 118 doses in the post-protocol group. A total of 62% of total maintenance doses were administered in adherence to protocol. Length of hospital stay and number of positive blood cultures while on treatment were reduced.

CONCLUSIONS

Our initial audit revealed deficiencies in our clinical practice in the absence of a local vancomycin protocol for patients receiving intermittent haemodialysis. Following the implementation of our novel protocol, there was an improvement in therapeutic levels and fewer doses were withheld. Our sample size was too small to allow for interpretation of clinical outcome data.

Tunneled catheter-related bacteremia in hemodialysis patients: incidence, risk factors and outcomes. A 14-year observational study

BACKGROUND

Tunneled catheter-related bacteremia represents one of the major complications in patients on hemodialysis, and is associated with increased morbidity and mortality. This study aimed to evaluate the incidence of tunneled catheter-related bacteremia and, secondly, to identify possible factors involved in the first episode of bacteremia.

METHODS

This is a retrospective study of all tunneled catheters inserted between 1 January, 2005 and 31 December, 2019. Data on patients with a tunneled catheter were analyzed for comorbidities, catheter characteristics, microbiological culture results and variables related to the first episode of bacteremia. Patient outcomes were also assessed.

RESULTS

In the 14-year period under study, 406 tunneled catheters were implanted in 325 patients. A total of 85 cases of tunneled catheter-related bacteremia were diagnosed, resulting in an incidence of 0.40 per 1000 catheter days (81.1% after 6 months of implantation). The predominant microorganisms isolated were Gram-positive organisms: Staphylococcus epidermidis (48.4%); Staphylococcus aureus (28.0%). We found no significant differences in time to catheter removal for infections or non-infection-related reasons. The jugular vein, the Palindrome® catheter, and being the first vascular access were protective factors for the first episode of bacteremia. The 30-day mortality rate from the first tunneled catheter-related bacteremia was 8.7%.

CONCLUSIONS

The incidence of bacteremia in our study was low and did not seem to have a relevant impact on catheter survival. S. epidermidis was the most frequently isolated microorganism, followed by S. aureus. We identified Palindrome® catheter, jugular vein, and being the first vascular access as significant protective factors against tunneled catheter-related bacteremia.

Incidence and challenges in management of hemodialysis catheter-related infections

Catheter-related infections (CRI) are a major cause of morbidity and mortality in chronic hemodialysis (HD) patients. In this paper, we share our experience with CRI in HD patients. We recorded 49 cases of CRI among 167 patients during a period of 40 months (January 2018-April 2021). The incidence of CRI was 3.7 per 1000 catheter-days. The revealing symptoms were dominated by fever or chills (90%). Inflammatory signs were observed in 74% of cases with respectively concurrent exit-site (51%) and tunnel infection (6%). The biological inflammatory syndrome was found in 74% of patients (average CRP level = 198.9 mg/l). Blood cultures were performed in all cases and were positive in 65% of cases. Thirteen patients have been diagnosed with Infection complications, which were respectively infective endocarditis in 7 cases, septic arthritis in 3 cases, infective myositis in one case, cerebral thrombophlebitis in 1 case and mediastinitis in 1 case. The death occurred in eleven patients, it was due to septic shock in 9 cases, pulmonary embolism in one case and neurologic alterations related to cerebral thrombophlebitis. The mean seniority in HD was 16.5 months in the group with CRI and 3.7 months in the group without CRI (p < 0.04). We did not notice significant difference in mortality between tunnelled and non-tunnelled catheters. CRI does not seem to be more severe in patients with diabetes. Duration of use of the HD catheter (p < 0.007) and ferritin level (p < 0.0001) were independent factors that predispose to CRI in our population.

The cost of hospitalizations for treatment of hemodialysis catheter-associated blood stream infections in children: a retrospective cohort study

BACKGROUND

Hospitalization costs for treatment of hemodialysis (HD) catheter-associated blood stream infections (CA-BSI) in adults are high. No studies have evaluated hospitalization costs for HD CA-BSI in children or identified factors associated with high-cost hospitalizations.

METHODS

We analyzed 160 HD CA-BSIs from the Standardizing Care to Improve Outcomes in Pediatric End-stage Kidney Disease (SCOPE) collaborative database linked to hospitalization encounters in the Pediatric Health Information System (PHIS) database. Charge-to-cost ratios were used to convert hospitalization charges reported in PHIS database to estimated hospital costs. Generalized linear mixed modeling was used to assess the relationship between higher-cost hospitalization (cost above 50^th percentile) and patient and clinical characteristics. Generalized linear regression models were used to assess differences in mean service line costs between higher- and lower-cost hospitalizations.

RESULTS

The median (IQR) length of stay for HD CA-BSI hospitalization was 5 (3-10) days. The median (IQR) cost for HD CA-BSI hospitalization was $18,375 ($11,584-$36,266). ICU stay (aOR 5.44, 95% CI 1.62-18.26, p = 0.01) and need for a catheter procedure (aOR = 6.08, 95% CI 2.45-15.07, p < 0.001) were associated with higher-cost hospitalization.

CONCLUSIONS

Hospitalizations for HD CA-BSIs in children are often multiple days and are associated with substantial costs. Interventions to reduce CA-BSI may reduce hospitalization costs for children who receive chronic HD. A higher resolution version of the Graphical abstract is available as Supplementary information.

Performance of real-time PCR in suspected haemodialysis catheter-related bloodstream infection: a proof-of-concept study

Background

Catheter-related bloodstream infections (CRBIs) remain a major cause of mortality in haemodialysis (HD) patients with central venous catheters (CVCs), especially because of the non-specific symptomatology and the delay in microbiological diagnosis with possible use of non-optimal empiric antibiotics. Moreover, empiric broad-spectrum antibiotics increase antibiotic resistance development. This study aims to evaluate the diagnostic performance of real-time polymerase chain reaction (rt-PCR) in suspected HD CRBIs compared with blood cultures.

Methods

A blood sample for rt-PCR was collected simultaneously with each pair of blood cultures for suspected HD CRBI. The rt-PCR was performed on the whole blood, without any enrichment stage and with specific DNA primers: 16S (universal bacterial), Staphylococcus spp., Staphylococcus aureus and mecA. Each successive patient with a suspected HD CRBI in the HD centre of Bordeaux University Hospital was included. Performance tests were used to compare the result obtained in each rt-PCR assay with its corresponding routine blood culture.

Results

Eighty-four paired samples were collected and compared for 40 suspected HD CRBI events in 37 patients. Among these, 13 (32.5%) were diagnosed as HD CRBI. All rt-PCRs except mecA (insufficient number of positive samples) showed high diagnostic performances within 3.5 h: 16S (sensitivity 100%, specificity 78%), Staphylococcus spp. (sensitivity 100%, specificity 97%), S. aureus (sensitivity 100%, specificity 99%). Based on the rt-PCR results, antibiotics could be more appropriately targeted, thus cutting anti-cocci Gram-positive therapy from 77% to 29%.

Conclusions

The performance of rt-PCR in suspected HD CRBI events showed fast and high diagnostic accuracy. Its use would improve HD CRBI management with an antibiotic consumption decrease.

Distribution of mecA and qacA/B genes among coagulase negative staphylococci isolated from central venous catheters of intensive care unit patients

PURPOSE

This study was designed to detect the prevalence of antibiotic and antiseptic resistance genes, mecA and qacA/B in coagulase negative Staphylococcus (CoNS) species isolated from intensive care unit patients with catheter related blood stream infections (CRBSI) or colonized central venous catheters (CVC).

METHODS

Consecutive CoNS isolates from ICU patients with CRBSI or colonized central venous catheters were speciated and antibiotic susceptibilities were determined. The mecA and qacA/B genes were detected by polymerase chain reaction.

RESULTS

Eighty-two CoNS isolates from ICU patients with CRBSI (n ​= ​8) or colonized CVC (n ​= ​74) were included. The mecA gene was detected in 62 CoNS isolates (76%). The commonest species isolated was S. haemolyticus (n ​= ​34; 41%) and 30 of these possessed mecA which was significantly higher compared to other CoNS species (p ​= ​0.036). The qacA/B gene was detected in 13 (16%) isolates. Eleven (13%) CoNS had both genes. A significant association was seen with the presence of mecA and resistance to cloxacillin (p ​< ​0.001) and erythromycin (p ​= ​0.046). Presence of qacA/B (p ​= ​0.007) or both mecA and qacA/B (p ​= ​0.014) was associated with a higher resistance to clindamycin.

CONCLUSION

A considerably high prevalence of mecA and qacA/B genes as well as co-existence of both genes is noted among the CoNS isolated from ICU patients. This indicates the need of taking prompt actions in hospital acquired infection prevention including continuous surveillance.

The Effect of Humanistic Care Combined with Predictive Nursing on Negative Emotions and Incidence of Cardiovascular Events in Hemodialysis Patients

Objective

To explore the effect of humanistic care combined with predictive nursing on the negative emotions and incidence of cardiovascular events in hemodialysis patients.

Methods

A total of 90 patients undergoing hemodialysis in our hospital from December 2020 to September 2021 were selected as the research subjects and divided into the study group (n = 45) and the control group (n = 45) by the random number table method. The patients in the control group were given routine nursing, and the patients in the study group were given humanistic care combined with predictive nursing. The effects between the two groups were compared.

Results

After nursing, cardiac troponin I (cTn I) level, Hamilton Depression Scale (HAMD) scores, and Hamilton Anxiety Scale (HAMA) scores in the two groups decreased, and the scores were lower in the study group than the control group (P < 0.05). The World Health Organization on Quality of Life Brief Scale (WHOQOL-BREF) scores in both groups increased and were higher in the study group than the control group (P < 0.05). The nursing satisfaction in the study group was higher than that in the control group, and the incidence of cardiovascular adverse events in the study group was lower than that in the control group (P < 0.05).

Conclusion

In the process of hemodialysis, the application of humanistic care combined with predictive nursing to hemodialysis patients can significantly decrease the cTn I level, reduce the negative emotions of patients, improve the quality of life and nursing satisfaction of patients, and reduce the occurrence of adverse cardiovascular events.

[Diagnosis and treatment of catheter-related bloodstream infection in hemodialysis: 10 years later]

Patients in hemodialysis on central venous catheter as vascular access are at risk of infections. Catheter-related bloodstream infection is one of the most serious catheter-complications in hemodialysis patients. Its clinical and microbiological diagnosis is challenging. The implementation of empiric antibiotic therapy is based on old recommendations proposing the combination of a molecule targeting methicillin-resistant Staphylococcus aureus and a betalactamin active on P. aeruginosa, and also adapting this probabilistic treatment by carrying out a microbiological register on a local scale, which is rarely done. In our hemodialysis center at Bordeaux University Hospital, an analysis of the microorganisms causing all catheter-related bloodstream infection over the period 2018-2020 enabled us to propose, in agreement with the infectious disease specialists, an adapted probabilistic antibiotic therapy protocol. This approach allowed us to observe a low incidence of meticillinoresistance of Staphylococcus. For catheters inserted more than 6 months ago, we observed no Staphylococcus, no multi-resistant Pseudomonas, and only 2% of Enterobacteria resistant to cephalosporins. A frequent updating of the microbiological epidemiology of catheter-related bloodstream infection, in partnership with the infectious diseases team in each hemodialysis center, allowing an adaptation of the probabilistic antibiotic therapy, and seems to have a good feasibility. This strategy might favor the preservation of microbial ecology on an individual and collective scale in maintenance hemodialysis patients.

Optimising Access Surgery in Senior Haemodialysis Patients (OASIS): study protocol for a multicentre randomised controlled trial

INTRODUCTION

Current evidence on vascular access strategies for haemodialysis patients is based on observational studies that are at high risk of selection bias. For elderly patients, autologous arteriovenous fistulas that are typically created in usual care may not be the best option because a significant proportion of fistulas either fail to mature or remain unused. In addition, long-term complications associated with arteriovenous grafts and central venous catheters may be less relevant when considering the limited life expectancy of these patients. Therefore, we designed the Optimising Access Surgery in Senior Haemodialysis Patients (OASIS) trial to determine the best strategy for vascular access creation in elderly haemodialysis patients.

METHODS AND ANALYSIS

OASIS is a multicentre randomised controlled trial with an equal participant allocation in three treatment arms. Patients aged 70 years or older who are expected to initiate haemodialysis treatment in the next 6 months or who have started haemodialysis urgently with a catheter will be enrolled. To detect and exclude patients with an unusually long life expectancy, we will use a previously published mortality prediction model after external validation. Participants allocated to the usual care arm will be treated according to current guidelines on vascular access creation and will undergo fistula creation. Participants allocated to one of the two intervention arms will undergo graft placement or catheter insertion. The primary outcome is the number of access-related interventions required for each patient-year of haemodialysis treatment. We will enrol 195 patients to have sufficient statistical power to detect an absolute decrease of 0.80 interventions per year.

ETHICS AND DISSEMINATION

Because of clinical equipoise, we believe it is justified to randomly allocate elderly patients to the different vascular access strategies. The study was approved by an accredited medical ethics review committee. The results will be disseminated through peer-reviewed publications and will be implemented in clinical practice guidelines.

TRIAL REGISTRATION NUMBER

NL7933.

PROTOCOL VERSION AND DATE

V.5, 25 February 2021.

Microbial Repercussion on Hemodialysis Catheter-Related Bloodstream Infection Outcome: A 2-Year Retrospective Study

Background

Albeit growing technical advances in the design of hemodialysis catheters, intravascular catheter-related bloodstream infection (CRBSI) still represents an utmost clinical challenge to the health-care workers (HCWs). Data regarding the influence of the culprit organism on the scenario of CRBSI in the literature are extremely lacking. Thereby, this research was carried out.

Methods

We undertook a retrospective cohort study over an interval of 2 years, involving patients who underwent regular hemodialysis via catheters in the Renal Dialysis Unit (RDU) of Dr. Soliman Fakeeh Hospital (DSFH), Jeddah, Kingdom of Saudi Arabia (KSA). The study enrolled 139 patients (56.8% females and 43.2% males), with mean age of 60.79 ± 11.45 years.

Results

The aggregate rate of CRBSI was 5.1/1000 catheter days. Amongst the 139 study candidates confirmed of having CRBSI, while 69.8% of CRBSIs were ascribed to Gram-positive cocci, about one-third of the infectious episodes were secondary to Gram-negative bacilli. Interestingly, fever was the most common presentation of S. aureus CRBSI compared to CoNS and Gram-negative bacilli CRBSIs (20.9% versus 12.9% versus 6.5%, p= 0.0001), whereas CRBSIs due to CoNS were presented mainly with rigors (19.4%). Of note, CRBSIs caused by Gram-negative bacilli had a tendency to manifest with unusual symptoms such as vomiting or hypotension. Besides, they were more prone to involve hospitalization or ICU admission. In this study, no mortality was attributed to CRBSIs.

Conclusion

Our study disclosed that the illicit organism has a repercussion on the clinical presentation as well as the fate of CRBSI among hemodialysis patients. This highlights the worth of identifying the infected cases in a periodic manner, to avoid the occurrence of devastating complications. A large body of work from various hemodialysis centers should take place in the near future so as to provide more insight in this perspective.

The impact of anatomical variables on haemodialysis tunnelled catheter replacement without fluoroscopy

AIM

Tunnelled haemodialysis (HD) catheters can be used instantly, but there are several anatomical variables that could impact it survival. This study aimed to examine the impact of different novel anatomic variables, with catheter replacement.

METHODS

In a single-centre a prospective cohort in chronic kidney disease G5 patients were conducted. The primary outcome was to determine the factors associated with catheter replacement during the first 6-month of follow-up. All procedures were performed without fluoroscopy. Three anatomic regions for catheter tip position were established: considered as superior vena cava (SVC), cavo-atrial junction (CAJ) and mid-to deep atrium (MDA). Many other anatomical variables were measured. Catheter-related bloodstream infection was also included.

RESULTS

Between January 2019 and January 2020 a total of 75 patients with tunnelled catheter insertion were analysed. Catheter replacement at 6-month occur in 10 (13.3%) patients. By multivariate analysis, the incorrect catheter tip position (SVC) (OR 1.23, 95% CI 1.07-1.42, p <.004), the presence of extrasystoles during the procedure (OR 0.88, 95% CI 0.78-0.98, p = .03), incorrect catheter tug (OR 1.31, 95% CI 1.10-1.55, p = .003), incorrect catheter top position (kinking; OR 1.40, 95% CI 1.04-1.88, p = .02) and catheter-related bloodstream infection (OR 2.60, 95% CI 2.09-3.25, p <.001) were the only variables associated with catheter replacement at 6-month follow-up.

CONCLUSION

The risk of catheter replacement at 6-month follow-up could be attenuated by avoiding incorrect catheter tug and top position, and by placing the vascular catheter tip in the CAJ and MDA.

Management of Vascular Infections in Low- and Middle-Income Countries

Background: Vascular infections are rare and challenging conditions with significant deaths and morbidity. Their management necessitates a multi-disciplinary approach and substantial human and financial resources. The management selected may be influenced by the available resources in low- and middle-income countries (LMICs), where such resources may be variable. Methods: We reviewed the published literature and reviewed the management options for various vascular infections with a focus on carotid, aortic, infrainguinal, and dialysis access infections. Results: Recommendations related to prevention and treatment will be offered from the perspective of LMICs. The general principles for prevention are in compliance with established surgical site infection guidelines and minimize the use of prosthetic material. Early detection and intervention by removing all infected prosthetic material, debridement, drainage, and coverage of the infected field with vascularized tissue are essential steps in the management of the infection. Revascularization using an extra-anatomic or in situ approach is individualized based on the resources and expertise available. Conclusions: The prevention and management of vascular infections in LMICs are effective by adhering to time-proven principles even with limited resources.

Effects of different catheter replacement methods on catheter service time and complications in hemodialysis patients: A cohort study

INTRODUCTION

Central venous catheter insertion for long-term vascular access is not recommended in clinical practice. However, since arteriovenous fistula creation is difficult to perform in some patients, central venous catheter insertion for long-term vascular access is performed. This study aimed to assess the complications and service time of central venous catheters replaced using different methods and to determine the influencing factors of service time.

METHODS

Study design: A retrospective observational cohort study. Setting and participants: Patients who underwent tunneled dialysis catheter malfunction (2009-2019) and had to undergo another dialysis catheter insertion were enrolled. Exposures: Ectopic replacement and in situ replacement. Outcomes: Factors such as age, sex, primary patency rate, secondary patency rate, early complications, and late complications were considered. Analytical approach: This study used a Cox proportional hazards regression model.

RESULTS

The first and the newly replaced catheter service time were 37.779 ± 24.563 months and 32.468 ± 26.638 (25) months in the ectopic group and 37.075 ± 20.550 months and 26.349 ± 22.672 months in the in situ group, respectively. In the early service time, the newly replaced catheter resulted in significant bleeding from the tunnel. The first catheter had the least complications, most adequate blood flow, and longest service time. Ectopic catheter replacement and the tip shape of the catheter were the independent factors for catheter service time. Catheter service time increased with age.

CONCLUSION

Ectopic catheter replacement can improve the primary patency rate and auxiliary primary patency rate of catheters. Ectopic catheter replacement may require sufficient surgical skills with digital subtraction angiography, resulting in a better prognosis.