Catheter-related bloodstream infections in a nephrology unit: Analysis of patient- and catheter-associated risk factors

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.

Effectiveness of nanoparticle-based antimicrobial agents in the prevention and treatment of Central Venous Catheter-Associated Bloodstream Infections

BACKGROUND

In healthcare settings, Central Venous Catheter-Associated Bloodstream Infections (CVC-BSIs) present a serious problem since they raise morbidity, mortality, and medical expense rates. The management of these illnesses is made more challenging by the development of antimicrobiotic resistance. Nanotechnology has attracted interest recently as a viable method for creating new antimicrobial agents. By putting antibacterial nanomaterials onto the catheter's appear, that may reduce the likelihood of getting sick by stopping germs from adhering and growing. Antimicrobial additives can be released gradually finishes, protecting over time through bioengineering sectors. To prevent and treat CVC-BSIs, this study will assess the efficacy of antimicrobial medicines based on nanoparticles.

METHODS

In the network Meta-Analyses (MA) and Systematic Review (SR), we looked for studies published from January 2010 to September 2021 using the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, CINAHL, and Web of Science databases. Ten papers in all were included in the review following the screening of the publications using inclusion and exclusion criteria.

RESULTS

In contrast to conventional catheters, the implementation of Antimicrobial Catheters (AC) and the use of chlorhexidine (CHG) or Silver Sulfadiazine (SS) demonstrated notably reduced occurrences of Central Venous Catheter-Associated Bloodstream Infections (CVC-BSIs) per 1000 Catheter Days (CD) (with Odds Ratios (ORs) and 95% Credibility Intervals (CrIs) of 0.66 and 0.54, respectively) by bioengineering sectors. Moreover, these interventions were linked to the lowest rate of Catheter Colonization (CC), with ORs as well as 95% CrIs of 0.45 and 0.31, respectively, underscoring their potential as effective strategies for minimizing the risk of infections associated with catheter use as well as bioengineering sectors innovations.

CONCLUSIONS

As a result, CVC-BSI has shown significant promise for prevention and treatment with nanoparticle-based antimicrobial medicines. Due to their special characteristics and modes of action, they are strong candidates for improving the security and effectiveness of central venous catheter use in clinical settings. Due to ongoing research and development in this area, nanoparticle-based coatings and therapies may be used to lessen the impact of CVC-BSIs and enhance patient outcomes.

Risk Assessment of Venous Thromboembolism among Septic Shock Patients: Single versus Concurrent Insertion of Central Venous Catheters

Background and Objectives: Thrombosis is a serious complication experienced by some hospitalized patients. While concurrent placement of two catheters (CVCs) in the same central vein offers several benefits in clinical settings, we aimed to investigate the role of this procedure in relation to the risk of thrombosis. Materials and Methods: Over a two-year retrospective analysis, we examined 114 patients with septic shock caused by a pulmonary infection, who underwent the insertion of one or more central lines into a central vein during their ICU stay. Logistic regression models were employed to assess the correlation between the Caprini risk score, the placement of two CVCs in the same vein, COVID-19 infection and the risk of venous thromboembolism (VTE). Results: In total, 53% of the patients underwent the concurrent insertion of two CVCs. The placement of two CVCs in the same vein appears to elevate the VTE risk by 2.5 times (95% CI: 1.03-6.12). Logistic regression analysis indicated that hemodialysis catheters amplify the VTE risk by nearly five times, even when accounting for a series of factors (95% CI: 1.86-12.31). Conclusions: Our study suggests that the elevated risk of VTE is likely associated with the insertion of the hemodialysis catheters rather than solely the presence of two concurrent catheters.

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.

Central venous catheter-related complications in older haemodialysis patients: A multicentre observational cohort study

BACKGROUND

Central venous catheters (CVC) remain a commonly used vascular access option in haemodialysis, despite guidelines advising to preferably use arteriovenous fistulae. Compared to younger patients, the risk-benefit ratio of CVC in older patients might be more beneficial, but previous studies mainly focussed on catheter-related bacteraemia and/or assessed tunnelled CVC (TCVC) only. This study's aim was to compare all catheter-related infections and malfunctions in older patients with younger patients using all CVC subtypes.

MATERIALS AND METHODS

We used data from DUCATHO, a multicentre observational cohort study in The Netherlands. All adult patients in whom a CVC was placed for haemodialysis between 2012 and 2016 were included. The primary endpoint was the occurrence of catheter-related infections, comparing patients aged ⩾70 years with patients aged <70 years (reference). As secondary endpoints, catheter malfunctions and catheter removal due to either infection or malfunction were assessed. Using Cox proportional hazards and recurrent events modelling, hazard ratios (HR) with 95% confidence intervals (CI) were calculated with adjustment of prespecified confounders. Additionally, endpoints were assessed for non-tunnelled CVC (NTCVC) and TCVC separately.

RESULTS

A total of 1595 patients with 2731 CVC (66.5% NTCVC, 33.1% TCVC) were included. Of these patients, 1001 (62.8%) were aged <70 years and 594 (37.2%) ⩾70 years. No statistically significant difference was found for the occurrence of catheter-related infections (adjusted HR 0.80-95% CI 0.62-1.02), catheter malfunction (adjusted HR 0.94-95% CI 0.75-1.17) and catheter removal due to infection or malfunction (adjusted HR 0.94-95% CI 0.80-1.11). Results were comparable when assessing NTCVC and TCVC separately.

CONCLUSION

Patients aged ⩾70 to <70 years have a comparable risk for the occurrence of catheter-related infections and catheter malfunction. These findings may help when discussing treatment options with older patients starting haemodialysis and may inform the current debate on the best vascular access for these patients.

Incidence, microbiological aspects and associated risk factors of catheter-related bloodstream infections in adults on chronic haemodialysis at a tertiary hospital in Uganda

Objectives

The high burden of infectious complications among patients receiving haemodialysis (HD) via central venous catheters increases morbidity and mortality. This study determined the incidence of catheter-related bloodstream infections (CRBSIs), microbiological profile of causative organisms, and associated predictors in patients on chronic HD.

Methods

A prospective single-centre cohort study of 121 adult patients with end-stage kidney disease was conducted from October 2019 to March 2020. Antibiotic susceptibility was determined by the Kirby-Bauer disk diffusion method. Cox proportional hazards model was used to determine predictors of CRBSI.

Results

The mean age was 50 (standard deviation 14.9) years and the median duration of follow-up was 69 (interquartile range 23-124) days. At least one CRBSI was recorded for 41% of patients, at a rate of 5.2 infections per 1000 patient-days. Causative organisms were predominantly Gram-negative bacteria (60.3%), and 36.5% of all isolates were multi-drug resistant. Anaemia [hazard ratio (HR) 5.44, P=0.019, 95% confidence interval (CI) 1.32-22.48] and previous bloodstream infection [HR 2.47, P=0.028, 95% CI 1.10-5.54] were predictors of CRBSI.

Conclusion

The high incidence of CRBSI in patients on chronic HD with predominance of Gram-negative bacteria means that catheter care bundles should include Gram-negative coverage.

Survival Analysis of Tunneled Cuffed Central Venous Catheters in Maintenance Hemodialysis Patients: A Retrospective Study in China

AIM

The study aimed to investigate the clinical epidemiological data and the survival rate of maintenance hemodialysis patients with tunneled cuffed central venous catheters (TCCs) in a single hemodialysis center in China.

METHODS

We retrospectively investigated the general clinical characteristics (including sex, age, primary causes, and catheter outcome) of 316 patients undergoing maintenance hemodialysis (MHD) via TCC for >3 months at Wannan Medical College Affiliated Yijishan Hospital, Wuhu, China, from July 2011 to June 2021. The long-term survival rate of the catheters was determined by Kaplan-Meier survival analyses.

RESULTS

A total of 316 patients (137 males, 179 females) were included, with a mean age of 65.0 ± 15.5 years. The right internal jugular vein was the most commonly used central vein, accounting for 89.1% of catheterizations. After censoring for noncatheter-related events leading to the removal of the catheter, the mean survival time of the TCCs was 26.2 ± 19.8 smonths and the median survival time was 58.0 (95% CI, 54.0-62.0) months. Seventy patients had catheter loss-of-function events, with an incidence of 22.2%. Moreover, 97.3% of TCCs survived 1 year and 43.3% survived 5 years, respectively. The sex and age of the patients were not related to the survival rate (p > 0.05). There were also no statistical differences between the primary diseases of patients and the survival rate of TCCs (p > 0.05).

CONCLUSION

In this study, we provide evidence of the mean TCC survival time beyond 2 years. We found that TCC is an effective alternative for MHD patients with poor vessel status or limited survival time or become a bridge waiting for arteriovenous fistula to mature, regardless of age, sex, and primary diseases.

Effect of sutureless securement on hemodialysis catheter-related bloodstream infection

The use of sutureless securement devices during catheterization might reduce the risk of catheter-related bloodstream infection (CRBSI) by suppressing catheter-exit infection and catheter dislodgement. However, the effectiveness of these devices in reducing CRBSI risk when securing hemodialysis catheters has not been explored. This single-center retrospective observational study examined 211 non-tunneled hemodialysis catheters (NTHCs) from 110 hemodialysis inpatients, of which 121 were secured using conventional skin sutures (Suture group) and 90 with GRIP-LOK (GRIP-LOK group). The stabilized inverse probability of treatment (SIPT)-weighting method was used to generate a new population (SIPT-weighted model) without group differences for each of the 12 predictors of CRBSI development (i.e., age, sex, dialysis history, concomitant acute kidney injury or diabetes, concurrent use of immunosuppressant drugs or aspirin, NTHC insertion site, methicillin-resistant Staphylococcus aureus, carriage, bacteremia event within 3 months before catheterization, hemoglobin level, and serum albumin titer). The effect of GRIP-LOK compared with sutures on CRBSI in the SIPT-weighted model was evaluated using univariate SIPT-weighted Cox proportional regression analysis, which showed a significant CRBSI suppression effect of GRIP-LOK compared with sutures (hazard ratio: 0.17 [95% CI 0.04–0.78], p = 0.023).　GRIP-LOK affords a lower risk of CRBSI due to indwelling NTHCs than conventional securement using sutures.

Targeting COVID-19 prevention in hemodialysis facilities is associated with a drastic reduction in central venous catheter-related infections

BACKGROUND

In hemodialysis (HD) patients, central venous catheter (CVC) related bloodstream infections are a major cause of morbidity and mortality. Hygienic precautions are a key aspect of dialysis care for infection prevention, but they are not sufficient to completely avoid the occurrence of CVC related infections. During the COVID-19 pandemic, hygienic precautions for preventing viral transmission have been markedly reinforced. We evaluated their effects on CVC-related infection rates.

METHODS

An observational retrospective study was conducted in two hemodialysis units of the same institution treating 215 chronic hemodialysis patients, 71 of whom are currently (33%) using a CVC. In the CVC cohort, we compared data on catheter-related infection rates during the maximum spread of the COVID-19 pandemic in Italy (February to May 2020) with data from the same period of the previous year and with the whole of 2019.

RESULTS

In 2019, we recorded a catheter-related bloodstream infection (CRBSI) rate of 1.19 (95% CI 0.81-1.68)/1000 days [2.07 (95% CI 1.12-3.52)/1000 days in the Feb-May 2019 period] and a tunnel and exit-site infection rate of 0.82 (95% CI 0.51-1.24)/1000 days [1.04 (95% CI 0.41-2.15)/1000 days in the Feb-May 2019 period]. Infection rates drastically decreased during the COVID-19 pandemic, with just one catheter-related bloodstream infection being recorded. Catheter-related bloodstream infection rates showed a significant reduction to 0.20 (95% CI 0.01-0.9)/1000 days (p < 0.05 and p < 0.005 compared to 2019 and to Feb-May 2019, respectively) and a non-significant reduction in tunnel and exit-site infections to 0.6 (95% CI 0.15-1.6)/1000 days.

CONCLUSIONS

The observed 91% reduction in catheter-related bloodstream infections compared to the same period in 2019 [IRR 0.09 (95% CI 0.002-0.64)] and the 83% reduction compared to the whole of 2019 [IRR 0.17 (95% CI 0.004-1.009)] suggest that a stricter implementation of hygienic precautions in the dialysis setting can markedly improve the problem of CVC-related infections.