The Ultimate Gift A newsletter from the transplant team at Rhode Island Hospital

Dear Colleagues:

Hemodialysis access comprises the bulk of our non-transplant practice and catheter complications are common. In this issue of the Ultimate Gift we are addressing an issue that affects many of our patients before transplantation—specifically dialysis catheter related infections.

Proper management of catheter infections varies in the literature and in clinical practice. Obviously the best strategy is to avoid the use of lines. However, even in the best of worlds, like Rhode Island for instance, this is not entirely possible. DOQI guidelines reflect this reality, setting a goal of 15% of patients initiating dialysis with a line. Other patients are condemned to a dialysis catheter having failed multiple extremity accesses and not being candidates for CAPD or transplantation. In these patients the dialysis catheter is literally a lifeline and managing catheter infections has an enormous impact on the patients' overall health and quality of life. Patient safety is paramount, but quality of life considerations play a role, including issues of hospital admission, temporary femoral access, length of stay, TEE, prolonged antibiotic administration, home infusions and subsequent creation of long-term dialysis access.

The management of catheter infections is often determined by the severity of illness (fever, rigors, constitutional symptoms, hypotension and co-morbid illnesses). Tailoring the approach to the severity of illness and the findings on examination (tunnel infection, exit site infection, extremity edema, etc.) has been advocated (KI 60:1-13, 2005). Cure rates are excellent (greater than 75%) for catheter exchange in all but the sickest of patients. Dr. Leonard Mermel has confirmed these results in patients without ESRD—"Management guidelines for catheter infections" in Clinical Infectious Diseases (32:1249, 2005).

Earlier this year, Drs. Mermel, Douglas Shemin and I created an algorithm for treating dialysis catheter infections (see below). With your assistance, I would like to follow these patients and evaluate the effectiveness of this strategy. The algorithm suggests standardized treatment guidelines rather than a research proposal. I look forward to your comments and, along with Dr. Gautam, your consideration in the care of these challenging patients.

Proposed Algorithm for Treating
Infected Tunneled Hemodialysis Catheters

Patient with known or suspected catheter related bacteremia (fever temporally related to dialysis, blood cultures (+), no other source identified)

Complicated

Temporary catheter (femoral vein, opposite side IJV or SCV) for 3-14 days depending on the severity of infection followed by reinsertion of a tunneled catheter.

Uncomplicated

Treat 3 -7 days with intravenous antibiotics,⁴ exchange catheter over wire (Cervical incision, divide the catheter above the clavicle, pass guide wire through the distal catheter and remove, remove the proximal catheter and hub from the chest wall, re-insert a new catheter, create a new tunnel and exit site)

Remove catheter; treat as outlined above with temporary catheter.

¹Vancomycin empirically, then convert to Nafcillin or cefazolin if susceptible. Antibiotic lock therapy is recommended if the catheter is retained (see above guidelines).

²Obtain TTE or preferably TEE. If ECHO is (+): remove the catheter and extend treatment for 4-6 weeks. Treat nasal carriage with mupirocin ointment (2%).

³Afebrile and negative repeat blood culture within 72* of treatment.

⁴Repeat blood cultures on antibiotics to document negative result.

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