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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO EDITOR Table of Contents   
Year : 2004  |  Volume : 15  |  Issue : 1  |  Page : 67-69
Antibiotic-Heparin Lock Technique: A Potentially Precious Tool to Prevent Hemodialysis Catheter-related Septicemia


Post-graduate Department of Medicine, King Fahad Hospital & Tertiary Care Center, Hofuf, Al-Hasa-31982, Saudi Arabia

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How to cite this article:
Panhotra B R, Al-Arabi Al-Ghamdi AM, Saxena AK. Antibiotic-Heparin Lock Technique: A Potentially Precious Tool to Prevent Hemodialysis Catheter-related Septicemia. Saudi J Kidney Dis Transpl 2004;15:67-9

How to cite this URL:
Panhotra B R, Al-Arabi Al-Ghamdi AM, Saxena AK. Antibiotic-Heparin Lock Technique: A Potentially Precious Tool to Prevent Hemodialysis Catheter-related Septicemia. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2019 Sep 20];15:67-9. Available from: http://www.sjkdt.org/text.asp?2004/15/1/67/32970
To the Editor:

Data from ESRD Network-11 revealed that 63% patients began HD through central venous catheters (CVCs) as lone vascular access, in1999, in the USA. [1] CVCs are used as an interim bridging solution to permit creation, maturation and revision of arterio­venous fistula (AVF) as well as a long-term solution in patients with exhausted vascular access sites or for comfort, in elderly end­stage renal disease (ESRD) patients having co-morbid conditions leading to limited life expectancy. The major problem associated with the use of CVCs is the high infection rates ranging from 14 to 54%. [2] Catheter­related septicemia (CRS) remains one of the major problems, accounting for mortality rate of 12-25.9% among HD patients. [2],[3],[4],[5]

The reported efficacy of primary treatment of CRS with systemic antibiotics alone, depending upon local prevalence of resistance patterns of bacterial flora, is just 25-32%. [3],[4] The procedure of catheter exchange over a guide wire, even with promising results of one-year success rates of up to 92%, remains controversial. [6] Antiseptic and antibiotic­coated CVCs which showed potential of 79% reduction in CRS with the use of chlor­hexidine-silver sulfadiazine-coated cathe­ters in intensive care (ICU) population were found to be of limited use in long-tern HD patients as catheters employed in ICU were in situ for around one week against HD CVCs that might be in place for several weeks to months. [7] Removing the infected CVCs and replacing them at alternative sites is a standard routine practice. Over time, with several catheter changes, vascular sites get depleted for the placement of permanent vascular access. Therefore, prevention and/or treatment of CRS without CVC removal would be optimal solution to the problem.

The eradication of CRS up to 90% was achieved in patients receiving home parentral nutrition without catheter removal using an antibiotic-lock with or without systemic anti­biotics. [8] Recently antibiotic-heparin lock was investigated for the prevention of gram-positive CVC-related bacteremia in neutropenic patients with cancer, showing encouraging results; none of the 60 patients receiving vancomycin­heparin lock developed CRS over an average of ten days of observation period. [9] In a small observational trial, continuous antibiotic infusion followed by antibiotic-heparin lock using vancomycin or ciprofloxacin success­fully eradicated CRS in all the 13 HD patients without CVC removal. [10] Currently, antibiotic­heparin lock has been reported to be asso­ciated with reduced risk of colonization of CVCs and consequent decrease in septicemic episodes. [11],[12] A number of third generation cephalosporins, ciprofloxacin, vancomycin and gentamycin have been found to be appropriate for antibiotic-heparin lock. A fairly lower concentration of antibiotics (10 mg/ml each for cephazolin, ceftazadime and vancomycin and 5mg/ml for gentamycin) as compared to their systemic dosage was required to fill the lumina of CVCs in order to prevent bacterial colonization during the inter-dialysis period. [13] Antibiotic-heparin locks are not in routine practice in patients undergoing HD through CVCs but they appear to have the potential to effectively prevent the recurrent episodes of CVC­related septicemia in this vulnerable group of ESRD patients.

The role of cefotaxime-heparin lock and assessment of its efficacy in primary prevention of catheter-related septicemia (CRS) among patients on long-term HD was deter­mined in a study carried out at our center from August 2000 to July 2001. The choice of cefo­taxime in combination of heparin was based on its broad spectrum with gram-negative bacilli coverage approximately equivalent to aminoglycosides besides being the most effective amongst third generation cephalo­sporins against Staphylococcus aureus. [14]

The prevalence of gram negative bacilli was relatively higher than that of S. aureus (54% versus 29%) among HD cohort at this center. [3] Cefotaxime has been reported to be the anti­biotic of choice for treatment and prophylaxis of nosocomial infections with high clinical and microbiological efficacy and safety profile in critically ill patients. [15] The best substitute to cefotaxime is gentamycin or amikacin that was deliberately avoided due to ototoxicity. [16]

The cefotaxime-heparin lock was prepared by combining cefotaxime at final concen­tration of 10 mg/ml with heparin 5000 U/ml. A final volume of 5 ml was prepared in a syringe under sterile conditions to fill 1.3 ml in venous and 1.2 ml in arterial lumen of the catheter with combined volume of approximately 2.5 ml containing a total of 25 mg of the drug. The caps of the catheter hubs were then secured tightly to "lock" the anti­biotic in the lumina of the catheter. [13] The lock was applied two/three times a week post-dialysis and also following any additional HD sessions. In this study, antibiotic-heparin lock using cefotaxime was employed imme­diately post-dialysis and within six hours of new CVC placement with the goal of primary prevention of CVC infection and consequent CRS. Reasonably higher concentrations of the fibrinolytic agent, heparin sodium (5000 units/ml), were used to penetrate/prevent slime layer formation and to overcome a iminished antimicrobial effect on bacteria embedded in biofilm. [17]

Blood samples were collected for culture and sensitivity both from the catheters and peri­pheral vein, on clinical suspicion of septicemia.

The present study included 197 ESRD patients with a mean age of 47.5 years (range 15-85 years). Of them, 67 (34.0%) were dialyzed through CVCs including 36 (18.3%) with permanent catheters (PC), 11 (5.6%) via subclavian catheters (SC) and 20 (10.1%) by means of femoral catheters (FC) while the remaining 130 (66.0%) had AVF.

An overall prevalence of CRS of 0.55 episodes/1000 catheter-days and the CRS­related mortality of 4.47% per year was observed in this study. The CRS prevalence was significantly lower than that of 1.19 episodes/1000 catheter-days documented in July 2000, at our center (95% CI), (p<0.001). 18 Likewise, mortality related to CRS of 4.47% per year after usage of cefotaxime-heparin lock was significantly lower than that of 7.5% achieved after realization of NKF­DOQI recommended goal of dialyzing over 50% of patients through arterio-venous fistula (AVF) in July 2000 at this center (95% CI, 1.253-4.92, p<0.02). 18 S.aureus was asso­ciated with all the seven CRS episodes including three deaths over the one year of study period.

Thus, in our study, cefotaxime-heparin locks offered complete protection from CRS caused by gram-negative bacilli but provided only partial, but clinically useful, shield against S. aureus related CRS, apart from enhancing the life-span of the CVCs.[18]

 
   References Top

1.Besarab A, Adams M, Amatucci S, et al. Unraveling the realities of vascular access: the network 11 experience. Adv Ren Replace Ther 2000;7:S 65-70.  Back to cited text no. 1    
2.Beathard GA. Management of bacteremia associated with tunnelled cuffed hemo­dialysis catheters. J Am Soc Nephrol 1999; 10:1045-9.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Saxena AK, Panhotra BR, Naguib M, et al. Vascular access related septicemia in hemodialysis: a focus on bacterial flora and antibiotic access salvage. Saudi J Kidney Dis Transplant 2002;13:29-34.  Back to cited text no. 3    
4.Marr KA, Sexton DJ, Conlon PJ, Corey GR, Schwab SJ, Kirkland KB. Catheter­related bacteremia and outcome attempted catheter salvage in patients undergoing hemodialysis. Ann Intern Med 1997;127: 275-80.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Tanriover B, Carlton D, Saddekni S, et al. Bacteremia associated with tunneled dialysis catheters: Comparison of two treatment strategies. Kidney Int 2000;57: 2151-5.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Robinson D, Suhoki P, Schwab SJ. Treat­ment of infected tunnelled access hemodialysis catheters with guidewire exchange. Kidney Int 1998;53:1792-4.  Back to cited text no. 6    
7.Raad I, Hachem R, Zermino A, Stephens LC, Bodey GP. Silver iantophoretic catheter: a prototype of a long-term anti-infective vascular access device. J Infect Dis 1996;173:495-98.  Back to cited text no. 7    
8.Messing B, Peitra-Cohen S, Debure A, Beliah M, Bernier JJ. Antibiotic-lock technique: a new approach to optimal therapy for catheter related sepsis in home parenteral nutrition patients. J Parenter Enteral Nutr 1988;12:185-9.  Back to cited text no. 8    
9.Carratala J, Niubo J, Fernandez-Sevilla A, et al. Randomized, double-blind trial of an antibiotic-lock technique for prevention of gram-positive central venous catheter-related infection in neutropenic patients with cancer. Antimicrob Agents Chemother 1999;43:2200-4.  Back to cited text no. 9    
10.Capdevila JA, Segarra A, Planes AM et al. Successful treatment of haemodialysis catheter related sepsis without catheter removal. Nephrol Dial Transplant 1993;8:231-4.  Back to cited text no. 10    
11.Krishnasami Z, Carlton D, Bimbo L, et al. Management of hemodialysis catheter-related bacteremia with adjunctive antibiotic lock solution. Kidney Int 2002;61:1136-42.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Pervez A, Ahmad M, Ram S, et al. Antibiotic lock technique for prevention of cuffed tunnel catheter associated with bacteremia. J Vasc Access 2002;3:108-13.  Back to cited text no. 12    
13.Vercaigne LM, Sitar DS, Penner SB, Bernstein K, Wang GQ, Burczynski FJ Antibiotic-Heparin lock: In vitro antibiotic stability combined with heparin in a central venous catheter. Pharmacotherapy 2000; 20:394-9.  Back to cited text no. 13    
14.Archer GL, Polk RE. Treatment and prophylaxis of bacterial infections, in Isselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, Kasper DL, Hauser SL, Longo DL. (Eds.) Harrison's Principles of internal Medicine, Chap.140, International Edition McGraw-Hill, Inc. NY.1998, pp 856-869.  Back to cited text no. 14    
15.Francisco IL, Mercedes P, Pedro O, Rafel S, Enrique C. Cefotaxime: twenty years later. Observational study in critically ill patients. Enferm Infect Microbiol Clin 2001;19:211-8.  Back to cited text no. 15    
16.Saxena AK. Ototoxicity from the aminoglycosides-heparin / citrate locks applied for the prevention of hemodialysis catheter -related infections. J Vasc Access 2003:4:35-6.  Back to cited text no. 16    
17.Passerini L, Lam K, Costerton JW, King EG. Biofilms on indwelling vascular catheters. Crit Care Med 1992; 20:665-73.  Back to cited text no. 17  [PUBMED]  
18.Saxena AK, Panhotra BR, Naguib M, et al. The impact of achieving goal for AV fistula set by NKF-DOQI, on Staphylococcus aureus septicemia. Dial Transplant 2002; 31:16-23.  Back to cited text no. 18    

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Correspondence Address:
Anil K Saxena
Post-graduate Department of Medicine, King Fahad Hospital & Tertiary Care Center, Hofuf, Al-Hasa-31982
Saudi Arabia
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PMID: 18202471

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