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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 1  |  Page : 54-58
Influence of intralumenal and antibiotic-lock of vancomycin on the rate of catheter removal in the patients with permanent hemodialysis catheters


1 Department of Vascular Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of General Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Nephrology, Isfahan University of Medical Sciences, Isfahan, Iran
4 Isfahan University of Medical Sciences, Isfahan, Iran
5 Alzahra Hospital, Isfahan University of Technology, Isfahan, Iran

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Date of Web Publication8-Jan-2010
 

   Abstract 

Infection of permanent catheters (Permcath) in hemodialysis (HD) patients can lead to catheter removal. The successful use of an antibiotic-lock to treat infection has reported good results in the treatment of catheters' infections. This study was designed to evaluate the impact of the intraluminal vancomycin in comparison with intravenous antibiotic administration. We included 67 (37 males and 30 females) chronic HD patients requiring Permcath insertion at our tertiary care hospital from July 2004 to June 2007. We studied two subgroups: an intervention group, which received 500 mg vancomycin infusion via both lumens of the Permcath and antibiotic lock of 1.5 mL each 48 hours with 1 g i.v. ceftriaxone every 12 hours for 7 days, followed by oral antibiotics according to the culture for three weeks; and a control group, which received 500 mg intravenous vancomycin with daily 100-150 mg amikacin intravenously. Our endpoint was the rate of catheter removal. The patients characteristics including age, sex, time of insertion of the catheter and number of dialysis sessions per week did not differ between both subgroups. Of 28 patients in the intervention group, there was one catheter removal, and of 39 patients in the control group, there were 22 catheter removals, (P< 0.001). We conclude that administration of vancomycin as an antibiotic-lock in permcaths is more effective than its mere intravenous injection, and can increase the life span of catheters.

How to cite this article:
Beigi AA, Khansoltani S, Masoudpour H, Atapour AA, Eshaghian A, Khademi EF. Influence of intralumenal and antibiotic-lock of vancomycin on the rate of catheter removal in the patients with permanent hemodialysis catheters. Saudi J Kidney Dis Transpl 2010;21:54-8

How to cite this URL:
Beigi AA, Khansoltani S, Masoudpour H, Atapour AA, Eshaghian A, Khademi EF. Influence of intralumenal and antibiotic-lock of vancomycin on the rate of catheter removal in the patients with permanent hemodialysis catheters. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Jul 23];21:54-8. Available from: http://www.sjkdt.org/text.asp?2010/21/1/54/58710

   Introduction Top


Patients who use permanent catheters (Permcath) as vascular accesses for long-term hemodialysis (HD) are occasionally confronted with catheter­related infections. Tunnel tract infection and ca­theter-mediated bacteremia are the primary rea­sons for catheter removal, [1] which is an impor­tant factor in morbidity and mortality of these patients. [2]

Gram-positive organisms are responsible for most of the catheter-related infections, with Sta­phylococcal infection accounting for 40-80%, and enterococci and Gram-negative bacilli ac­counting for the remainder of the infections. [3],[4],[5],[6],[7],[11] A 2-3 week course of appropriate systemic anti­biotic therapy without catheter removal has re­sulted in catheter salvage in only 20-30% of the infected patients. [7],[8]

NKF-DOQI clinical practice guidelines for vas­cular access recommend that catheter-related bacteremia, with or without systemic signs or symptoms of illness, should be treated by ini­tiating parenteral treatment with an appropriate antibiotic(s), and catheters should be removed in all instances if the patients remain symp­tomatic more than 36 hours. The catheter should also be removed in any clinically unstable pa­tient. Some reports proposed an alternative approach by changing the catheter over a guide­wire plus a minimum of 3 weeks of systemic antibiotic therapy. [9]

Since systemic antibiotic therapy alone with­out catheter removal is unlikely to eradicate ca­theter-related bacteremia, [10] HD patients with in­fected central venous catheters, who have to be treated for bacteremia with systemic antibiotic therapy, should always receive an antibiotic­ lock of the catheter after each HD session. [11],[12],[13],[14],[15]

We aim in this study to evaluate the efficacy of the intraluminal permcath administration of vancomycin, which minimally diffuses outside the catheter, in comparison with intravenous an­tibiotic administration and the rate of catheter removal as an end point.


   Patients and Methods Top


This prospective interventional controlled study included 67 (37 males and 30 females) end-stage renal disease (ESRD) patients of diverse etio­logy enrolled for long-term HD from July 2004 to June 2006 at our tertiary care hospital. Those patients with primary diagnosis of permcath in­fection were eligible for the study. We excluded patients with known allergy to vancomycin. The local ethics committee approved the protocol, and written informed consent was obtained from the study patients.

The study patients were categorized to two groups: group I received 500 mg vancomycin (in 100 mL normal saline 0.9%) injected 50 mL via each lumen of permcath and antibiotic-lock by the last 1.5 mL that was repeated each 48 hours in addition to 1 gr IV Ceftriaxone (each 12 hours) for 7 days, and then oral antibiotics were admi­nistered according to the culture for 3 weeks. If the culture was negative, 400 mg Cefixime daily was administered for 3 weeks.

Group II received Vancomycin 500 mg i.v. in a peripheral vein in addition to 100-150 mg Amikacin daily i.v. If the patients did not res­pond adequately, then more antibiotics were added.

The catheters were removed, if the patients did not improve after 3 days of antibiotic therapy. Our study endpoint was catheter removal, while protocol success was defined as resolution of fever and clinical improvement lasted at least one week following completion of the protocol. Protocol failure was defined as persistence of fever or positive bacterial culture.


   Statistical analysis Top


All statistical calculations were performed with SPSS 15.0 (SPSS Inc, Chicago, IL, USA). Dif­ferences between groups were analyzed by Fi­sher's exact test to determine the effect of me­thod on catheter removal. P value less than 0.05 was considered as statistically significant.


   Results Top


The study Patients' characteristics including age, sex, time of insertion of permcaths and number of dialysis per week are described in [Table 1]. They were not different between the study subgroups. In group I, culture was positive in 5 patients. Culture results include: Staphylococcus aureus Scientific Name Search  (S. aureus) (sensitive to ampicillin, ceftriaxon, cefotaxime), alpha hemolytic streptococcus (sen­sitive to amikacin), klebsiella spp (sensitive to vancomycin), coagulase negative staph. (sensi­tive to vancomycin, cefalotin, cefotaxime, clin­damycin), acintobacter spp (sensitive to ami­kacin).

Of 28 patients in group I, there was 1 (3%) ca­theter removal, and of 39 patients in group II, there were 22 (56%) catheter removals, (P< 0.001), [Figure 1].


   Discussion Top


In this non-blinded, non-randomized study, in­traluminal injection with antibiotic-lock of van­comycin was superior to its peripheral intrave­nous administration.

In-vivo, ex-vivo, and in-vitro experiments in­dicate that despite adequate vancomycin con­centration in plasma, there is no adequate pe­netration of vancomycin into the lumen of the dual lumen cuffed HD catheters. In previous re­ports, the use of an antibiotic-lock technique in conjunction with systemic antibiotic therapy could eradicate catheter-associated bacteremia and salvage the catheter in about one half of cases. Moreover, this management approach offers clinical advantages over routine catheter exchange. [16] Cefotaxime-heparin locks, [17] teicopla­nin antibiotic locks [18] , ampicillin [19] , vancomycin and gentamycin, [20] catheter-restricted filling with gentamicin and citrate antibiotic-lock therapy, [21] tricitrasol and gentamicin as an antibiotic-lock, and Tricitrasol and gentamicin as an antibiotic­lock [14] led to a significant reduction in the inci­dence of catheter-related bloodstream infections.

Antibiotic-lock therapy combined with sys­temic antibiotics seems to be effective for treat­ment of catheter-related bacteremia, especially those caused by Gram-negative bacteria and coa­gulase-negative staphylococci, which is associa­ted with an elevated rate of therapeutic failure. [22]

In a recent study, by 113 catheter-dependent hemodialysis outpatients with Staphylococcus aureus catheter-related bacteremia treated with a standardized antibiotic- lock protocol, the ca­theter could not be salvaged in 67 patients (59%) because of persistent fever and recurrent bacteremia. [23]

This study demonstrates that administration of vancomycin via permcaths is more effective than intravenous injection, and increases life span of catheters. However, our study has some limitations. The dose and type of antibiotic used in this study was different in the subgroups. Based on the antibiotic coverage, similar results had been expected. Heparin was not adminis­tered in the catheter because administration of vancomycin with heparin can deposit in the catheter. [9]

We conclude that the catheter salvage rate is remarkable in our study and a simple change in the technique of vancomycin administration in patients with infection of permcaths can make a difference in the outcome of treatment. The cost of treatment is not added, but the preservation of the catheter is favorably improved. More stu­dies with randomized and blinded method with patients follow up are needed; comparison of administration of Vancomycin via catheter with Antibiotic-Lock method is recommended.

 
   References Top

1.Suchoki P, Conlon P, Knelson M, Harland RC, Schwab SJ. Silastic cuffed catheters for hemo­dialysis vascular access: Thrombolytic and me­chanical correction of HD catheters malfunction. Am J Kidney Dis 1996;28:379-86.  Back to cited text no. 1      
2.US Renal Data System: VI. Causes of death. Am J Kidney Dis 1995;26:S93-102.  Back to cited text no. 2      
3.Cheesbrough JS, Finch RG, Burden RP. A pros­pective study of the mechanisms of infection associated with hemodialysis catheters. J Infect Dis 1986;154:579.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Dryden M, Samson A, Ludlam H, Wing AJ, Phillips I. Infective complications associated with the use of Quinton permcath for long term central vascular access in hemodialysis. J Hosp Infect 1991;19:257.  Back to cited text no. 4      
5.Swartz R, Messana J, Boyer C, Lunde NM, Weitzel WF, Hartman TL. Successful use of cuffed central venous hemodialysis catheters inserted percutaneously. J Am Soc Nephrol 1994;4:1719.  Back to cited text no. 5      
6.Almirall J, Gonzalez J, Rello J, et al. Infections of hemodialysis catheters: Incidence and me­chanisms. Am J Nephrol 1989;9:454.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]  
7.Marr KA, Sexton DJ, Conlon PJ, Corey GR, Schwab SJ, Kirkland KB. Catheter-related bac­teremia and outcome of attempted salvage in patients undergoing hemodialysis. Ann Intern Med 1997;127:275.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Moss A, Vasilakis C, Holley J , Foulks CJ, Pillai K, McDowell DE. Use of a silicon dual­lumen catheter with a Dacron cuff as a long­term vascular access for hemodialysis patients. Am J Kidney Dis 1990;16:211.  Back to cited text no. 8      
9.Gilmore J. Clinical practice guidelines and cli­nical practice recommendations 2006 updates. Hemodialysis adequacy peritoneal dialysis ade­quacy vascular access. Nephrol Nurs J 2006;33 (5):487-8.  Back to cited text no. 9      
10.Marr K, Krekland K, Seefon D, Conlon P, Conly R, Schwab SJ. Catheter related bacteremia in hemodialysis patients. Ann Intern Med 1997; 127(4):275-80.  Back to cited text no. 10      
11.Bastani B, Minton J, Islam SH. Insufficient penetration of systemic vancomycin into the PermCath lumen. Nephrol Dial Transplant 2000; 15:1035-7.  Back to cited text no. 11      
12.Capdevila JA, Segarra A, Planes AM, et al. Successful treatment of haemodialysis catheter­related sepsis without catheter removal. Nephrol Dial Transplant 1993;8:231-4.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]  
13.Chang JM, Tsai JC, Hwang SJ, Chen HC, Guh JY, Lai YH. Treatment of PermCath-related sepsis in uremic patients. Kaohsiung J Med Sci 1997; 13(3):155-61.  Back to cited text no. 13      
14.Pervez A, Ahmed M, Ram S, et al. Antibiotic lock technique for prevention of cuffed tunnel catheter associated bacteremia. J Vasc Access 2002;3(3):108-13.  Back to cited text no. 14      
15.Allon M. Saving infected catheters: Why and how. Blood Purif 2005;23(1):23-8.  Back to cited text no. 15      
16.Krishna Sami Z, Carlton D, Bimbo L, et al. Management of hemodialysis catheter-related bacteremia with an adjunctive antibiotic lock solution. Kidney Int 2002;61(3):1136-42.  Back to cited text no. 16      
17.Saxena AK, Panhotra BR. The impact of catheter-restricted filling with cefotaxime and heparin on the lifespan of temporary hemodia­lysis catheters: A case controlled study. J Nephrol 2005;18(6):755-63.  Back to cited text no. 17      
18.Cuntz D, Michaud L, Guimber D, Husson MO, Gottrand F, Turck D. Local antibiotic lock for the treatment of infections related to central catheters in parenteral nutrition in children. JPEN J Parenter Enteral Nutr 2002;26(2):104-8.  Back to cited text no. 18      
19.Elwood RL, Spencer SE. Successful clearance of catheter-related bloodstream infection by antibiotic lock therapy using ampicillin. Ann Pharmacother 2006;40(2):347-50.  Back to cited text no. 19      
20.Al-Hwiesh AK, Abdul-Rahman IS. Successful prevention of tunneled, central catheter infection by antibiotic lock therapy using vancomycin and gentamycin. Saudi J Kidney Dis Transpl 2007; 18(2):239-47.  Back to cited text no. 20      
21.Dogra GK, Herson H, Hutchison B, et al. Preven­tion of tunneled hemodialysis catheter-related infections using catheter-restricted filling with gentamicin and citrate: A randomized controlled study. J Am Soc Nephrol 2002;13(8):2133-9.  Back to cited text no. 21      
22.Fernandez-Hidalgo N, Almirante B, Calleja R, et al. Antibiotic-lock therapy for long-term intra­vascular catheter-related bacteraemia: Results of an open, non-comparative study. J Antimicrob Chemother 2006;57(6):1172-80.  Back to cited text no. 22      
23.Maya ID, Carlton D, Estrada E, Allon M. Treat­ment of dialysis catheter-related Staphylococcus aureus bacteremia with an antibiotic lock: A quality improvement report. Am J Kidney Dis 2007;50(2):289-95.  Back to cited text no. 23      

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Correspondence Address:
Hassan Masoudpour
Department of Surgery, Isfahan University of Medical Sciences, Alzahra Hospital, Isfahan
Iran
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PMID: 20061693

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