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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2019  |  Volume : 30  |  Issue : 5  |  Page : 1187-1189
Hemodialysis tunneled catheter-related infection in a tertiary care center: A changing trend


Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Submission03-Jan-2019
Date of Acceptance07-Jan-2019
Date of Web Publication4-Nov-2019
 

How to cite this article:
Pattanashetti N, Ramachandran R, Kohli H S, Gupta K L. Hemodialysis tunneled catheter-related infection in a tertiary care center: A changing trend. Saudi J Kidney Dis Transpl 2019;30:1187-9

How to cite this URL:
Pattanashetti N, Ramachandran R, Kohli H S, Gupta K L. Hemodialysis tunneled catheter-related infection in a tertiary care center: A changing trend. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Nov 20];30:1187-9. Available from: http://www.sjkdt.org/text.asp?2019/30/5/1187/270280


To the Editor,

Types of central venous catheters (CVCs) used for chronic hemodialysis (HD) include tunneled cuffed catheters and nontunneled catheters. In developing and underdeveloped world, nontunneled CVCs remain an irreplaceable tool for the majority of the end-stage renal disease patients at the time of initiation of HD because of their cost and convenience of insertion. The risk of developing bacteremia varies with site of CVC insertion, type of device, and duration of CVC use.[1] Tunneled catheters are used as permanent access or as a bridge to permanent vascular access like arteriovenous fistula (AVF). Relative risk of mortality due to bacteremia is multiple folds higher with the use of tunneled catheters compared to AVF and lower compared to non-tunneled catheter. In our unit, we started using tunneled catheter as there was higher infection rate with nontunneled catheter[2] and as a bridge Ιΰ AVF.

In the present manuscript, we report a reallife situation of the incidence, spectrum of causative organisms, and the outcome of tunneled catheter infection in HD patients. The study included all CKD-VD patients who underwent tunneled catheter insertion at our center over a period of six months. All the patients were followed up for a period of six months. Suspicion of catheter-related blood stream infection (CRBSI) was based on the clinical presentation of fever, chills, and/or hypotension in a patient with a tunneled vascular catheter and diagnosis of CRBSI (definitive, probable, and possible) was made based on the KDOQI guidelines.[3] During the study period, a total of 102 patients underwent tunneled catheter insertion. At six months, 42 (41.17%) patients had suspected CRBSI. Blood culture was positive in 31 (73.8%) patients, and 11 (37.8%) patients were reported as culture negative, although none of them had any identifiable focus of infection and responded clinically with IV antibiotics and removal of the catheter. The mean duration for developing CRBSI was 56 days (range, 15 to 120). Majority of them belonged to low socioeconomic status (59.5%). All patients presented with high-grade fever with chills and rigors, seven (16.7%) had shock, and pus discharge from exit site was seen in two (4.8%) cases. Infective endocarditis was seen in two (4.8%) patients. Infection with Gram-negative organisms (19; 45.2%) was more common compared to Grampositive organisms (10; 23.8%), and fungal infection was seen in two (4.8%) patients. Most common organism isolated was Klebsiella pneumoniae (8; 19%) followed by Staphylococcus aureus (5; 11.9%) and various other organisms [Table 1]. Fourteen (33.3%) patients improved with intravenous antibiotics without removal of catheter and 28 (66.7%) patients failed to respond initial antibiotic therapy and required removal of catheter.
Table 1: Depicts the microbiological organisms isolated from blood cultures in catheter-related blood stream infection.

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Highlights of the study:

  1. Very high rate of infection in tunneled catheter
  2. Gram-negative infection is more common in these patients


Compared to the previous studies,[4],[5] our study showed that higher incidence of CRBSI and Gram-negative organisms are more frequently associated with CRBSI and most common organism involved was K. pneumoniae compared to s. aureus. The higher prevalence of Gram-negative infections in our study may be related to poor socioeconomic status, poor hygiene, and water contamination, as these patients were dialyzed in some local dialysis centers because our institute does not provide maintenance HD. Hence, a higher incidence of Gram-negative infection should be taken into account, and empirical Gramnegative antibiotic should also be started along with Gram-positive coverage for suspected CRBSI to salvage catheters and preserve vascular access. Because the data on HD tunneled catheter infection rates in developing country are limited, the use of tunneled vascular catheters is limited by economic constraints.

However, this study provides good information regarding higher infection rates as well as high Gram-negative infections in patients with low socioeconomic status, poor hygiene, and patients getting dialysis in local centers. Considering the high infection rate with the use of tunneled catheter in this population, patient selection and nature of center providing dialysis play a crucial role.


   Limitation Top


Limitations of this study are the small sample size, short duration of follow-up, and some patients had their dialysis done in outside centers. However, this is a real-life scenario of developing world.


   Conclusion Top


Though tunneled catheters have lower infection rate than nontunneled catheters, in resource poor settings the infection rates are high and Gram-negative infection are commoner than Gram-positive infection and empirical antibiotics should be given to cover both Grampositive and Gram-negative organisms. Considering high infection rates with tunneled catheter, we strongly advocate AVF as the first and preferred policy.

Conflict of interest: None declared.



 
   References Top

1.
Jaber BL. Bacterial infections in hemodialysis patients: Pathogenesis and prevention. Kidney Int 2005:67:2508 19.  Back to cited text no. 1
    
2.
Sethi J, Bagai s, Ramachandran R, et al. Time to revisit the use of nontunneled dialysis vascular catheters even in cost-limited setting. Indian J Nephrol 2018:28:406-7.  Back to cited text no. 2
    
3.
Vascular Access Work Group. Clinical practice guidelines for vascular access. Am J Kidney Dis 2006:48 Suppl 1:S248-73.  Back to cited text no. 3
    
4.
Al Saran k, Sabry A, Alghareeb A, Molhem A. Central venous catheter-related bacteremia in chronic hemodialysis patients: Saudi single center experience. J Nephrol Ther 2011:1:105.  Back to cited text no. 4
    
5.
Lok CE, Mokrzycki MH. Prevention and management of catheter-related infection in hemodialysis patients. Kidney Int 2011:79:587-98.  Back to cited text no. 5
    

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Correspondence Address:
K L Gupta
Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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DOI: 10.4103/1319-2442.270280

PMID: 31696863

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