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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 1  |  Page : 43-46
Catheter associated infections in hemodialysis patients

1 Iran University of Medical Science, Iran
2 Shahed University, Iran

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Hemodialysis catheter related infections (HCRI) are one of the major causes of increasing mortality, morbidity and cost of therapy in hemodialysis patients. Prevention of HCRI requires the identification of predisposing risk factors. To determine the frequency of HCRI risk factors, we studied 116 patients (54% male, mean age of 49.5±16 years) patients with HCRI between 2003-2004. Forty one percent of the patients were diabetic. There was a history of previous catheter placement and infection in 41% and 32% of patients,respectively.Pathogenic organisms isolated from blood cultures included Staphylococcus­aureus 42%, Coagulase-negative Staphylococci 20%, E.Coli 19%, Enterococci 7%, Streptococcus D 7%, Pseudomonas aeroginosa 4%, and Klebsiella 1%. Bacterial resistance to vancomycin and amikacin was present in 7% and 4% of the cases, respectively. Hemodialysis catheter related blood borne infections comprised 67% of the total blood­borne infections in our hospital. No significant statistical association was found between HCRI and age, gender, diabetes mellitus, serum albumin level<30 g/L, leukocyte count, erythrocyte sedimentation rate, anatomical location of catheter, mean duration of antibiotic therapy, mean catheter duration, frequency of hemodialysis sessions, pathogenic organisms, and history of previous catheter infection. We conclude that the prevalence of pathogenic organisms of HCRI were similar to previous studies. However, bacterial resistance to antibiotics was low. The mean duration of catheter usage was longer than previously reported.

Keywords: central venous catheter infection, hemodialysis, Staphylococcus aureus

How to cite this article:
Sanavi S, Ghods A, Afshar R. Catheter associated infections in hemodialysis patients. Saudi J Kidney Dis Transpl 2007;18:43-6

How to cite this URL:
Sanavi S, Ghods A, Afshar R. Catheter associated infections in hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2020 Oct 22];18:43-6. Available from: https://www.sjkdt.org/text.asp?2007/18/1/43/31844

   Introduction Top

Proper vascular access is essential to hemodialysis therapy. Temporary vascular access can be established by the percuta­neous insertion of a catheter into a large central vein. However, temporary catheters have many complications that include infection, which can manifest as life threate­ning events such as septicemia, suppurative thrombophlebitis, and endocarditis. These complications result in a considerable increase in health care costs, morbidity and mortality. [1]

Determining risk factors of catheter associated infections may aid in its prevention and subsequently lower therapeutic cost and improve patient survival and quality of life life.[2] In one study, attributable mortality from infection was estimated between 12-25% and the estimated cost to the health care system was $25000 per episode.[3] There is a scarcity of data about the frequency, risk factors, and pathogenic organisms in hemodialysis catheter related infections (HCRI) in Iran.

In this study, we aimed to evaluate the frequency of pathogenic organisms and related factors of HCRI in our center.

   Materials & Methods Top

This cross-sectional descriptive study was conducted during 2003-2004 in hemodialysis patients with temporary catheter infections who were referred to Hashemi-nejad Hospital of Iran University of Medical Science.

All hemodialysis patients with temporary catheters who experienced fever, chills, purulent discharge from the catheter site, erythema, tenderness over exit site, and signs of bacteremia in the absence of any focus of infection on clinical and laboratory exami­nations were included in this study. Patients with clinical or laboratory evidence of another infected site or negative blood culture were excluded from study.

The collected data included age, gender, history, and physical examination. The laboratory investigations included complete blood count (CBC), erythrocyte sediment­ation rate (ESR), C- reactive protein (CRP), serum albumin level, and catheter and blood cultures. Immediately, after sending blood samples for culture, empiric antibiotic therapy for HCRI with appropriate coverage against S. aureus, coagulase-negative staphylococci, and gram negative bacteria that included vanco­mycin 15mg/kg i.v., and Amikacin 5-7.5 mg/kg i.v. was initiated.[1],[4]

Catheter removal was performed in severely ill patients who had systemic infections due to S. aureus and/or gram negative infections that were unresponsiveness to antibiotic therapy after 72hours. After catheter removal, the tip was sent for culture.

All data analysis were conducted using the SPSS, X2 test.

   Results Top

There were 116 study patients (53% were male and the mean age was of 49.5±16 years). Forty-one percent of the patients were diabetic, 41% had history of previous catheter placement, and 32% had a history of catheter associated infections. Previous insertion sites included right jugular, subclavian, femoral, and left jugular veins in 46%, 44% , 23%, and 8% of cases , respectively.

Leukocytosis was found in 66% of patients. ESR>100mm/hr, ESR<50 mm/hr and 50mm/hr < ESR<100mm/hr were observed in 30%, 27% & 47% of cases, respectively. In 82% of patients, serum albumin levels were less than 30 g/L.

The pathogenic organisms isolated from blood cultures were: S.aureus (42%), Coagu­lase-negative staphylococci (20%), E.coli (19%), Enterococci (7%), Streptococci D (7%), Pseudomonas aeroginosa (4%), klebsiella pneumoniae Scientific Name Search  (1%) [Table - 1].

Bacterial resistance to vancomycin and amikacin was observed in 7% and 4% of the cases, respectively. HCRI formed 67% of total blood stream infections in the study patients.

No significant statistical relationship was observed between the pathogenic organisms and age, gender, diabetes mellitus (DM), serum albumin level <30g/L, leukocytosis, ESR, CRP, anatomical location of catheter, mean duration of effervescence following antibiotic therapy (42hours), mean duration of catheter placement (43 days) or mean frequency of hemodialysis sessions (17 sessions) were found. Moreover, a history of previous catheter infections was not significantly associated with diabetes mellitus.

Catheters were removed in 70% of the cases with prolonged effervescence (> 48%). Catheters were retained only in 24% of the patients in whom fever subsided within 24hours. There was no statistically significant association between the mean duration of effervescence and catheter removal rate.

   Discussion Top

HCRI is an important nosocomial infection that increases morbidity and mortality and mandates appropriate therapy in HD patients.1' [1],[3]

In a prospective trial, HCRI rates were 1.1 per 1000 dialysis sessions. Coagulase­negative staphylococci and S. aureus were caused infections in 67% of the cases, while Klebsiella and Enterobacter were the cause in 14.6% of cases. [5] In other studies, S.aureus was the cause of HCRI in 33-80% of cases. [6],[7],[8] In our study, S. aureus was the most common cause of HCRI (42%), followed by coagulase negative Staphylococci and E.coli.

Proper aseptic techniques during catheter insertion or manipulation have been recom­mended to reduce the incidence of HCRI. [2] Focused education of dialysis staff may result in a significant reduction in the incidence of HCRI. [9]. Fortunately, in our study, bacterial resistance to antibiotic therapy was low, especially to vancomycin and Amikacin. Enterococci, E, coli, and Klebsiella pneumoniae were the most common resistant organisms. In a study on intensive care patients, 26% of isolated Enterococci was resistant to vancomycin. [10]

In our study, we did not observe any associations between age, gender, diabetes mellitus, serum albumin level < 30g/L and pathogenic organisms, while other studies found diabetes mellitus a risk factor for HCRI and an association between the HCRI rate and the anatomical catheter placement. [1],[11],[12]

In our study, the catheters were retained in place for 30 days or 12 dialysis sessions in 60% of patients. This is longer than the recommended three week duration for non­cuffed catheters. [1],[2]

Catheter removal is a therapeutic inter­vention in HCRIs. In some studies, catheters were preserved successfully with antibiotic therapy in 31% of the HCRIs. In our study, we preserved the catheters in 24% of patients who became afebrile within 24 hours of antibiotic therapy initiation. Catheter change over a guide-wire was also advocated. [1],[13]

The low mean duration of effervescence following antibiotic therapy in our study was not significantly correlated with catheter removal rate but was due mostly to the high frequency of mild infections; 54% of HCRIs were produced by organisms with low pathogenicity.

Finally, HCRI was the cause of blood borne infections in 67% of the cases in our hospital in comparison to 90% in the USA.[14],[15]

We conclude that the pattern of pathogenic organisms of HCRIs observed in this study was similar to other studies. Aseptic techniques in catheter manipulations may prevent HCRIs and administration of anti­biotics with proper dose and duration may save catheters.

   References Top

1.Daugirdos J1. Hand book of dialysis third edition, lippincott williams & wilkins, 2001; 4:43; 50, 28:496-500.  Back to cited text no. 1    
2.po'Grady N, Alexander M. Guidelines for the prevention of intravascular catheter related infections-I. Up to Date 2005; 800:998-6374.  Back to cited text no. 2    
3.Band DJ. Diagnosis and management of central venous catheter-related infections. Up to Date 13.1-2005; (800) 998-6374. (781) 237-4788.  Back to cited text no. 3    
4.Schrier RW. Disease of the kidney & urinary tract, seventh Edition, Lippincott. Williams & wilkins, 2001; 99: 2991.  Back to cited text no. 4    
5.Dopirak M, Hill C, Dumigan D. Surveillance of HD associated primary blood stream infections. Infect control Hosp Epidemiol 2002; 23; 713-5.  Back to cited text no. 5    
6.Gray ED, Peters G, Verstegen M, Regeimann WE. Effect of extra cellular slime substance from Staphylococcus epidermidis on the human cellular immune response. Lancet 1984; 1:365.  Back to cited text no. 6    
7.Band DJ. Prevention of central venous catheter related infections. UP to Date 13.1, 2005.  Back to cited text no. 7    
8.Band DJ. Central venous catheter related infections: type of devices and definitions. Up to Date 13.1, 2005.  Back to cited text no. 8    
9.Warren DK, Zack JE, Cox MJ. An educational intervention to prevent catheter-associated bloodstream infections in a non teaching, community medical center. Crit Care Med 2003; 31(7):1959-63.  Back to cited text no. 9    
10.CDC. National Nosocomial Infections (NNIS) system report, data summary from January 1990 , issued june 1999. Am J infect control 1999; 27:520.  Back to cited text no. 10    
11.Cappello M, De Pauw L, Bastin, G, et al. Central venous access for hemodialysis using the Hickman catheter. Nephrol Dial Transplant 1989; 4:988.  Back to cited text no. 11    
12.Salgado OJ, Urdaneta B, Colmenares B, Garcia R. Right versus left internal jugular vein catheterization for hemo­dialysis. Artif Organs 2004; 28(8): 728-33.  Back to cited text no. 12    
13.Carlisle EJ, Blake P, Mc carthy F. Septicemia in infection by changing the catheter over a guide wire. Int J Artif organs 1990; 14(3):150-3.  Back to cited text no. 13    
14.Farkas JC, Liu N, Bleriot JP, et al. Single-versus triple-lumen central catheter-related sepsis: a prospective randomized study in a critically ill population. Am J Med 1992; 93:277.  Back to cited text no. 14    
15.Kairaitis LK, Gottlieb T. Outcome and complications of temporary haemo­dialysis catheters. Nephrol Dial Transplant 1999; 14:1710.  Back to cited text no. 15    

Correspondence Address:
Reza Afshar
Mostafa Khomeini Hospital, Shahed University Italia St., Tehran
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PMID: 17237890

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