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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2009  |  Volume : 20  |  Issue : 6  |  Page : 1091-1095
Catheter related infection in hemodialysis patients

Department of Medicine, Nephrology Division, King Fahd Specialist Hospital, Buraida, Al Qassim, Saudi Arabia

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Date of Web Publication27-Oct-2009


To determine the frequency of hemodialysis (HD) catheter related infection, causative microorganisms and predisposing factors contributing to these infections at our center, we con­ducted a prospective study in 2007 involving 57 (45.6% males) patients in whom a temporary catheter was inserted for HD. The patients were followed for one month to document any episodes of hemodialysis catheter related infection (HCRI). There were 11 (19.3%) patients who developed HCRI proven by blood culture; 5 patients were infected with more than one organism. Staphyloco­ccus Coagulase negative and Staphylococcus aureus (S. aureus) remain the most common patho­gens. All the organisms were sensitive to antibiotics administered empirically, however, 3 patients developed multiple resistant S. aureus (MRSA). All the infected patients experienced previous epi­sodes of HCRI, which formed a risk factor in addition to low albumin when compared to the non­infected group (P=0.024 and P= 0.001, respectively). We conclude that the rate of HCRI and the causative organisms found in our study is comparable to previous reports. We still need to adopt measures to minimize the use of temporary vascular accesses by creation of fistulas in a timely fashion.

How to cite this article:
Nabi Z, Anwar S, Barhamein M, Al Mukdad H, El Nassri A. Catheter related infection in hemodialysis patients. Saudi J Kidney Dis Transpl 2009;20:1091-5

How to cite this URL:
Nabi Z, Anwar S, Barhamein M, Al Mukdad H, El Nassri A. Catheter related infection in hemodialysis patients. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2022 Oct 5];20:1091-5. Available from: https://www.sjkdt.org/text.asp?2009/20/6/1091/57275

   Introduction Top
Patients with renal failure undergoing hemo­dialysis (HD) are known to be at increased risk of infection. Various risk factors may predispose to infection including the underlying disease, the uremic state, and the dialysis procedure it­self. [1] Sepsis is the second most common cause of death in hemodialysis patients after cardio­vascular disease. [2]

Temporary catheters are designed for short­term use in HD patients who do not have per­manent accesses for dialysis. Catheter related infections may be classified as bacteremia or exit site/tunnel infections. [3] Exit site and tunnel infections may predispose to bacteremia via extra luminal colonization of the catheter.

Central venous catheter related blood stream infection is a major cause of morbidity and mortality in HD patients. [4] The majority of bac­teremias are caused by the vascular accesses, with the incidence being 10 times greater with indwelling catheters than either fistulas or synthetic grafts. [5],[6],[7] The risk factors for catheter in­fection include prolonged duration of usage, a history of previous catheter-related bacteremia, recent surgery, diabetes mellitus, iron overload, Staphylococcus aureus Scientific Name Search  nasal colonization, old age, and low hemoglobin and serum albumin levels. [8],[9],[10] 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. [11]

In this study, we aimed to determine the fre­quency of HD catheter related infection, causa­tive microorganisms, and predisposing factors contributing to these infections at our center.

   Materials and Methods Top

This prospective study was conducted in he­modialysis patients at King Fahd Specialist Hos­pital, Buraida, Al-Qassim, Saudi Arabia during year 2007.

All HD patients with temporary catheters in­serted for more than one week were included in this study. The patients were followed up for one month after insertion of catheter for any evidence of hemodialysis catheter related infec­tion (HCRI). Catheter related bacteremia was suspected when a patient experienced fever, chills, purulent discharge from catheter site, erythema or tenderness over exit site, in the ab­sence of any other focus of infection. The pa­tients with clinical or laboratory evidence of another focus of infection were excluded from study.

Central and peripheral blood cultures were sent immediately for suspected HCRI followed by initiation of empiric antibiotic therapy which included vancomycin and ceftazidime.

   Statistical Analysis Top

Data analysis was performed using the SPSS version-10.0. Frequency and percentages were computed to present categorical variables such as catheter related infection, causative micro­organisms, gender, history of catheter related infection, causes of ESRD, blood C/S and bio­chemical parameters categorized as per stan­dard normal range. Logistic regression analysis was performed to compare these categorical response variables between the group of pa­tients with and without catheter related infec­tion. All continuous response variables such as patient's age, biochemical parameters were pre­sented as the mean ± SD; Student's "t" test was applied to compare the means of these variables between two groups. Statistical significance was considered as P < 0.05.

   Results Top

Out of 57 patients 26 (45.6%) males) who re­ceived a central catheter for HD, 11 (19.3%) patients who developed catheters related HCRI proven by blood culture. The frequency of the causative microorganisms is detailed in [Table 1]. The causative microorganisms were sensitive to the empirically used antibiotics.

[Table 2] shows the characteristics of the in­fected and non-infected patients. Statistically insignificant difference of gender distribution was found between both groups. The mean age of the patients with HCRI was higher than the non-infected group, but the difference was in­significant (55.5 ± 17.1 vs. 48.7 ± 20.5, P= 0.172, respectively). The causes of kidney fai­lure did not significantly differ between both groups. The HCRI group had past history of si­milar infection.

The comparison of the mean levels of the bio­chemical parameters between the patients with and without HCRI is presented in [Table 3]. Insig­nificant differences of the mean levels of bio­chemical parameter except albumin level were found between both groups.

   Discussion Top

Uncuffed, nontunneled hemodialysis catheters remain the preferred means to gain immediate access to circulation although bacteremia is the primary complication that limits their use. [12] Our results documented the high rate of HCRI (19.3%) with temporary non cuffed non tunne­led catheters as mentioned in the literature. [13],[14],[15] The percentage is a little higher in our study than that found by Oliver et al [12] but at the same time we did not classify infection rate according to the anatomic site as done by them. The diffe­rence in rate of HCRI according to anatomic site has recently been negated by Parienti et al who demonstrated that jugular venous access does not reduce the risk of infection as com­pared with femoral catheters. [16]

Coagulase -ve S. hemolyticus and S. aureus were the most common causative organisms in our study, which is comparable to the prospective trial performed by Dopairak et al, [17] Kairaitis et al [18] and Blakestijin. [19] Our study confirmed asso­ciation of low albumin level and previous epi­ sodes of catheter related infection as predis­posing risk factors for HCRI. Hypoalbumine­mia was also found to be a risk factor for HCRI by Tanriover B et al. [20] Interestingly our study did not demonstrate leukocytosis in the HCRI patients in contrast to what has been reported before. [21]

Our study has few limitations, the number of patients was small and we did not classify in­fection rate and outcome according to anatomic site. We also did not correlate the association of nasal S. aureus carriage to HCRI as mentioned by Jean et al [22] who noted in their study that 35% of the patients had positive nasal carriage of S. aureus; the range is from 20 to 58%. [23]

We conclude that the rate of HCRI and the causative organisms found in our study is com­parable to previous reports. We still need to adopt measures to minimize the use of tem­porary vascular accesses by creation of fistulas in a timely fashion.

   References Top

1.Jaber BL. Bacterial infections in hemodialysis patients: Pathogenesis and prevention. Kidney Int 2005;67(6):2508-19.  Back to cited text no. 1      
2.UK Renal Registry: New adult patients starting renal replacement therapy in UK in 2004.UK Renal registry report. Bristol, UK Renal Registry, 2005. chapter3, pp12-26.  Back to cited text no. 2      
3.Lok CE, Stanley KE, Hux JE, et al. Hemodialysis infection prevention with polysporin ointment. J Am Soc Nephrol 2003;14:169-79.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Katneni R, Hedayati SS. Central venous cathe­ter related bacteremia in chronic hemodialysis patients: epidemiology and evidence based ma­nagement. Nat Clin Pract Nephrol 2007;3(5): 256-66.  Back to cited text no. 4      
5.Fan PY, Schwab SJ. Vascular access: Concepts for the 1990s. J Am Soc Nephrol 1992;3(1):1­11.  Back to cited text no. 5      
6.Inrig JK, Reed SD, Szczech LA, et al. Relationship between clinical outcomes and vascular access type among hemodialysis pa­tients with Staphylococcus aureus bacteremia. Clin J Am Soc Nephrol 2006;1(3):518-24  Back to cited text no. 6      
7.Taylor G, Gravel D, Johnston L, et al. Incidence of bloodstream infection in multicenter incep­tion cohorts of hemodialysis patients. Am J Infect Control 2004;32:155-60.  Back to cited text no. 7      
8.Kozeny GA, Venezio FR, Bansal VK, et al. Incidence of subclavian dialysis catheter-related infections. Arch Intern Med 1984;144:1787-94.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Allon M. Dialysis catheter-related bacteremia: treatment and prophylaxis. Am J Kidney Dis 2004;44:779-91.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Teehan GS, Bahdouch D, Ruthazer R, et al. Iron storage indices: novel predictors of bacteremia in hemodialysis patients initiating intravenous iron therapy. Clin Infect Dis 2004;38:1090-4.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]  
11.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. 11      
12.Oliver MJ, Callery SM, Thorpe KE, Schwab SJ, Churchill DN. Risk of bacteremia from tempo­rary hemodialysis catheters by site of insertion and duration of use: a prospective study. Kidney Int 2000;58(6):2543-5.  Back to cited text no. 12      
13.Tokars JI, Miller ER, Stein G. New national Surveillance system for hemodialysis associated infections. Am J Infect Control 2002;30:288-95.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]  
14.Stevenson KB, Adcox MJ, Mallea MC, Nara­simhan N, Wagnild JP. Standardized surveillance of hemodialysis vascular access infections: 18­month experience at an outpatient, multifacility hemodialysis center. Infect Control Hosp Epidemiol 2002;21:200-3.  Back to cited text no. 14      
15.Taylor G, Gravel D, Johnston L, Embil J, Holton D, Paton S. Prospective surveillance for primary blood stream infections occurring in Canadian hemodialysis units. Infect control Hosp Epidemiol 2002;23:716-22.  Back to cited text no. 15      
16.Parienti JJ, Thirion M, Megarbane B, et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA 2008;299(20):2413-22.  Back to cited text no. 16      
17.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. 17      
18.Kairaitis LK, Gottlieb T. Outcome and compli­cations of temporary hemodialysis catheters. Nephrol Dial Transplant 1999;14(7):1710-4.  Back to cited text no. 18      
19.Blakestijn PJ. Treatment and prevention of ca­theter related infections in hemodialysis pa­tients. Nephrol Dial Transplant 2001;16:1975-8.  Back to cited text no. 19      
20.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. 20  [PUBMED]  [FULLTEXT]  
21.Sanavi S, Ghods A, Afshar R. Catheter asso­ciated infections in hemodialysis patients. Saudi J Kidney Dis Transpl 2007;18:43-6.  Back to cited text no. 21  [PUBMED]  Medknow Journal  
22.Jean G, Charra B, Chazot C, et al. Risk factor analysis for long term tunneled dialysis catheter­related bacteremia. Nephron 2002;91:399-405.  Back to cited text no. 22  [PUBMED]  [FULLTEXT]  
23.Boelaert JR, Van Landuyt HW, Godard CA, et al. Nasal mupirocin ointment decreases the incidence of staphylococcus aureus bacteremia in hemodialysis patients. Nephrol Dial Transplant 1993;8:235-9.  Back to cited text no. 23  [PUBMED]  [FULLTEXT]  

Correspondence Address:
Zahid Nabi
Assistant Consultant Nephrology, King Faisal Specialist Hospital & Research center, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

PMID: 19861882

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  [Table 1], [Table 2], [Table 3]

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