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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2021  |  Volume : 32  |  Issue : 5  |  Page : 1348-1355
Infections from temporary catheters in hemodialysis patients in Kosovo


1 Clinic of Nephrology and Hemodialysis, UCCK Kosovo Hospital, Circle n.n. 10000; Medical Faculty, University of Pristina “Hasan Prishtina”, Circle n.n. 10000, Pristina, Kosovo
2 Clinic of Hematology, UCCK Kosovo Hospital, Circle n.n. 10000, Pristina, Kosovo
3 Clinic of Nephrology and Hemodialysis, UCCK Kosovo Hospital, Circle n.n. 10000, Pristina, Kosovo

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Date of Web Publication4-May-2022
 

   Abstract 


The objective of this study is to evaluate the frequency of infections from central venous temporary catheters and the type of a microorganism caused, from January 2017 up to December 2019. This study was performed on patients who were on hemodialysis (HD) through the central temporary venous catheter, right and left femoral vein, right jugular vein, and right subclavian vein.The patients in the HD center in Pristina, Kosovo, were used as a clinical sample. In this study, 1902 patients with temporarily central venous catheters (CVCs) were involved, while the control group consisted of 642 patients. Both groups were matched for age and gender. In all patients and the subjects of the control group, following data were obtained: Anamnesis, medical examination, as well as biochemical and hematological laboratory tests, CVC swab and antibiogram and hemoculture. Data analysis was performed using the descriptive statistical methods and the Chi-square test comparing the laboratory results of a HD patients treated through the central temporary venous catheter. Based on the results of this research, higher incidence of infections occurred with femoral vein access, compared to other CVCs accesses. The most common microorganisms responsible were Staphylococus epidermidis, while the 2019 had the highest incidence of infection.

How to cite this article:
Rudhani I, Morina N, Elezi G, Avdulahu A. Infections from temporary catheters in hemodialysis patients in Kosovo. Saudi J Kidney Dis Transpl 2021;32:1348-55

How to cite this URL:
Rudhani I, Morina N, Elezi G, Avdulahu A. Infections from temporary catheters in hemodialysis patients in Kosovo. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 May 25];32:1348-55. Available from: https://www.sjkdt.org/text.asp?2021/32/5/1348/344754



   Introduction Top


Nearly half of deaths in patients with terminal kidney disease treated with hemodialysis (HD), occurs as a result of complications from infections and cardiovascular disorders.[1],[2],[3],[4],[5],[6] Treatment with HD as a substitute form of kidney function has helped the patients to live without problems and to improve the quality of life. For the first time, HD was performed in humans through venous arterial shunt in 1944 and in early 1966 through arterio-venous fistula, which was way more sophisticated method.[7] HD is a procedure that removes the wastes, and excess fluid from the bloodstream.

Once the HD is indicated by the physician, venous access should be provided if there is no preoperative arteriovenous fistula, then it should be decided for the site of insertion of central venous catheter (CVC) for HD.[8],[9] It is very important to select the appropriate location where the HD catheter will be inserted, such as the right or left femoral vein (LFV), the right or left internal jugular vein. Only in cases where there is no possibility for other insertion site, the CVCs will be inserted in right subclavian vein (RSCV) and left subclavian vein (LSCV).[4],[10] The catheters used were 11.5 Fr/Ch (38 mm) ×16 cm.


   Objective Top


The objective of our study is to evaluate the frequency of catheter-related infections resulting from the use of temporary CVCs and the type of bacterial infections caused by the Gram negative, Gram-positive bacteria and mycoses, from January 2017 until December 2019. The other purpose of this research is also the comparison of the laboratory results, between the treated patients and the control group.


   Methods Top


This is a three-year prospective study, conducted at the Clinic of HD and Nephrology in Pristina, Kosovo, from January 2017 until December 2019. This study was conducted in patients treated with HD through the temporary CVC inserted in the left and right femoral vein (RFV), left and right jugular vein (RJV), and right and LSCV. This study included 1902 patients with CVCs while the control group comprised of 642 patients. The groups were matched with respect to their age and gender.

The following data were collected from all patients: anamnesis, medical examination, biochemical and hematological laboratory tests, swabs from CVC with antibiogram and hemoculture.

During the years 2017, 2018, and 2019, the control group consisted a total of 642 patients, of which, 322 were male and 320 were female. Two hundred and fourteen patients were examined, of which 107 were male and 106 were female, with a mean age of 54 years. There was no infection in this group. Both groups were matched for age and gender. The anamnesis, objective examination as well as biochemical and hematological laboratory tests were taken from both groups.

Data analysis was performed through the descriptive statistical methods and the Chi-square test by comparing laboratory results from HD treated patients through temporary CVC and control group using IBM SPSS Statistics software version 21.0 (IBM Corp., Armonk, NY, USA) where the value of P <0.05 will be considered significant.


   Results Top


During the study period, 1902 patients were admitted, of whom 989 were male and 913 were female. The patients’ age in this study was 19–87 years, while the mean age was 53 years. The control group consisted of 642 patients, of whom 322 were male and 320 were female, with a mean age of 54 years.

During the year 2017, 602 CVCs were inserted, of which 307 (51%) in male patients and 295 (49%) CVCs in female patients [Figure 1]. Three hundred and thirty-eight CVCs were inserted in RFV, 87 were inserted in LFV, 160 were inserted in RJV, and 17 in RSCV [Figure 2].
Figure 1: Insertion of central venous catheters in the period January 2017–December 2019.

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Figure 2: Insertion of central venous catheters based on localization.
RFV: Right femoral vein, LFV: Left femoral vein, RJV: Right jugular vein, RSCV: Right subclavian vein.


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During the year 2018, 620 CVCs were inserted, of which 322 (52%) in male patients, and 298 (48%) in female patients [Figure 1]. Three hundred and forty-eight CVCs were inserted in RFV, 70 were inserted in LFV, 190 were inserted in RJV, and 12 in RSCV [Figure 2].

In 2019, 680 CVCs were inserted, of which 360 (53%) in male patients and 320 (47%) in female patients [Figure 1], of which 361 CVCs were inserted in RFV, 103 were inserted in LFV, 198 in RJV, and 18 in RSCV [Figure 2].

During the study period 2017–2019, in 1047 cases the CVCs were inserted in RFV, 548 cases the CVCs were inserted in RJV and in 260 cases the CVCs were inserted in LFV, whereas in 47 cases were inserted in RSCV [Figure 2].

During 2017, CVCs were inserted as shown in [Figure 2]: RFV – 338 (56%), LFV – 87 (14%), RJV – 160 (27%), RSCV – 17 (3%).

In 2018, CVCs were inserted: 348 in RFV (56%), in LFV – 70 (11%), in RJV – 190 (31%), RSCV – 12 (2%). In 2019, CVCs were inserted in RFV – 361 (53%), in LFV – 103 (15%), in RJV – 198 (29%) and in RSCV – 18 (13%).

As per the site of CVCs insertion, the prefered site of insertion was RFV, followed by RJV, LFV, and RSCV. According to this, the number of CVCs inserted in RJV increased in number during the years 2017–2019 [Figure 2].

During 2017, from 602 patients, only 78 (13%) cases were positive for CVC-related infections, of which 43 (55%) were female and 35 (45%) were male. In 2018 from 620 cases with CVC, 68 (11%) were positive for CVC-related infections of which 40 (59%) were female and 28 (41%) were male. In 2019 from 680 cases with CVCs, 61 (9%) resulted as positive for infection [Figure 3]. [Figure 4] showed that there is a significant decrease through years in positive swabs from catheters.
Figure 3: Presentation of positive swab cases by gender.

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Figure 4: Presentation of cases with positive and negative swabs of central venous catheter.
CVC: Central venous catheter.


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During 2017, from infected CVCs, the most common causative pathogens isolated were Gram-negative bacteria in 30 (38%) of cases and 48 (62%) cases with Gram-positive bacteria. During 2018, 21 (31%) cases were with Gram-negative bacteria, whereas 47 (69%) cases were with Gram-positive bacteria. In 2019, 30 (49%) cases were with Gram-negative bacteria, whereas 31 (51%) cases were with Gram-positive bacteria. It is obvious that in the first two years of infected catheters, the highest percentage was with Gram-positive bacteria, whereas in the last year, this ratio seems to be somewhat equated [Figure 5].
Figure 5: Presentation of positive case strains by type of cause in Gram positive and Gram negative bacteria.

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During 2017, from Gram-positive bacteria isolated, 26 (54%) cases were with Staphylococcus epidermidis, 15 (31%) cases with Staphylococcus aureus, four (9%) cases with Candida albicans, and three (6%) cases with other microorganisms. In 2018, from Gram-positive bacteria isolated, 25 (53%) cases were with S. epidermidis, 11 (23%) cases with S. aureus, four (9%) cases with C. albicans and seven (15%) cases with other microorganisms. In 2019, from Gram-positive bacteria isolated 18 (58%) cases were with S. epidermidis, 10 (32%) cases with S. aureus, two (7%) cases with C. albicans and one (3%) case with other microorganisms. Therefore, the most causative pathogen was found to be S. epidermidis, followed by S. aureus and the less percentage with C. albicans and other microorganisms [Figure 6].
Figure 6: Presentation of cases with Gram positive swabs by type of cause.

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In 2017, 36 cases were Gram negative bacteria, of which 24 (67%) with Escheria coli, seven (19%) were with Proteus, three (8%) with Enterooccus and two (6%) others. In 2018, 21 cases were Gram-negative bacteria, of which 15 (71%) were with E. coli, three (14%) were with Proteus, two (10%) with Enterococcus and one (5%) other. In 2019, 30 cases were Gram-negative bacteria, of which 18 (60%) with E. coli, seven (23%) were with Proteus, four (14%) with Enterococcus, and one (3%) other. The most causative pathogen was found to be E. coli, followed by Proteus and Enteroccocus [Figure 7].
Figure 7: Presentation of cases with Gram negative swabs by type of cause.

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During the years 2017-2019, the control group consisted a total of 642 patients, of which 322 were male and 320 were female. Each year 214 patient were examined, of which 107 were males and 106 were females, the mean age was 54 years. There were no infection in this group.

Based on the Chi-square test results, we can conclude that the values of the analysis of the control group for three years compared with the values of the analysis in patients with HD have a significant difference since for each analysis in three years we saw that the p (alpha) value is smaller than the permissible value (P <0.05). Therefore we can conclude that we certify the validity of hypothesis H1, the values of the analyzes in patients with HD, compared to the control group have a significant difference and we reject the invalid hypothesis H0 [Table 1],[Table 2],[Table 3].
Table 1: Comparison with Chi-square test of laboratory data in hemodialysis patients and the subjects of control group in 2017.

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Table 2: Comparison with Chi test of laboratory data in hemodialysis patients and the subjects of control group in 2018.

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Table 3: Comparison with Chi test of laboratory data in hemodialysis patients and the subjects of control group in 2019.

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   Discussion Top


In our study, femoral venous access was associated with a significantly higher incidence of infection than jugular and subclavian access.

In this study it has resulted that the average for years of patients dialyzed through the temporary CVC with contaminated catheter has been 11.5%. According to the literature, 1% to 13% of CVCs develop infection.[11],[12] The most common cause of catheter infection was S. epidermidis, followed by S. aureus and the lowest percentage were Candida albigans and others. In one of the researches it has resulted as follows: 43.3% coagulase-negative staphylococci, 16.9% S. aureus, 9.43% Enterococcus faecalis, 1.89% Bacillus spp, 15.09% E. coli; 3.77% Enterobacter cloacae, 3.77% Pseudo-monas aeruginosa, and 5.66% C. albicans.[13]

Regarding the place of localization of CVC, the first place is occupied by RFV followed by RIJV, LFV, and RSCV. Access to the femoral veins indicates a higher incidence for infection, probably due to the higher density of local skin flora in the groin area.[14]


   Conculsion Top


During the study period 2017–2019, 550 CVCs were inserted in RJV, 1047 in RFV, and 257 in LFV, whereas 47 CVCs were inserted in RSCV.

The outcome of this study was that the average of cathether related infections with temporary CVCs were 11.5%. The most causative pathogen was found to be S. epidermidis, followed by S. aureus and the least percentage was with C. albicans and other pathogens. As per the insertion site, the first site was RFV followed by RIJV, LFV, and RSCV.

Over the years, there is a significant decrease in temporary CVC-related infections. This decrease in the number of infected patients was the result of taking preventive measures in terms of personal hygiene, maintenance of temporary CVC, timely performed AV fistulas, and therapy applied. Therefore, based on the analysed results, we recommend that temporary CVC should be inserted in RJV and LJV as they were the least infection-related sites.

Conflict of interest: None declared.



 
   References Top

1.
Tordoir J, Canaud B, Haage P, et al. EBPG on vascular access. Nephrol Dial Transplant 2007;22 Suppl 2:ii88-117.  Back to cited text no. 1
    
2.
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. 2
    
3.
Nassar GM, Ayus JC. Infectious complications of the hemodialysis access. Kidney Int 2001;60:1-13.  Back to cited text no. 3
    
4.
Levey AS. Controlling the epidemic of cardiovascular disease in chronic renal disease: Where do we start? Am J Kidney Dis 1998;32:S5-13.  Back to cited text no. 4
    
5.
Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998;32:S112-9.  Back to cited text no. 5
    
6.
Mailloux LU, Haley WE. Hypertension in the ESRD patient: Pathophysiology, therapy, outcomes, and future directions. Am J Kidney Dis 1998;32:705-19.  Back to cited text no. 6
    
7.
Harnett JD, Foley RN, Kent GM, Barre PE, Murray D, Parfrey PS. Congestive heart failure in dialysis patients: Prevalence, incidence, prognosis and risk factors. Kidney Int 1995;47:884-90.  Back to cited text no. 7
    
8.
Foley RN, Parfrey PS, Kent GM, Harnett JD, Murray DC, Barre PE. Long-term evolution of cardiomyopathy in dialysis patients. Kidney Int 1998;54:1720-5.  Back to cited text no. 8
    
9.
Aoki J, Ikari Y, Nakajima H, et al. Clinical and pathologic characteristics of dilated cardiomyopathy in hemodialysis patients. Kidney Int 2005;67:333-40.  Back to cited text no. 9
    
10.
Manes MT, Gagliardi M, Misuraca G, Rossi S, Chiatto M. Left ventricular geometric patterns and cardiac function in patients with chronic renal failure undergoing hemodialysis. Monaldi Arch Chest Dis 2005;64:27-32.  Back to cited text no. 10
    
11.
Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: Effect of site of placement and catheter type. Infect Control Hosp Epidemiol 1998;19:842-5.  Back to cited text no. 11
    
12.
Rello J, Coll P, Net A, Prats G. Infection of pulmonary artery catheters. Epidemiologic characteristics and multivariate analysis of risk factors. Chest 1993;103:132-6.  Back to cited text no. 12
    
13.
Lorente L, Henry C, Martín MM, Jiménez A, Mora ML. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care 2005;9: R631-5.  Back to cited text no. 13
    
14.
Bozzetti F, Terno G, Camerini E, Baticci F, Scarpa D, Pupa A. Pathogenesis and predicttability of central venous catheter sepsis. Surgery 1982;91:383-9.  Back to cited text no. 14
    

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Correspondence Address:
Naim Morina
Clinic of Nephrology and Hemodialysis, UCCK Kosovo Hospital, Circle n.n. 10000 Pristina
Kosovo
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-2442.344754

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