This document discusses bacterial infection of tunneled hemodialysis catheters. It notes that while fistulas are preferred, many patients still initiate dialysis with catheters which have a high risk of infection. Catheter-related bloodstream infections can lead to serious complications and increased mortality. Common pathogens involved include Staphylococcus, Pseudomonas, and Candida. Prevention strategies include proper insertion technique, exit site care, and use of antimicrobial locks. Treatment of infections involves antibiotics tailored to the pathogen as well as potentially removing the catheter. Duration of treatment depends on the severity and type of infection.

1. Bacterial infection of
tunneled hemodialysis
catheter
Dr. Muhamed Al Rohani, MD
Consultant nephrologist

2. To remember
• In 1980s permanent catheters
• Despite the Fistula First Initiative, nearly 80% of
patients initiate hemodialysis with a central venous
catheter
• Recent USRDS report observed high 1st
and 2nd
month death rates after HD initiation, coincident
with the increase in CVC placement rates.
• The mortality rate from infection is now 2.4 times
greater than in 198. Hospitalizations is more than
doubled between 1993 and 2005.
• A tunneled central venous catheter have a 15-fold
increased risk of catheter-related bloodstream
infection (CRBSI) and an all-cause mortality rate
ranging from 12% to 25%.
• Ten percent to 20% of CRBSIs are associated with
metastatic complications
• Catheter-related infections:
• Exit site infections,
• Tunnel infections,
• Bacteremia
• The risk of sepsis with a CVC is 2 – 5 fold
higher than that with AVG and AVF
• After an episode of sepsis, the rate of adverse
cardiovascular events increases by up to
2fold, these include:
• Myocardial infarction,
• Congestive heart failure,
• Peripheral vascular disease,
• Cerebral vascular accident events.

3. Hemodialysis Catheters
Tunneled, cuffed cathetersNon-tunneled, non-cuffed catheters

5. Summary of bloodstream infection data
AJKD, 2002; 39 (3): 549-555

6. Risk factors for catheter-related bacteremia
1. AJKD 2004, 44(5): 779
2. AJKD 2005, 46(3): 501
3. KI, 2000; 57(5): 2151
• Duration of catheterization
• Conditions for insertion
• Catheter site and catheter site care
• Repeated catheterization
• Increased catheter maniplation
• Tunneled vs nontunnelled catheters
• Immunosuppressive therapy
• Hypoalbuminemia
AJKD, 2005; 46 (3): 501. Lee T. Et all, «Tunneled
catheters in hemodialysis patients: Reasons and
Subsequent Outcomes»
The most important risk factor for tunneled catheter-related bacteremiais prolonged duratiom of usage

8. Catheter Exit Site infection
Photo provided by Stephanie Booth, used with permission
Catheter Tunnel infection
New catheter Catheter with biofilm

9. Biofilm:
• The critical adherence of the organism to the
catheter surface initiates the common pathway of
biofilm production.
• A mature biofilm is a unique self-sustaining
community of microorganisms protected by an
exopolysaccharide matrix that is stimulated and
secreted by the microorganisms.
• Common microorganisms found in biofilms include
Staphylococcus, Candida, Pseudomonas, and
other.
• ‘fibrin sheath’ or ‘adherent biological material’:
universal endoluminal coverage of material
consistent with biofilm but without universal
colonization by bacteria (electron microscopy
scanning)
• super resistant barrier to antibiotic penetration
and action

11. Evaluation, diagnosis and differential diagnosis
• CRB suspect threshold should be low.
• Two blood cultures should be drawn;
• Peripheral vein and catheter
• Separate peripheral veins
• Differential diagnosis includes pneumonia, foot infection and other infections
UpToDate, 2014
The definitive diagnosis of CRB requires one of the following
• Concurrent positive blood cultures of the same organism from the catheter and a peripheral vein.
• Culture of the same organism from both the catheter tip and at least one percutaneous blood
culture.
• Cultures of the same organism from two peripherally drawn blood cultures and an absence of
alternate focus of infection.

12. JASN, 1999: 10(5): 1045
Gerald A. Beathard
Table 2: Bacterial isolates from 18 blood
cultures.
Count %
Gram-positive organisms
Coagulase-negative Staphylococcus (CONS) 3 (14.3)
Bacillus sp. 3 (14.3)
Methicillin sensitive Staphylococcus aureus
(MSSA)
2 (9.52)
Methicillin resistant Staphylococcus aureus
(MRSA)
1 (4.76)
Enterococcus sp. 1 (4.76)
Gram-negative organisms
Stenotrophomonas sp. 3 (14.3)
Pseudomonas sp. 2 (9.52)
Enterobacter sp. 2 (9.52)
Citrobacter sp. 1 (4.76)
Flavobacterium sp. 1 (4.76)
Morganella sp. 1 (4.76)
Serratia sp. 1 (4.76)
International Journal of Nephrology
Volume 2014 (2014), Article ID 629459, 6 pages

13. Staphylococcus Aureus:
•Annual incidence bacteremia in HD patients is
between 6 and 27%.
•CRB is associated with more than 3-fold higher rate of
infectious complications, and 4-fold greater risk of
recurrent bacteremia or septic death in 3 months,
•The mortality rate associated with S. aureus access
infections has been reported to be as high as 30%.
Pseudomonas Aragenosa:
•Sepsis
•Death
Gram-negative species are isolated in 27–
36% of episodes.
The high mortality rates reported in
Pseudomonas sepsis associated with
visceral nosocomial infections (non-CRB),

14. Clinical manifestations of hemodialysis catheter infections
• Fever and/or chills
• Purulence at the catheter insertion site
• Hemodynamic instability
• Catheter dysfunction
• Hypothermia
• Acidosis
• Hypotension
• Manifestations of metastatic infections
UpToDate, 2014
Complications
•Endocarditis
•Osteomyelitis
•Epidural abscess
•Septic shock
•Septic arthritis
•Septic thrombophlebitis
•Death

15. Transesophageal echocardiogram image of the mitral
valve (MV), anterior MV leaflet (m), and posterior MV
leaflet (mm) with a vegetation (*) attached by a stalk
to the left atrial (LA) side of the posterior MV leaflet,
near its tip. LV, left ventricle
Autopsy image of a large cardiac valvular vegetation

16. Prevention of infection
Catheter insertion and position
• Catheters should be inserted under strict aseptic conditions.
• The right internal jugular vein position is the preferred
location for insertion, followed by the left internal jugular
vein position. The use of the femoral vein position is
discouraged.
• The use of the subclavian vein position is discouraged for
reasons not related to infection (frequent stenosis).
Nurse care
Universal precautions, a sterile environment and aseptic
technique should be applied at any occasion when a venous
catheter is manipulated, connected or disconnected.
Preventive antimicrobial catheter locks and catheter
surface treatment:
•Vancomycin/ceftazidime/heparin
•Vancomycin/heparin
•Ceftazidime/heparin
•Cefazolin/heparin
•Gentamycine/heparin
•Taurolidine
•4% and 30 % citrate
•70 % ethanol
Acceptable exit site cleaning solutions:
chlorhexidine 2%
alcohol 70%
povidone-iodine 10% solution
1. The use of chlorhexidine skin antisepsis at the catheter exit site, catheter hub disinfection,
2. The application of triple antibiotic (or povidone iodine) ointment to catheter exit sites during
dressing changes. Similar “bundled” care efforts in intensive care units have shown dramatic
decreases in nondialysis CRBSI rates.
 54% reduction (P<0.001) in CRBSI during the 15-month intervention period.

17. Different Locking Solutions
Prevent thrombosis Risk of bleeding Prevent Infection Systemic effect Bacteria resistance
Heparin yes yes no yes no
Citrate 30% yes no yes yes no
Gentamicin + Citrate yes no yes yes yes
Taurolidine + Citrate yes no yes no no
Isopropyl alcohol 70 % yes no yes no no
The success rate of an antibiotic lock:
 Gram-negative infections 87 to 100% ,
 S. epidermidis infections 75 to 84%,
 S. aureus infections 40 to 55%
Potential risks:
 Arrhythmias,
 Toxicity,
 Allergic reactions,
 Development of resistance to antibiotics

18. Recent studies:
1. Abbas et al : using bundled care without antimicrobial locks have achieved CRBSI rates of ≤1 per 1000 catheter-
days, can the use of antimicrobial locks further reduce CRBSI?
2. Maki et al: Performed an observational study of gentamicin-heparin versus heparin catheter locks,
3. Moran and their colleagues performed randomized controlled trials with gentamicin-trisodium citrate (citrate)
and citrate–methylene blue–methylparaben–propylparaben, respectively.
 Conclusions: All three studies achieved CRBSI rates of <1 per 1000 catheter-days in their control groups and yet
still showed a significant decrease in infection rates with their interventions (Abbas, Moran, and Maki et al.
reported rates of 0.62, 0.28, and 0.24 events per 1000 catheter-days, respectively).
However, two major unanswered questions remain:
(1)Does the routine use of antimicrobial locks in dialysis patients with tunneled central venous catheters lead to a
mortality benefit?
(2)Is there risk of antibiotic resistance in patients using antibiotic-based lock solutions?

19. To answer the mortality
Moore et al: conducted a prospective, multicenter, observational cohort study to compare the effectiveness of a
gentamicin-citrate lock versus heparin. They included the use of a triple antibiotic ointment (bacitracin, neomycin, and
polymyxin B) on the exit site. The dose of gentamicin (0.32 mg/ml) used with 4% citrate. The authors report a reduced rate
of CRBSI in the antibiotic lock period of 0.45 per 1000 catheter-days compared with 1.68 events during the heparin period
(P=0.001). The use of gentamicin-citrate lock was also associated with a significant reduction in all-cause mortality (0.32;
95% confidence interval, 0.14 to 0.75 after multivariate adjustment).
CJASN, 2014
The issue of the antibiotic resistance in hemodialysis catheter remains discussable
 The CDC and the Infectious Diseases Society of America do not recommend the routine use of antimicrobial lock in
hemodialysis patients dialyzed with a central venous catheter. They suggest reserving this treatment for patients with a
history of multiple CRBSIs, citing concerns for the potential emergence of antibiotic resistance.
 In contrast, the European Best Practices Report has concluded that the effectiveness of antimicrobial lock to reduce
CRBSI outweighs any potential risk and recommends prophylactic antimicrobial lock use in all patients with ESRD who
have tunneled central venous catheters.

20. Prevention of catheter related infection
General measures:
• Every dialysis unit must develop written protocol for maniplation of hemodialysis catheters and exit-site dressing
technique,
• Hand hygiene before and after patient contact,
• Wear nonsterile gloves and masks during catheter procedures,
Other methods:
• Elimination of S. Aureus nasal carriage,
• Topical application of different substances,
• Utilize antibiotic-lock technique,
• Usage of different catheters (Are there catheters with a lower infection rate?)
• impregnated with antimicrobial agents,
• with subcutaneos port,
• Usage of Tego needlefree hemodialysis connector

21. TREATMENT
Management of diaysis-catheter induced bacteremia
• Antibiotic therapy
• Empiric systemic antimicrobial therapy
• Tailored systemic antimicrobial therapy
• Removal or exchange of catheter
UpToDate, 2014

22. Approach to the management of a patient with a tunneled central venous catheter (CVC)— or a
surgically implanted device (ID)—related bloodstream infection.
Leonard A. Mermel et al. Clin Infect Dis. 2001;32:1249-1272
© 2001 by the Infectious Diseases Society of America

23. Empiric systemic antimicrobial therapy for hemodialysis
catheter infection
AJKD, 2009: 54(1): 13. Treatment guidelines for dialysis catheter-related bacteremia

24. Methicillin-resistant Staphylococcus
• With the isolation of a methicillin-resistant Staphylococcus,
• Continue to administer vancomycin if the organism has a low-minimal inhibitory concentration.
• Patients with vancomycin allergy can be treated with daptomycin.
UpToDate, 2014
Methicillin-sensitive Staphylococcus
• With the isolation of a methicillin-sensitive Staphylococcus,
• Vancomycin should be substituted with cephazolin.
• 20 mg/kg cephazolin, IV, after each hemodialysis session.
• Vancomycin is the preferred treatment for patients who are penisillin allergic.
Cephazolin as empiric therapy in hemodialysis-related infections. AJKD 1998, 32(3):410.
Use of vancomyin or cephazolin for treatment of hemodialysis-dependent patients with methicillin-susceptible staphyloccocus aureus bacteremia. Clin Infect Dis 2007, 4
Vancomycin-resistant Enterococcus
• Can be treated with daptomycin,
• 6 mg/kg, following a dialysis session in inpatients,
• 7 mg/kg (low- flux dialyzers), during the last 30 minutes of each dialysis session,
• 9 mg/kg (high-flux dialyzers) , during the last 30 minutes of each dialysis session
Intradialytic administration of daptomycin in end stage renal disease patients on hemodialysis CJASN 2009, 4(7):1190

25. Gram-negative organisms
• Up to 95 % of Gram-negative bacteria isolated in dialysis catheter-related bacteremia are presently sensitive to both
aminoglycosides and third-generation cephalosporins.
• prefer ceftazidime for longer-term treatment, rather than gentamycin, given the risk of aminoglycoside ototoxicity.
• In regions or institutions in which resistance to ceftazidime is more common, aminoglycosides or carbepenems may be
alternate choices.
UpToDate, 2014
Candidemia
• catheter removal
• treatment with an appropriate antimicrobial agent
Management of hemodialysis catheter-related bacteremia with an adjunctive antibiotic lock solution. KI 2002;61(3):1136

26. Duration of antimicrobial therapy for CRB
• Uncertain. It depends on clinical, microbiologic features and whether the catheter is removed
• Treat uncomplicated CRB for two or three weeks.
• Treat uncomplicated CRB due to S. Aureus for four weeks.
• If there is evidence of metastatic infection, use of antibiotics at least six weeks.
• When blood cultures remain positive after three or more days of appropriate therapy, use antibiotics at least six weeks.
• Among patients with osteomyelitis, experts advise treatment for six to eight weeks.
UpToDate, 2014
Catheter management in case of CRB
• Immediate catheter removal, followed by placement of a temporary non-tunneled catheter for short-term dialysis access.
After bacteremia has resolved, a new tunneled dialysis catheter can be inserted.
• Replacement of the infected catheter via exchange over a guidewire.
• Use an antibiotic lock in the infected catheter.
• Leave the infected catheter in place (no replacing, no an antibiotic lock)

27. Conditions for immediate removal of infected hemodialysis
catheters
• Severe sepsis,
• Hemodynamic instability,
• Evidence of metastatic infection,
• Signs of accompanying exit-site or tunnel infection,
• If fever and /or bacteremia persist 48 to 72 hours after
initiation of antibiotics to which the organism is susceptible,
• When infection is due to difficult-to-culture pathogens, such as
S. Aureus, Pseudomonas, Candida, other fungi, or multiply-
resistant bacterial pathogens.
UpToDate, 2014

28. Guidewire catheter exchange
«If there is no conditions of immediate catheter removal, delayed exchange of
the infected cuffed catheter over a guidewire with a new catheter two or three
days after institution of effective antimicrobial therapy is a reasonable option.»
KI 2000;57(5):2151. Bacteremia associated with tunneled dialysis catheters: comparison of two treatment strategies.
AJKD 1995;25(4):593. Catheter-related sepsis complicating long-term, tunnelled central venous dialysis catheters: management by guidewire exchange.
KI 1998;53(6):1792. Treatment of infected tunneled venous access hemodialysis catheters with guidewire exchange.
Conditions for guidewire replacement of the catheter
• Afebrile after 48 hours of antibiotic therapy
• Clinically stable patient
• No evidence of tunnel tract involvement
CJASN 2009, 4: 1102–1105. Catheter exchange over a guidewire in conjunction with antifungal therapy is an effective and safe treatment regimen
also in catheter-related candidemia cases.

29. Leaving the catheter in place without intervention
• Only systemic antibiotics,
• Without replacing the infected catheter,
• Without instilling an antibiotic lock,
• Clinical cure rate, 22-37 %
• Eradication of bacteria imbedded in biofilms ?
UpToDate, 2014