Hemodialysis Catheter-Related Infection: Jafar Alsaid, M.B.CH.B, Md. Fasn. Facp. 2021 1

Hemodialysis Catheter-related
infection
JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 1

CAN YOU MAKE A DIFFERNCE??
OUTLINE
 Statistics.
 How to reduce infection?
 Infection types.
 CDC data.
 Ochsner data.
 Proposed protocol for dialysis infection control.

ESRD Prevalence
USRDS 2020

In Center
HD
Transplant
PD
Home HD

303
257
111
7
8
Vascular access use at initiation and on day
of eligibility, 2011.
USRD
50% S2013
Figure 1.21 (Volume 2) Incident hemodialysis patients, 2011. USRDS

2013.
Access use at first outpatient hemodialysis,
by pre-ESRD nephrology care, 2011
USRD
S
2013
Figure 1.22 (Volume 2) Incident hemodialysis patients, 2011. USRDS

2013

Access use at first outpatient hemodialysis,
by pre-ESRD nephrology care, 2011
HD catheter
USRDS
2020
Figure 1.22 (Volume 2) Incident hemodialysis patients, 2011. USRDS 2013

HD Catheters
70%
USRDS 2020
USRDS 2020
92%

We have to learn how to live with the
hemodialysis catheters, whether we like it or not.
Jafar Alsaid

How can we improve our catheter care and
reduce infection?

Hemodialysis catheter infection
 Second cause of mortality.
 First cause of Morbidity.
 Bacterial flora migration.
 Exoluminal and Endoluminal growth.
 Increased catheter loss, bacteremia, hospitalization.
Ishani A, Collins AJ, Herzog CA, Foley RN: Septicemia, access and cardiovascular disease in dialysis patients: The
USRDS Wave 2 study. Kidney Int 68: 311–318, 2005

Catheter Bacterial Colonization
C

Types of catheters
 Cuffed / non-Cuffed.
 Gauge.
 Length.
 Luminal design.
 Material.
 Tip design.
 Antiseptic impregnated.

Catheter related Bacteremia
 Cuffed rate 1.6-5.5/1000 d.
 Non cuffed 3.8-6.6/1000 d.
High mortality and morbidity.

Related with Catheter tip colonization.
Higher risks:
 Immunosuppressed patients.
 S. Alb < 3.5g/dl.
Organisms; G+, less common G- bacilli.
Beathard GA, Urbanes A: Infection associated with tunneled hemodialysis catheters. Semin dial 21: 528–538, 2008.
DURATION

Rate of uncuffed cath. infection:
 8% by 2wks.
 25% by 1 month.
 50% by 2 months.
Catheter related septicemia is 2 -20%.
Agarwal, Anil K, Asif Arif. NephSAP. Interventional Nephrology, ASN. 361-375. 2009.
Recommended duration for HD catheters:
Vascath:
 IJ 2-3wks?
 Subclavian 2-3wks?
 Femoral. 2-5days?
Cuffed tunneled:
 1 year –Indefinite.
Agarwal, Anil K, Asif Arif. NephSAP. Interventional

JAFAR ALSAID, M.B.CH.B, MD. Nephrology,
FASN. FACP. 2021 ASN. 361-375. 2009. 23
Cuffed Tunneled Cath. Duration
Catheter survival will depend on:
1. Design.
2. Site of insertion.
3. Rt. IJ > Lt IJ> Femoral.
4. Non Dm.
Fry AC, Stratton J, Farrington K, Mahna K, Selvakumar S, Thompson T, Warwicker P: Factors affecting long-term survival of tunneled
haemodialysis catheters: A prospective audit of 812 tunneled catheters. Nephrol Dial Transplant 23: 275–281, 2008
Catheter
Location
JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021

25
Complication in relation with location 865 patient from 14 HD centers
Wang K, et al. BMJ Open 2015;5:e007136. doi:10.1136/bmjopen-2014-007136

Location of HD catheters

Signs and symptoms of Hemodialysis Catheter
related infection
 Immunosuppressed patients.
 Inflammatory signs:
 redness, hotness, pain, swelling, discharge.
 Fever during Hemodialysis.
The catheter is the cause of fever unless proven otherwise.
 Redness over the exit site.
 Discharge from the exit site.

Classification of Hemodialysis Catheter related infection
Types:
1. Exit site infection.
2. Tunnel Infection.
3. Blood steam infection.
4. Distant organ septic embolization and abscesses.

JAFAR ALSAID, M.B.CH.B, MD. Nephrology,
FASN. FACP. 2021 ASN. 361-375. 2009. 29
Investigations for catheter infection
 CBC.
 Blood Culture peripheral and from catheter.
 Catheter tip Cx. ??
 Exit site discharge.
 Others: Urine, Sputum, Drains..etc.
 Radiology: CXR, US, …etc.

Vascular access infection definitions
Agarwal, Anil K, Asif

JAFARArif. NephSAP.
ALSAID, Interventional
M.B.CH.B, MD. FASN. FACP. 2021 Nephrology, ASN. 361-375. 2009. 31
Vascular access infection definitions
Rate of uncuffed cath. infection:
 8% by 2wks.
 25% by 1 month.
 50% by 2 months.
Catheter related septicemia is 2 -20%.
Agarwal, Anil K, Asif

JAFARArif. NephSAP.
ALSAID, Interventional
M.B.CH.B, MD. FASN. FACP. 2021 Nephrology, ASN. 361-375. 2009. 33
Catheter Exit Site infection & Tunnel infection

Definition of Exit Site infection
Lok CE, Huber TS, Lee T, et al; KDOQI Vascular Access Guideline Work Group. KDOQI clinical
practice guideline for vascular access: 2019 update. Am J Kidney Dis. 2020;75(4)(suppl 2):S1-S164.
Definition of Exit Site infection
• Erythema.
• Area < 2cm.
• Purulent Discharge.
• May be associated with

Bacteremia, fever ..etc.
practice guideline for vascular access: 2019 update. Am J Kidney Dis. 2020;75(4)(suppl 2):S1-S164.
Exit site infection
• Erythema, discharge and tenderness.
• Obtain Cx.
• Could be treated with Local and oral AB.
• Rarely required removing the catheter.
Catheter Tunnel infection
• Inflammatory signs over the tunnel.
• Purulent discharge.
• IV AB.
• Exchange of the catheter.
• Different site.

JAFAR ALSAID, M.B.CH.B, Nephrology, ASN. 361-375. 2009
MD. FASN. FACP. 2021 39
Catheter Tunnel infection
Lok CE, Huber TS, Lee T, et al; KDOQI Vascular Access Guideline Work Group. KDOQI clinical practice guideline
for vascular access: 2019JAFAR
update.
ALSAID, Am J Kidney
M.B.CH.B, MD. FASN. Dis. 2020;75(4)(suppl 2):S1-S164.
FACP. 2021 40
Catheter related Bacteremia
Clinical picture:
 Fever with chills.
 May be only during HD.
 patient with Central catheter.
 No other focus.
 Sepsis.
Dx: Blood Cx > 15CFU. From peripheral and catheter.
Treatment: AB for 2-3 wks with exchange of the catheter.

Definition of Central Venous Catheter Blood stream infection
AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020
Lok CE, Huber TS, Lee T, et al; KDOQI Vascular Access Guideline Work Group. KDOQI clinical practice
guideline for vascular access:
JAFAR ALSAID, 2019 update.
M.B.CH.B, MD. FASN.Am
FACP.J2021
Kidney Dis. 2020;75(4)(suppl 2):S1-S164. 42
Definition of Central Venous Catheter Blood stream infection
CLINICAL + BLOOD (Peripheral / Catheter) + No other source
 Clinical symptoms.
 Blood Cx. from Peripheral. Or dialysis circuit.
 Catheter (Hub or tip Cx.) >15 CFU/cath. seg. or > 100 /Cath semiquantitative
 Same organism from catheter and peripheral.
 No other apparent source.
 2 hours interval.
 Ratio > 3/1 Catheter / peripheral .
 Positive Blood Cx with no other possible source.

Investigations for catheter infection
 CBC.
 Blood Culture peripheral + from catheter.

 Catheter tip Cx. / Hub culture ??
 Exit site discharge.
 Others: Urine, Sputum, Drains..etc.
 Radiology: CXR, US, CT …etc.

Proposed protocol for catheter related for Central Venous catheter related infection
practice guideline for vascular access: 2019 update. Am J Kidney Dis. 2020;75(4)(suppl 2):S1-
Strict Infection Control Protocol.
Can it work?

47
Nurses' catheter
care
Infection Control
Protocol
BSH Hemodialysis population,
over 112 months. Jan.
% 2004 – May. 2013
AVF 20%
Access types:
AVG 18%
Cuffed
56%
cath.
N= 147 patients.
Vascath. 6% 8741 HD
0% 20% 40% 60%

Jafar Alsaid. 2013. ASN poster
69
JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021
70
Access Type per dialysis over the years
1400
AVF AVG VC PC
1200
1000
800
600
400
200
0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
72
ASN Poster

HD related blood stream infection progress
International Our Unit Our Unit Our Unit Out Unit

2011 2015 2017 2019
Hemodialysis Blood stream
infection rate /100 patient 0.75-4.4 0.019 0.007 0.004 0.003
month
Admission rate for HD 108 0.79 0.68 0.73 0.4
bacteremia/1000 patient year
Admission for vascular access 110 0 0 0 0
infection
76
Hemodialysis Blood steam infection at BSH
Jan. 2004 - Sep. 2019
0.025
International data 0.75-4.4
0.02 0.02
/100 patient month
0.015
0.01
0.007
0.004
0.005
0.003
0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
77
Year
Admission for Hemodialysis related blood stream infection per 1000 patient-year
0.9
0.79 International rate 108
0.8 0.73
/ 1000 patient Year
0.68
0.7
0.6
0.5
0.4 0.4
0.3
0.2
0.1
0
2011 2015 2017 2019
Years 78
Catheter Salvage in poor access
30% AB treatment could clear infection.
80% AB with exchange over guide wire.

Tanriover B, Carlton D, Saddekni S, Hamrick K, Oser R, Westfall AO, Allon M: Bacteremia associated
with tunneled dialysis catheters: Comparison of two treatment strategies. Kidney Int 57: 2151–2155,
2000
Exchange:
 72 hours post AB.
 No need for negative blood Cx.
National Kidney Foundation: KDOQI clinical practice guidelines and clinical practice
recommendations for vascular access 2006. Am J Kidney Dis 48[Suppl 1]: S176–S322, 2006

Antibiotic Lock
 Is indicated in reinfection with same organism.
 In limited catheter sites.
 Catheter Salvage is acceptable.
Onder AM, Chandar J, Simon N, Diaz R, Nwobi O, Abitbol CL, Zilleruelo G: Comparison of tissue plasminogen activator–
antibiotic locks with heparin–antibiotic locks in children with catheter-related bacteraemia. Nephrol Dial Transplant 23:
2604–2610, 2008.
Rijnders BJ, Van Wijngaerden E, Vandecasteele SJ, Stas M, Peetermans WE: Treatment of long-term intravascular catheter-
related bacteremia with antibiotic lock: Randomized, placebo-controlled trial. J Antimicrob Chemother 55: 90–94, 2005
Antibiotic locking solutions

Types of Antibiotic Lock
 Cefazolin, Cephotaxim, Vancomycin, Tobramycin, Gentamyin.
Concentration: 5mg/ml.
mixed with Citrate, EDTA, Heparin, rtPA. .
Systemic AB with Antibiotic lock more effective for

 G. Neg.
 Less effective for Staph. Epidermidis.
 Worst for Staph aureus.
Maya ID, Carlton D, Estrada E, Allon M: Treatment of dialysis catheter-related Staphylococcus aureus bacteremia with antibiotic lock: A
quality improvement report. Am J Kidney Dis 50: 289–295,2007
Different AB surface coating catheters
Dwyer A: Surface-treated catheters:

JAFAR A review.
ALSAID, M.B.CH.B, Semin
MD. FASN. FACP.Dial
2021 21: 542–546, 2008 83
Antibiotic Lock
RCT
 79 children.
 264 episodes of Catheter related bacteremia.
 Early or Late Antibiotic lock.
 All with systemic AB.
Results:
 Less likely to exchange with early AB lock.
 Infection recurrence within 45 days was similar.
 Infection free survival of catheter was longer for early
AB lock.
Onder AM, Chandar J, Billings AA, Simon N, Diaz R, Francoeur D, Abitbol C,
Zilleruelo G: Comparison of early versus late use of antibiotic locks in the treatment
JAFAR
of catheter-related ALSAID, M.B.CH.B,
bacteremia. ClinMD. FASN.
J Am SocFACP. 2021
Nephrol 3: 1048–1056, 2008 84
Antibiotic Lock
RCT.
 18 children.
 24 episodes of Catheter related Bacteremia.
 Randomized to Heparin or rtPA AB lock.
 No significant difference in both.
Onder AM, Chandar J, Simon N, Diaz R, Nwobi O, Abitbol CL, Zilleruelo G:

Comparison of tissue plasminogen activator–antibiotic locks with heparin–
antibiotic locks in children with catheter-related bacteraemia. Nephrol Dial
Transplant 23: 2604–2610, 2008
Hemodialysis Catheter distant infection
 Osteomyelitis.
 Endocarditis.
 Septic arthritis.
 Spinal epidural abscess.

Historic Point
University of Berkley 1941.

Stanford University Medical School 1945.
Minnesota University Masters 1951.
Washington University 1958-1982
Belding Scribner MD.

1921-2003

Hemodialysis Catheter-Related Infection: Jafar Alsaid, M.B.CH.B, Md. Fasn. Facp. 2021 1

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Hemodialysis Catheter-related

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 1

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 3

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 5

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 6

Figure 1.21 (Volume 2) Incident hemodialysis patients, 2011. USRDS

Figure 1.22 (Volume 2) Incident hemodialysis patients, 2011. USRDS

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 10

Figure 1.22 (Volume 2) Incident hemodialysis patients, 2011. USRDS 2013

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 14

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 15

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 16

 Second cause of mortality.

 First cause of Morbidity.

 Bacterial flora migration.

 Exoluminal and Endoluminal growth.

 Increased catheter loss, bacteremia, hospitalization.

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 17

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 18

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 19

High mortality and morbidity.

Organisms; G+, less common G- bacilli.

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 21

Catheter related septicemia is 2 -20%.

Agarwal, Anil K, Asif Arif. NephSAP. Interventional

3. Rt. IJ > Lt IJ> Femoral.

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021

Wang K, et al. BMJ Open 2015;5:e007136. doi:10.1136/bmjopen-2014-007136

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 27

 redness, hotness, pain, swelling, discharge.

 Fever during Hemodialysis.

The catheter is the cause of fever unless proven otherwise.

 Redness over the exit site.

 Discharge from the exit site.

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 28

1. Exit site infection.

3. Blood steam infection.

4. Distant organ septic embolization and abscesses.

Agarwal, Anil K, Asif Arif. NephSAP. Interventional

 Blood Culture peripheral and from catheter.

 Catheter tip Cx. ??

 Exit site discharge.

 Others: Urine, Sputum, Drains..etc.

 Radiology: CXR, US, …etc.

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 30

Agarwal, Anil K, Asif

Catheter related septicemia is 2 -20%.

Agarwal, Anil K, Asif

JAFAR ALSAID, M.B.CH.B, MD. FASN. FACP. 2021 34

• Area < 2cm.

• May be associated with

• Erythema, discharge and tenderness.

• Could be treated with Local and oral AB.

• Rarely required removing the catheter.

• Exchange of the catheter.

Agarwal, Anil K, Asif Arif. NephSAP. Interventional

 May be only during HD.

 patient with Central catheter.

Dx: Blood Cx > 15CFU. From peripheral and catheter.

Treatment: AB for 2-3 wks with exchange of the catheter.

AJKD Vol 75 | Iss 4 | Suppl 2 | April 2020

CLINICAL + BLOOD (Peripheral / Catheter) + No other source