Approach to the Infected Catheter
Vascular access is imperative to all hemodialysis patients. Although the rate of chronic central venous catheter (CVC) use has declined, the majority of dialysis patients still initiate using a CVC. This device increases the infectious complication rate a
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10
Laura Maursetter
10.1
Introduction
Vascular access is a continuous challenge for any patient receiving either acute or chronic hemodialysis (HD). The type of access used and its maintenance can impact the outcome of the patient. It is imperative that the practicing nephrologist knows how to deal with complications of vascular access including infections. This chapter will focus on the approach to a patient with an infected catheter.
10.2
Background
Use of central venous catheters (CVC) is essential to the practice of critical care medicine with more than seven million sold annually in the USA [1]. A life-threatening complication of CVC is a bloodstream infection. Approximately 80,000 episodes of catheter-related bloodstream infections (CRBSI) occur in the USA annually at a cost of approximately $25,000–$45,000 per episode [1, 2]. Serious complications of this illness can occur in as many as 44 % of bacteremic episodes making optimal treatment imperative. Serious complications include endocarditis, osteomyelitis, thrombophlebitis, septic arthritis, epidural abscess, and death [3]. These data are not specific to the HD population, but CVC are essential to many patients who require dialysis making management of the infected catheters an important topic for nephrologists. Over the last decade there has been a push to place fistulas earlier in chronic kidney disease patients. This was started because the United States Renal Data System (USRDS) showed that patients using a catheter were four times more likely to get an infection than those using a graft and eight
L. Maursetter, DO Division of Nephrology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA e-mail: [email protected]
times more likely than those using a fistula [4]. The Fistula First initiative has decreased the number of chronic kidney disease patients who initiate HD with a catheter, but more than 65 % of US patients will still have their first HD session using a catheter. This is compared to 14 % who use arterial-venous fistulas [5]. With 116,395 incident cases of end-stage renal disease in 2009, this means more than 75,000 patients experienced catheter use at the start of their dialysis careers [5]. Many HD patients are rapidly transitioned to other means of venous access, but the increased risk associated with catheters is imposed on the majority of end-stage renal disease (ESRD) patients at dialysis initiation. The use of CVC as an option for permanent hemodialysis access began in the mid1980s. Current first-year infection-related mortality is 2.4 times higher than it was in 1981, much of which has been attributed to CVC use [3, 5]. In addition, when comparing total cost of a patient receiving dialysis through an arterialvenous fistula, those with a catheter have a 25 % higher cost, mostly attributed to catheter-related infection costs [5]. The increased mortality from catheter use heightens the already elevated mortality rate for this high-risk population [6]. It is imperative that
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