GUIDELINES [ back to index ]
14. Management of autogenous A/V fistula infection after 1st month of placement
*1 Fistula infection present
• Clinical signs of infection are tenderness, erythema, warmth, induration, local serous or purulent discharge and skin ulcers. However, even in the absence of these clinical signs, infection may be present, especially in cases of unexplained sepsis, leukocytosis or fever.
• If fistula infection is suspected, a re-evaluation of precautionary measures to prevent infections, e.g. the correct puncture technique (see *5 below) and treatment of nasal S. aureus carriers, must be performed (see algorithm “Routine Management of A/V Fistula and Graft”, *8).
*2 Assess for other causes
• It is important to distinguish infection from skin changes due to allergic dermatitis, venous hypertension, or inflammation secondary to thrombosis. Unfortunately, fistula infection can present without fever, high leukocyte count or local signs of infection such as redness, warmth or purulent discharge.
• If laboratory parameters such as elevated CRP suggest an infection, other sources of infection, e.g. infection of a diabetic foot, should also be excluded.
*3 Antibiotic treatment up to 6 weeks
• Extensive A/V fistula infection should be treated like subacute bacterial endocarditis with six weeks of parenteral antibiotics. Excision of the fistula is only necessary in case of infected thrombi and septic emboli 1. For details of treatment see appendix “Antibiotic Treatment”.
*4 Antibiotic treatment for 2 to 3 weeks
• Localised puncture site infections should be treated with antibiotics for at least two weeks in the absence of fever and bacteraemia, and at least for four weeks in presence of fever and / or bacteraemia 1.
*5 Check correct puncture technique
• Infection of A/V fistulas after the first month of placement is usually due to a violation in the aseptic procedure of vascular access handling. Aseptic handling procedure of the vascular access must be completely reconsidered. The protocol for A/V fistula needling must be revised in concert with a hygienist and/or the local infection control committee. Nursing staff and other care providers must be briefed and trained to strictly apply established protocols. Hygienic rules of how to prepare the patient must be reconsidered. Washing and cleaning procedures of the patient’s hands and arms must be reinforced. Skin disinfection must be adapted and the choice of the disinfecting agent and the application time on the skin must be considered.
• Patients at risk, such as chronic carriers of pathogenic bacteria, patients with stomata or with infectious urological disorders must be identified and treated accordingly. Nursing staff must reinforce the aseptic conditions of A/V fistula needling. Hand washing with disinfecting soap is required. The use of sterile gloves, mask and gown is highly desirable during the needling procedure and the use of sterile drape to isolate the skin area for needling, is advised in high risk patients, although expensive and time-consuming.
• Similarly, aseptic technique should be used for the removal of needles and while applying pressure to the puncture sites for haemostasis post dialysis (see appendix: “Aseptic techniques“).
• Nursing staff should be examined for nasal carriage of S. aureus, and bacteria should be eradicated with mupirocin ointment.
*6 Endocarditis
• Endocarditits may occur in up to 12 percent of bacteraemia in dialysis patients. As the mortality is high (patient survival after 30 days was only 71 %), it has been proposed that transoesophageal echocardiography should always be performed to exclude endocarditis in patients with positive blood cultures 2.
*7 Epidural abscess
• Bacteraemia might also lead to epidural abscesses. Therefore epidural abscess should be excluded in all patients with recently treated or ongoing bacteraemia and severe back pain 3 4.
*8 Check for other A/V fistula possibilities
• In the case of an infected forearm A/V fistula, the construction of a new access at the elbow level ought to be considered. The decision can be facilitated substantially by ultrasonographic investigations to exclude perivascular infectious material and/or haematoma. In addition, the status of the venous segment selected for a new A/V anastomosis can be reliably defined. If the infection is located in the region of the elbow, there will be only a limited number of alternatives to create another A/V fistula.
• In any case of severe infection and delayed healing, the contralateral arm should be considered for the construction of a new vascular access since it may be much simpler to create a new access there than to perform major repair surgery of the formerly infected arm. In these situations, native A/V fistulas have absolute priority. In the presence of any infection, insertion of graft material has to be avoided.
*9 Place new access after 3 to 4 weeks
• After complete resolution of local and systemic signs of infection, a new access can be constructed. The risk of re-infection is very low, when no prosthetic material is used 5 6 7. A new A/V fistula can be created in the same arm, if there are suitable vessels remaining. If this is not the case, the other arm must be used. A new autogenous A/V fistula should, of course, be preferred to a graft.