GUIDELINES [ back to index ]
26. Management of tunneled catheter infection
*1 Culture from catheter aspirate and clot
• Blood from the catheter hub and aspirated clots should be cultured if catheter infection is suspected. Biofilms are frequent in catheters. In over 80 % of biofilms bacterial growth can be proven. The clinical importance, however, is still speculative 1.
*2 Peripheral blood culture
• At least three blood cultures should be taken 10 to 30 minutes apart, one of them should be drawn from the catheter, and the others from peripheral sites.
• Marr et al. defined catheter-related bacteraemia if the same organism could be cultured from the catheter and from a peripheral site or from two peripheral locations. 2 Capdevila et al. described a 94 % sensitivity and a 100 % specificity, if the count of colony-forming units (CFU) was fourfold higher in the blood drawn from the catheter than in simultaneously drawn peripheral blood.3 A single bacterial count of > 100 CFU/ml from the catheter hub port with an identical organism growing from the peripheral blood specimen is highly suggestive of catheter-related bacteraemia.
*3 Remove catheter
• Immediate removal of the catheter is recommended in case of severe symptoms 4 5, in clinically unstable patients and in patients who remain symptomatic for more than 36 hours 6.
• Catheter replacement should be delayed (see *5) 7 4 5.
• After removal of the catheter, the catheter tip should be cultured. The culture result may retrospectively implicate the catheter as the cause of sepsis 8 9.
*4 Replace after resolution of infection
• A new permanent tunneled catheter should not be placed before resolution of signs and symptoms of bacteraemia and after cultures have been negative for at least two days after cessation of antibiotic therapy 7 4 5.
*5 Exchange catheter over a guidewire
• Catheter exchange over a guidewire is a recognised procedure to treat proven or suspected catheter related infection 10 11 12 13. In one study, exchange over a guidewire led to similar infection-free survival compared with removal and delayed replacement, with fewer procedures for the patient 14.
• However, despite the fact that this option is quoted in the DOQI guidelines, many experts do not recommend such catheter exchange, since this is a way of inducing blood stream infection from a localised source infection (endoluminal catheter infection or track infection). Such procedure may constitute a perfect condition for delayed septic metastasis or endocarditis. Catheter withdrawal and insertion of a new permanent catheter in a different venous site is the recommendable alternative.
• Metastatic endocarditis 15, epidural 16 and psoas abscess 17 have been described in catheter related bacterial infections treated without catheter removal. However, Marr et al. did not find an increased risk of complications in patients where attempts were made to leave the catheter in place 2.
• There is clearly no consensus in the policy regarding how to manage catheter sepsis. Each patient should be managed on his/her merits with risk and benefit considered.
*6 Antibiotic lock of the catheter
• Bacteraemia can also be treated without catheter removal but with an additional antibiotic lock of the catheter after each dialysis session for two weeks. This option has also been proposed by the European Best Practice Guidelines on Haemodialysis 6.
• Infection in permanent Tunneled catheters have been successfully treated with an antibiotic lock of the catheter and systemic antibiotics in 40 out of 79 patients (51%) 18.
• In an implanted, subcutaneous device for haemodialysis, bacteraemia has been successfully treated with systemic antibiotics and antibiotic lock of the device 19.
• In instances of bacteraemia, antibiotic treatment without antibiotic lock of the catheter and without catheter removal successfully salvaged the catheter in 32 % of the attempts. Marr et al. stated that attempted salvage may not increase the risk of complications 2.
*7 Remove catheter in case of tunnel infection
• Tunnel infections, i.e. infections extending along the tunnel and beyond the cuff in cuffed catheters, are best treated by catheter removal and replacement at a new venotomy site 4 5.
*8 Local antiseptics
• Isolated exit site infection, i.e. infection distal to the anchoring cuff in cuffed catheters, presenting with redness, exudation and crusts, should be treated conservatively with topical antibiotics or antiseptics (e.g. antibiotic creams such as mupirocin or fucidin or antiseptics such as povidone iodine cream or dressings soaked in hypertonic saline) during the dialysis session 4 5.
• However, silicone catheters must not be treated with povidone ointment due to possible damage to the catheter.
*9 i.v. antibiotics
• Exit site infections without bacteraemia, which do not respond to therapy with local antibiotics or antiseptics, should be treated with systemic antibiotics for two weeks 6. Whilst culture results are pending, empirical antibiotic treatment should be initiated and later on adjusted according to the culture and antibiotic sensitivities (see appendix for "Antibiotic Treatment“).
*10 Choice of antibiotic treatment
• Immediate antibiotic therapy must be started as soon as infection is suspected and blood samples have been drawn. Initial empirical treatment should take into account the likely bacterial species. Staphylococci are the most prevalent isolates (60 to 90 %) in haemodialysis catheter-related bacteraemia, the relative prevalence of S. aureus and coagulase-negative Staphylococci being equal. Enterococci were found in 11 to 19 % and Gram negative rods have been reported in up to 33 % of the cases 7 20 21 22 23 24 25.
• Systemic antibiotics should be administered for at least two weeks in cases of exit site infection and for at least four weeks following bacteraemia 6. Blood cultures should be taken repeatedly to monitor effectiveness of the treatment. Antibiotic sensitivities should dictate the antibiotic choice as soon as these are available 4.
• Parenteral antibiotics such as methicillin, cefazolin, vancomycin or teicoplanin are recommended for the initial treatment. When the probability of MRSA is low, vancomycin and teicoplanin should perhaps be reserved as a second-line treatment. In the United States, however, about 45 – 70 % of the Staphylococci are methicillin resistant (MRSA) which is less of a problem in Europe. MRSA strains with decreased susceptibility to glycopeptides have also been reported, mainly in the dialysis community and may present a challenging problem in the future.
• For details on antibiotic treatment, please refer to appendix chapter “Antibiotic Treatment”.
*11 Replacement of catheter in the presence of exit site infection
• The new catheter can be placed through the same venotomy site as the previous one but a new tunnel should be created to avoid the infected site. Alternatively, the catheter should be placed with a new venotomy site, a new tunnel and a new exit site again avoiding the infected skin area 4 5.
*12 Monitor catheter
• Persistence or recurrence of fever, increase in CRP and white blood cell count or positive blood cultures after catheter removal and antibiotic treatment suggest septic metastasis. Echocardiography or, preferably transoesophageal echocardiography, must be performed to search for endocarditis. Total body scintigraphy with labelled white cells may be helpful in identifying metastatic infection sites, such as in bone and joints.
• Catheter monitoring is mandatory to ensure dialysis efficacy and to prevent catheter-related hazards (see: “Placement of Tunneled Catheter”).