Infectious complications of dialysis access devices

KEYWORDS Dialysis  Device infection  Renal disease During the past 2 decades, the incidence of end-stage renal disease (ESRD) in theUnited States has more than doubled, with more than 380,000 patients currentlyreceiving maintenance dialysis.During this same time period, significant advanceshave been made in dialysis care and overall However, dialysis access canbe problematic, including vascular access for hemodialysis (HD) and peritonealaccess for peritoneal dialysis (PD). Dialysis access remains the Achilles heel ofESRD management, and represents a major source of morbidity for these patientswhile contributing significantly to health care costs.
Infections are a significant, potentially modifiable, contributor to access-related difficulties. In general, infections represent the second leading cause of death inESRD patients, behind only cardiovascular disease, and are a leading cause of hospi-talization.Between 2007 and 2008, HD patients experienced a rate of 0.47infection-related hospitalizations per patient-year, reflecting an almost 50% increasesince 1993.Similarly, albeit to a lesser degree, the rate of infection-related hospital-ization has increased by 7.5% in PD The rate of hospitalization specifically There was no outside support for this work.
The authors have nothing to disclose.
a Division of General Medicine, University of Michigan and Veterans Affairs Ann ArborHealthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USAb Division of Infectious Diseases, University of Michigan and Veterans Affairs Ann ArborHealthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, USAc Division of Nephrology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor,MI 48109, USAd Department of Internal Medicine, Divisions of Infectious Diseases and Geriatric Medicine,University of Michigan and Ann Arbor Veterans Affairs Ann Arbor Healthcare System, GeriatricResearch Education and Clinical Center, 2215 Fuller Road, 111-I, 8th Floor, Ann Arbor, MI 48105,USA* Corresponding author. VA Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105.
E-mail address: 0891-5520/12/$ – see front matter Published by Elsevier Inc.
for vascular access–related infections has improved but remains at 0.11 per patient-year.There clearly remains much room for improvement.
In this review the authors consider the important infectious complications associ- ated with dialysis access. The discussion includes the epidemiology, microbiology,management, and outcomes related to dialysis-access infections.
More than 90% of prevalent maintenance dialysis patients in the United States (morethan 350,000 patients) undergo HD therapy, with the vast majority receiving in-centerdialysis thrice weekly.Infectious complications contribute significantly to themorbidity and mortality of these patients.
Patients with chronic kidney disease (CKD) are at higher risk of bacteremia than those without CKD, and patients requiring hemodialysis are at even higher risk ofsystemic Uremia-associated phagocyte dysfunction, iron overload, andcomorbidities including diabetes mellitus, can affect host immunity. Additional riskfactors for bacteremia in HD patients include a previous history of bacteremia, receiptof immunosuppressive therapy, anemia, and hepatitis C However, one ofthe most significant risk factors for infection is the type of HD access used, which isa potentially modifiable risk factor.
provides an overview of the different vascular access options available for HD patients. The risk of access-related infection is highest for nontunneled catheters,followed by tunneled catheters and then arteriovenous grafts (AVGs), while arteriove-nous fistulas (AVFs) have the lowest overall risk of infection.A large, multicenter,prospective study found the rate of bloodstream infection with AVFs was 0.2 per 1000dialysis procedures, and the relative risk of infection was 2.5 with AVGs, 15.5 withtunneled catheters, and 22.5 with nontunneled The primary preferred access is an AVF, due to its low risk of infection and high long- term patency rates. However, AVFs typically require 2 to 3 months to mature aftersurgical creation, and primary failure rates are high. As a result, less than 20% ofnew ESRD patients initiate maintenance dialysis with AVFs.To address this, in2004 the Centers for Medicare and Medicaid Services introduced the national “FistulaFirst Initiative,” and during the past several years the use of AVFs in the overall HDpopulation has improved from 32.2% in 2003 to 55.8% in 2010.
After an AVF, the next best option is generally considered to be an AVG, in which an artery is connected to a vein using exogenous material, most commonly polytetra-fluoroethylene. The advantages of an AVG over an AVF include less maturation time(typically 3–4 weeks after placement or even immediate use with newer graft materials)and lower primary failure rates. However, an AVG involves implantation of a foreignbody and therefore has a higher infection risk. There is also a higher risk of access-related thrombosis and lower average access life span compared with an AVF. Thisaccess type is generally considered when an AVF is not feasible because of poorendogenous veins. In some cases, graft material is also placed as a patch to salvagea nonmaturing AVF.
Hemodialysis catheters are associated with the highest incidence of complications, particularly infection, and are therefore considered the least favorable option for HDaccess.More than 80% of incident ESRD patients in the United States starthemodialysis with catheter access, in stark contrast to rates in other industrializednations (23% in Germany and 29% in Japan).
During the first 6 months of dialysis patients with catheters have higher hospitaliza- tion rates, especially for infection-related complications, and the relative risk of sepsis Table 1Vascular access options for hemodialysis patients Abbreviations: ESRD, end-stage renal disease; HD, hemodialysis.
a Relative infectious risk: 1 5 lowest, 4 5 highest.
is Mortality is also higher, and this difference is especially pronounced inolder While the issue of catheter-related infection affects all patients withcentral venous catheters (CVCs), it is of particular importance to patients receivingHD. This aspect was highlighted in a recent report by the Centers for Disease Controland Prevention (CDC) showing that, whereas catheter-related bloodstream infections(CRBSI) in intensive care units have decreased over the past decade, CRBSI rates indialysis units remain There are two main types of HD catheter: tunneled and nontunneled. Nontunneled catheters are the easiest access to place for immediate dialysis needs and thereforerepresent the most common access type used in patients with acute kidney injuryrequiring hemodialysis therapy. These catheters also have the highest infection rate,due to the direct connection between the bloodstream and skin surface. Tunneledcatheters are associated with a lower risk of infection because of the creation ofa subcutaneous tract (typically at least 10 cm) between the vascular insertion siteand the cutaneous exit site. If temporary dialysis access is needed but the catheteris expected to stay in place for more than 2 to 3 weeks, a tunneled catheter is prefer-able to a nontunneled catheter.
The site of an HD catheter may also play a role in the relative risk of infection.
Femoral catheters are generally believed to be associated with a higher risk of infec-tion, followed by internal jugular and then subclavian catheters.However, onelarge, randomized, multicenter study found that jugular catheters did not reduce therisk of infection compared with femoral catheters, except among adults with a highbody mass index (>28.4 kg/m2).
Exit-site infections (ESIs) are characterized by erythema, tenderness, induration, orpurulence at the CVC exit site, while tunnel infections (TIs) are characterized by signsof infection extending greater than 2 cm from the exit site.ESIs and TIs may occurconcurrently with CRBSIs, especially with Staphylococcus aureus According to the Infectious Disease Society of America (IDSA) guidelines, diagnosis of CRBSI requires either growth of the same organism from a percutaneous bloodculture and from a catheter tip culture, or that two blood samples (one sample froma catheter and the other from a peripheral vein) meet quantitative or differential timeto positivity (DTP) Quantitative blood cultures are defined by blood drawnthrough the catheter demonstrating a bacterial colony count 3 times greater thanblood drawn peripherally, while DTP requires that bacterial growth from catheter-drawn blood occurs 2 hours before blood drawn from a peripheral For bothof these criteria it is important to ensure that the same volume of blood has beeninserted into each culture bottle. Blood cultures should be drawn before initiatingtreatment because receipt of antimicrobials can decrease the sensitivity.
These testing paradigms may be difficult to adhere to for practical reasons. HD catheters are often not immediately removed when infection is suspected, patientsmay have limited peripheral vascular access for blood draws, and quantitative orDTP criteria can be problematic for a variety of other logistic reasons. Therefore,CRBSI in hemodialysis patients is often presumed without these strict standards beingmet. When a symptomatic patient with an indwelling HD catheter has positivecatheter-drawn and/or peripheral blood culture, with no other identifiable source ofinfection, CRBSI may be presumed.If blood cannot be drawn peripherally, samplesmay be drawn through multiple catheter lumens. Positive blood cultures and evidenceof exit-site or tunnel infection can also indicate CRBSI, and drainage at the exit siteshould be cultured if present.
AVG or AVF infections can present with erythema, pain, and warmth at the access site, though this is not always the case. Imaging may be helpful for patients withbacteremia and arteriovenous access. Some experts advocate the use of indiumscans to diagnose occult arteriovenous access infections when there is high clinicalsuspicion,although the sensitivity and specificity of this approach is not wellestablished.
It may be difficult to tell whether a single positive blood culture represents true infec- tion rather than contamination. In general, certain virulent organisms (ie, S aureus)should never be treated as contaminants, whereas less virulent organisms (ie,coagulase-negative Staphylococcus) may be considered contaminants if the patientis asymptomatic and repeat blood cultures remain negative.
Although gram-negative and fungal CRBSIs do occur, gram-positive cocci make upthe vast majority of HD-related infections. Most cases are attributable to S aureusand coagulase-negative Staphylococcus (CoNS), but enterococcal infections alsooccur.The microbiology appears to vary by access type. Nontunneled cath-eter–associated CRBSIs are caused most often by CoNS, followed by S aureus,Candida species, enteric gram-negative bacilli (GNB), Pseudomonas, and entero-Tunneled catheter CRBSI are caused most often by CoNS, followed byenteric GNB, S aureus, Pseudomonas, enterococci, and Candida.Whereas CoNSis responsible for most CVC infections, S aureus is more common with AVF andAVG S aureus is more often associated with treatment failure and infec-tious complications of CRBSI.
Infections with antimicrobial resistant organisms are a growing concern among dial- ysis patients. In 2005, the incidence of invasive methicillin-resistant S aureus (MRSA)infection among dialysis patients was 45.2 cases per 1000 population, compared withrates in the general population that have ranged from 0.2 to 0.4 infections per 1000Infections with vancomycin-resistant enterococci (VRE) also remaina challenge. VRE bloodstream infections are associated with hemodialysis, andamong dialysis-dependent patients risk factors for VRE colonization include previousantimicrobial use, specifically b-lactams, and extended durations of hospitaliza-tion.Furthermore, vancomycin-intermediate S aureus (VISA) infections havebeen reported among hemodialysis patients; often after extended exposure to vanco-mycin for MRSA infections.Vancomycin-resistant S aureus (VRSA) strains are anemerging issue in parts of the United States, and may become a bigger concernamong HD patients in the Azole-resistant Candida species are associatedwith many HD-related infections, and non-albicans Candida species (particularly Cglabrata and C krusei), are responsible for more episodes of fungemia among HDpatients than in non-HD patients (31% vs 17%).
Hematogenous complications of CRBSI include endocarditis, osteomyelitis, epidural abscess, and septic arthritis.Hemodialysis dependence is a risk factorfor complications of CRBSI, as is the presence of a long-term intravascular catheterand attempt at catheter salvage.MRSA has a particular propensity to causehematogenous complications.In patients with prolonged bacteremia or funge-mia, particularly after hemodialysis catheter removal, other foci of infection should besuspected.
The general approach toward a patient with fever and an indwelling HD catheter is tofirst obtain blood cultures, then consider initiating antimicrobial therapy and removing the catheter, depending on the clinical scenario. This approach is often complicatedby limited vascular access sites and the ongoing need for HD.
The approach to empiric antimicrobial choice among dialysis patients is beyond the scope of this article; however, a few key points are summarized here. Vancomycin isthe preferred empiric therapy for CRBSI in heath care settings with an elevated prev-alence of MRSA, whereas daptomycin is preferred in settings where vancomycinminimum inhibitory concentration values greater than 2 mg/mL are common. Empiriccoverage for GNB therapy should be used in critically ill patients and patients withfemoral lines, and coverage for multidrug-resistant (MDR) GNB should be consideredin immunocompromised patients, critically ill or septic patents, or patients witha history of MDR GNB infections or colonization. Coverage for Candida species shouldbe considered in critically ill patients with a femoral line and in immunosuppressedpatients, with use of total parenteral nutrition (TPN) or prolonged use of broad-spectrum antibiotics, or colonization with Candida species at multiple Optimal dosing of antimicrobials can be problematic in dialysis patients. For example, vancomycin dosing can be affected by the type of dialysis filter used, dura-tion of and intervals between dialysis sessions, body weight, and residual renal func-tion; and while low levels can be associated with treatment failures and the emergenceof drug resistance, high levels have been associated with increased risk of nephrotox-icity and ototoxicity.Duration of antimicrobial therapy depends on the clinicalscenario and presence of other foci of infection.
In most situations, the ideal approach to catheter-related infections includes antimi- crobial therapy along with prompt removal of the catheter followed by a line-freeinterval before catheter replacement in a different site. Unfortunately, such anapproach is complicated by a variety of issues unique to HD patients. First, the possi-bility of a line-free interval is limited by dialysis needs. In addition, HD catheters areoften seen as a patient’s life-line, and the risk of losing vascular access altogethercan result in hesitance toward early catheter removal. Some HD patients haveextremely limited access options, and failure to establish new access representsa terminal complication. As such, a frequent approach is to try to salvage the dialysisaccess.
Although it is generally accepted that catheter salvage is not advisable for S aureus or Candida infections, salvage may be successful in certain situations. In uncompli-cated CRBSI involving organisms that are relatively easy to eradicate, such asCoNS, treatment may be attempted without catheter removal. A recent retrospectivestudy concluded that catheter salvage may be possible in CRBSI caused by CoNS,even with concurrent ESI.However, IDSA guidelines recommend removing long-term catheters in the setting of sepsis, tunnel infection, or hematogenous spread ofOther indications for removal of tunneled HD catheters include failure toclear blood cultures after 72 hours of therapy, or for infections due to S aureus, Pseu-domonas aeruginosa, fungi, mycobacteria, or other bacteria difficult to eradicate(Bacillus, Micrococcus, or Propionibacteria).Most studies have shown that cathetersalvage has a 25% to 33% chance of An observational study of 226patients with tunneled-catheter infections found that HD catheter salvage resultedin an overall fourfold higher risk of treatment failure, and an eightfold higher risk oftreatment failure in patients with S aureus Another prospective study evaluated attempted salvage of infected tunneled dial- ysis catheters in 154 patients with clinical response to antimicrobials within 48 Two-thirds of cases demonstrated no recurrence or complications during the 6-monthfollow-up period, although salvage was only attempted in 74% of cases and treatmentdurations were long (6 weeks). No differences in outcome were observed based on the organism isolated; however, no cases of candidemia were included in the catheter-salvage group. Infection recurrence tended to occur in the second month followingattempted catheter salvage, and success decreased with each subsequent attemptat catheter salvage. Clinicians must be aware that although catheter salvage is appro-priate in some cases, such an approach frequently results in worse outcomes.
In certain situations, catheter exchange over a guide wire may be the only feasible way to replace a dialysis catheter without risk of losing vascular access entirely.
Although CDC guidelines do not recommend guide-wire exchanges for catheter-related some data suggest that guide-wire exchange may reducesecondary vertebral or paraspinal infections compared with no andanother study suggested that outcomes do not differ when comparing tunneled-catheter exchange over a guide wire versus catheter removal and delayed replace-ment.A retrospective study of 40 HD patients with candidemia compared catheterexchange over a guide wire to catheter removal with delayed replacement and foundsimilar outcomes between the two groups, concluding that guide-wire exchange maybe an effective option for HD patients with candidemia.These data should be inter-preted with caution, as fungal CRBSIs are more likely to result in relapse of infection,even after tunneled-catheter removal and reinsertion.
Though rare, AVG infections can occur, and infection accounts for more than one- third of AVG losses or As with HD catheters, the decision to remove aninfected AVG is often not pursued aggressively, in favor of a more conservativeapproach comprising antimicrobial therapy and attempted salvage. In general, thedecision to pursue AVG removal must consider the urgency of the clinical picture,and balance the competing risks of a potentially worse infectious complication(such as sepsis or hematogenous complications) versus the loss of HD access andresultant commitment to catheter access for a minimum of 2 months. Graft removalis indicated with extensive infection if infection occurs before the graft has becomeembedded, or in septic Partial AVG excision with access salvage hasbeen found to be a reasonable option in patients with localized abscess or generallymore limited As already mentioned, the most significant approach to HD access infection preven-tion has been the major push to promote AVF use and limit HD catheter use. Despitethese efforts, a significant proportion of prevalent HD patients remain catheter depen-dent. In these patients, several preventive strategies have been used.
The use of topical antimicrobials at the CVC exit site has been suggested as a strategy to decrease infectious risk among HD patients. A 2010 Cochrane reviewconcluded that use of topical mupirocin ointment reduced the risk of CRBSI in patientson HD, while there was insufficient evidence to support the role of topical honey,povidone-iodine ointment, polysporin ointment, or various types of dressing to reducethe risk of catheter-related However, a recent study found that the use oftopical polyantibiotic ointment was associated a with decrease in CVC-related infec-tions,and the 2011 CDC guidelines for prevention of CRBSI recommend the routineuse of povidone-iodine antiseptic ointment or polyantibiotic ointment at the HD cath-eter exit site at the end of each dialysis although its use may be limited byinstances of contact dermatitis.
There is much literature regarding the use of antimicrobial-impregnated catheters in the intensive care unit, and CDC guidelines recommend the use of theseantimicrobial-coated CVCs in populations with high rates of catheter-related infec-tions.A prospective study using minocycline/rifampin-coated HD catheters showed decreased rates of infection in patients with acute kidney injuryhowever, this prac-tice has not been widely studied in the chronic dialysis population. Indeed, thisapproach may be impractical because of the higher costs associated with these cath-eters. The data on silver-coated dialysis catheters have been mixed. A prospective,randomized study looking at silver-coated tunneled dialysis catheters did not finda reduction in infection or but a second prospective study founddecreased bacterial colonization on the silver-coated catheter.
Antimicrobial locks are another strategy to reduce the risk of recurrent infection among catheter-dependent patients, including those receiving HD. The most recentguidelines recommend considering using lock therapy among patients who developrecurrent infections despite optimal adherence to aseptic The techniqueinvolves filling the catheter lumen with a lock solution and allowing it to dwell when thecatheter is not in use. Lock solutions include antibiotics (most often vancomycin or anaminoglycoside) as well as other agents (ie, ethanol and recombinant tissue plasmin-ogen activator). Gentamicin/heparin and taurolidine/citrate catheter locks have beenshown to reduce rates of CRBSI when compared with heparin alone; however, genta-micin can be associated with ototoxicity, and taurolidine is not available in the UnitedRecently, a novel lock solution containing sodium citrate, methylene blue,methylparaben, and propylparaben (C-MB-P) has shown promise among HDpatients.A multicenter, randomized trial demonstrated that catheters locked withC-MB-P were significantly less likely to be associated with CRBSI. The cost-effectiveness of antimicrobial locks has not been fully evaluated, and this approachcarries the risk of increasing antimicrobial resistance. Further studies are needed toconfirm these results and to determine whether this approach should be applied ona larger scale.
Among incident ESRD patients, only 6% choose peritoneal dialysis as their initialIn contrast to HD, the only access option for PD is a tunneled PD catheter.
Patients undergoing PD are at risk of PD catheter–related peritonitis, ESIs, or TIs.
During the past 2 decades the rate of PD-associated infections has improved dramat-ically, but peritonitis remains the most common cause of PD failure, leading to transferto While sharing the same underlying risk characteristics as HD patients, PD patients face different challenges specific to their chosen dialysis modality. Although PDpatients do not have indwelling vascular access, the near constant dwell ofa dextrose-rich solution in the peritoneal space provides a high-risk environment forinfection. PD catheters are accessed multiple times daily, in contrast to the thriceweekly use of HD catheters. Lastly, PD patients must rely on themselves (or their care-givers) to maintain sterile technique and avoid contamination, whereas HD patientsare managed by trained technicians and nurses. Nevertheless, with appropriatetraining and motivation, PD can be performed with great success and relatively fewinfectious complications.
Older patients, females, and smokers appear to be at higher risk of PD-associated peritonitis.The choice of PD fluid may affect the risk of infection, and solutions withlow concentrations of glucose degradation products may be associated withdecreased infection rates, although data are inconclusive.The location of abdomi-nally placed peritoneal catheters may contribute to infectious risk, and presternalplacement of peritoneal catheters may have a lower risk of infection.Certain dialy-sate bag systems (Y-set bag systems versus double-bag systems) may also be associated with higher risk of peritonitis.Recently published data suggest that auto-mated PD, defined as use of a machine to do exchanges, typically overnight, is asso-ciated with a lower risk of infection than is continuous ambulatory PD, although it isunclear whether this is related to the connection system used or the number of timesthe catheter is accessed.
PD-associated ESIs are characterized by purulent drainage and erythema surroundingthe catheter. PD-associated TIs are characterized by erythema, edema, or tendernessover the catheter tunnel, and usually occur in conjunction with an ESI, especially withS aureus and P aeruginosa. Cultures from the PD catheter exit site should only be ob-tained when there is clinical suspicion of infection, as a positive culture alone maysimply represent colonization.
Patients on PD with cloudy effluent and/or abdominal pain should be evaluated for peritonitis. According to the International Society for Peritoneal Dialysis guidelines,PD-associated peritonitis (PDP) is defined as any 2 of the following: (1) signs andsymptoms consistent with PDP; (2) white blood cell count greater than 100/mL inPD effluent and greater than 50% neutrophils after a dwell time of at least 2 hours;and (3) a positive culture of an organism from the PD effluent.While Gram stainand culture should be performed to help guide therapy, cultures are often nega-tive.Leukocyte esterase strips have shown promise for the detection of PDP,with sensitivity approaching 100% and specificity greater than 95%.
PD-associated infections are most commonly caused by CoNS, which accounts forapproximately 30% of cases, followed by nonpseudomonal Gram negatives andS aureus; while 10% to 30% of cases are culture negative.Patients withculture-negative PDP are more likely to have had recent antimicrobial exposure.Fungal peritonitis occurs in fewer than 5% of cases of PDP; it is typically caused byCandida species and is commonly preceded by antimicrobial use.Poor outcomeand PDP-related morbidity is typically associated with gram-negative stain, and fungalPseudomonal peritonitis, in particular, is associated with higherfrequency of ESI and TI, higher hospitalization rates, increased catheter loss, andlower rates of Resistant gram-positive organisms, including VISA, have been associated with PDP-related peritonitis, notably in patients who have had long courses of antimicro-bials. In fact, one of the first documented cases of VISA infection was in a PD-dependent patient who had previously been treated with 18 weeks of vancomycinfor recurrent MRSA After obtaining fluid for cell count, Gram stain, and culture, antimicrobials should bestarted as soon as possible for suspected cases of PDP. Empiric therapy for PD cath-eter–associated ESIs or TIs should include coverage for S aureus, and local resistancepatterns may indicate a need for MRSA coverage. Gram-negative organisms,including Pseudomonas, may also cause PDP, and therapy should be tailoreddepending on culture results. Intraperitoneal antimicrobials are typically preferredfor PDP and hold the major advantage of not requiring additional intravenous accessas compared with parenteral administration. Vancomycin, cephalosporins, and ami-noglycosides all have demonstrated stability and bioactivity in PD solution. However,certain agents cannot be mixed in the same bag, and care should be taken to ensure compatibility of intraperitoneal antimicrobials infused together. In addition, to ensureappropriate absorption of the drug, intraperitoneal dwell time should be at least 6hours. Specifics on antimicrobial choice and dosing are beyond the scope of thisreview but are discussed elsewhere.
Catheters can usually be salvaged for culture-negative or CoNS PDP, but catheter removal is typically required in cases of refractory or relapsing peritonitis; Pseudo-monas, S aureus, or fungal peritonitis; and peritonitis with TI or ESI.When cath-eter removal is indicated, simultaneous insertion of a new PD catheter is oftensuccessful, although some data suggest that this approach is less successful duringactive infection, and for Pseudomonas or fungal peritonitis.
Complicated PDP is associated with concurrent ESI, elevated effluent white cell count after 3 to 5 days of treatment, and low serum protein Ultrasonographymay be used to predict treatment failure, and a lucency of greater than 1 mm aroundthe external cuff, following antimicrobial treatment, has been associated with poorclinical outcome.Other factors associated with treatment failure include diabetesmellitus and Pseudomonal, fungal, or mycobacterial peritonitis.
Isolation of multiple enteric organisms may indicate underlying intra-abdominal pathology including diverticulitis, cholecystitis, ischemic bowel, and appendicitis,and are associated with an increased risk of death.Prompt surgical evaluationshould be considered in these situations.
Topical mupirocin application has been used to prevent PDP and ESI, with some Although data from animal models have been promising, data on theuse of antimicrobial-coated PD catheters in humans are mixed. A randomized,prospective study evaluating silver-coated PD catheters did not show any reductionin PDP or ESI rates.There have been some data to support use of prophylactic flu-conazole in patients with bacterial PDP to prevent subsequent fungal peritonitis,although this practice is not Despite overall progress, access-associated infections remain a major source ofmorbidity and mortality among dialysis patients. In HD patients the risk may be modifi-able with appropriate access planning, but in PD patients the risk factors for infectionare less well understood. In both groups, gram-positive cocci account for the majorityof infections, although gram-negative infections are not uncommon and resistantorganisms represent a growing concern. In addition, practitioners should be awareof the unique issues surrounding dialysis access, namely that access representsa life-line for ESRD patients. A decision for early access removal must recognize thepotential risks of losing dialysis access; conversely, a decision to treat through andsalvage an access must be carefully weighed against the risk of greater infectiouscomplications. Such therapeutic decision making must be individualized to eachpatient’s specific situation.
The authors thank Jonathan H. Segal, MD for his thoughtful review of this work.
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