Néphrologie 2001 - 8

Prevention of Intravascular Catheter Infections – Insights and Prospects for Hemodialysis Catheters L.A. Mermel
Division of Infectious Diseases, Rhode Island Hospital and Brown University School of Medicine, Providence, Rhode Island, USA Hemodialysis catheters have become an invaluable device in In a prospective, randomized trial, maximal barrier precau- management of patients with acute renal failure and they are tions during central venous catheter insertion (sterile gloves, being used with increased frequency in patients with chronic long-sleeved sterile gown, mask, cap, and large sterile sheet renal failure. One in five new hemodialysis patients in the United drape) significantly reduced the incidence of catheter-related States are dialyzed with tunneled, cuffed catheters and 13% are bloodstream infection compared with standard (sterile gloves dialyzed through the same catheter 60 days after starting dialy- and small drape) precautions (0.08 /1000 vs. 0.3 /1000 catheter sis.1 The increased use of these devices is not without risk of seri- days, respectively, p = 0.02).14 These results are supported by the ous infectious complications. For example, a recent meta-analysis findings of a prospective, observational study of pulmonary of prospective studies found 16.2% of non-cuffed hemodialysis artery catheters.3 Similar studies of hemodialysis catheters are catheters were associated with catheter-related bloodstream unavailable. However, based on this data, maximal barrier pre- cautions should be the standard of care during hemodialysis Strategies aimed at prevention of hemodialysis catheter- related bloodstream infections should be based on an under- There are no adequately powered, randomized studies of the standing of the pathogenesis of such infections. In general, impact of subcutaneous tunneling of hemodialysis catheters on intravascular catheters become infected by microbes migrating the risk of catheter-related infection. A review of studies carried down the length of the catheter from colonized catheter hubs or out to date15 found the incidence of hemodialysis catheter- from colonization of the skin at the skin-catheter interface.3 For related bloodstream infections to be 4/1000 catheter days in hemodialysis catheters, the catheter hub appears to be main patients with non-tunneled, non-cuffed catheters, 1.9/1000 reservoir from which microbes migrate into the bloodstream catheter days in patients with tunneled, non-cuffed catheters, causing serious infection. This is supported by at least one and 1.8/1000 catheter days in patients with tunneled, cuffed prospective study of hemodialysis catheter-related bloodstream catheters. Based on this data, it would appear that subcuta- infections in which 100% of the episodes had the same of neously tunneled hemodialysis catheters should be carried out in microbe isolated from the catheter hub whereas only 36% of an effort to reduce the risk of infection. Ideally, future prospec- the cases had the same microbe at the catheter insertion site.4 tive, randomized studies of tunneling and use of cuffed Prevention is ever more important when one realizes that catheters will lead to more definitive recommendations.
catheter salvage in patients with hemodialysis catheter-related Use of povidone-iodine ointment on the insertion site of bloodstream infections is often unsuccessful and associated with hemodialysis catheters has been shown to reduce the incidence of complications. For example, in one prospective study, the success catheter-related bloodstream infection from 4.6/1000 catheter rate in 38 episodes of attempted catheter salvage was 32%.5Notably, the risk of recurrent bacteremia was significantly days to 0.4/1000 catheter days (p < 0.01) in one prospective, ran- greater if catheter salvage was attempted (OR 4.1, CI 1.6-10.3). domized study.16 Of note, none of the nasal S. aureus carriers in the There are numerous evidence-based strategies that are effec- povidone-iodine group developed catheter-related bloodstream tive in prevention of intravascular catheter-related bloodstream infection, whereas 29% did in the control group (p < 0.05). The infections6 and guidelines specific to hemodialysis already exist.7 results of this study have been confirmed by other investigators.17 Cutaneous antisepsis of catheter insertion sites with chlorhexi- Based on the available literature, povidone-iodine ointment should dine-based preparations has been associated with a significant be applied to the insertion site of hemodialysis catheters.
reduction in catheter colonization in three of four randomized, Application of mupirocin ointment to temporary hemodialy- controlled trials.8-11 There were non-significant reductions in sis catheter insertion sites reduced catheter-related bloodstream catheter-related bloodstream infections in three of these studies.
infection in a prospective, randomized trial from 6.0/1000 Although none of these studies involved hemodialysis catheters, catheter days to 0.4/1000 catheter days (p < 0.01).18 However, this data suggests that chlorhexidine-based antiseptics, particu- mupirocin ointment may impair the integrity of polyurethane larly those that are alcohol-based, are the antiseptics of choice catheters.19-20 In addition, prolonged use of mupirocin ointment for preparing the insertion site of hemodialysis catheters. It at catheter insertion sites leads to the development of mupirocin should also be noted that tincture of iodine is a more effective resistance.21 Therefore, mupirocin ointment should not be cutaneous antiseptic than povidone-iodine,12,13 yet there are no applied to catheter insertion sites.
published studies of this antiseptic in preparing the skin for As noted above, S. aureus carriage increases the risk of hemodialysis catheter-related bloodstream infection threefold.16 session III
Néphrologie Vol. 22 n° 8 2001, pp. 449-451 Two prospective, open trials22,23 have demonstrated that Future strategies to prevent hemodialysis catheter-related intranasal application of mupirocin ointment used to eradicate infection will undoubtedly be based on a better understanding nasal S. aureus carriage (e.g. applied twice daily for five days) fol- of the pathogenesis of these infections. At the present time, the lowed by once weekly application significantly reduced the inci- following strategies should be undertaken : cutaneous antisepsis dence of S. aureus bacteremia compared to historical controls.
of catheter insertion sites with chlorhexidine-based prepara- The development of mupirocin resistance was not observed and tions ; maximal barrier precautions during catheter insertion ; has been rarely observed even after seven years of intranasal use subcutaneous tunneling of catheters ; application of povidone- in hemodialysis patients.24 These studies included all hemodialy- iodine ointment on the insertion site ; intranasal mupirocin oint- sis patients and were not specific for patients hemodialyzed ment for S. aureus carriers ; and institutional standards assuring through intravascular catheters. Nevertheless, this data strongly appropriate staffing by nurses and infection control education of suggests that intranasal carriers of S. aureus dialyzed through intravascular catheters will have a high risk of S. aureus bac-teremia and this protocol should be considered for this patientpopulation, in addition to monitoring for the development ofmupirocin resistance.
Adresse de correspondance :
As reviewed elsewhere,6 assuring adequate nurse to patient ratios and infection control education for nurses and physicians, including appropriate care of intravascular catheters, signifi- cantly reduces the risk of catheter-related infection. In one observational study specifically of patients dialyzed through intravascular catheters, a five-fold increase in septic episodes was noted when patients were cared for by nurses with less pro- fessional experience.25 In toto, these data suggest that adequate physician and nursing education, experience, and appropriatenumbers of nurses caring for patients dialyzed through intravas-cular catheters, should reduce the risk of hemodialysis catheter-related infections. In this regard, institutional standards shouldbe developed and reviewed periodically to assure that appropri-ate staffing and infection control education is maintained. Prospective, randomized studies of central venous catheters impregnated on the outer surface with chlorhexidine-silver sulfa-diazine in situ for an average of 11 days or less significantly 1. Anonymous. Excerpts from the USRDS 1997 Annual Report IV. The reduces the incidence of catheter-related bloodstream infections USRDS dialysis morbidity and mortality study. Wave 2. Am J Kidney Dis (RR 0.4, 95%CI 0.2-0.8).6 However, no such studies with hemodialysis catheters have been published. Central venous Kluger DM, Maki DG. A meta-analysis of the risk of intravascular device- catheters impregnated with minocycline and rifampin on the related bloodstream infection based on 223 published prospective stu- inner and outer surface reduced the risk of catheter-related dies [abstract]. In : Program and Abstracts of the 39th Interscience Confe- bloodstream infection compared to the above-noted chlorhexi- rence on Antimicrobial Agents and Chemotherapy ; 26-29 September1999 ; San Francisco, CA. Washington, DC : American Society for Micro- dine-silver sulfadiazine impregnated catheters in a prospective, randomized trial (RR 0.1, 95% CI 0-0.6).26 Yet, there are no pub- Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis lished studies using these catheters in hemodialysis. and epidemiology of catheter-related infection with pulmonary artery There are a number of hopeful technologies currently under Swan-Ganz catheters : A prospective study utilizing molecular subtyping.
study to reduce the risk of hemodialysis catheter-related infec- Am J Med 1991 ; 91 (Suppl. 3B) : S197-S205.
tion. Preliminary studies suggest that hemodialysis catheters Cheesbrough JS, Finch RG, Burden RP. A prospective study of the mecha- coated with silver may reduce the risk of such infections in the nisms of infection associated with hemodialysis catheters. J Infect Dis future.27 Taurolidine (bis-(1,1-dioxoperhydro-1,2,4-thiabiazinyl-4) methane) is a unique antimicrobial agent which is a derivative of Marr KA, Sexton DJ, Conlon PJ, Corey GR, Schwab SJ, Kirkland KB.
the aminosulfonic acid taurine. Taurolidine has broad-spectrum Catheter-related bacteremia and outcome of attempted salvage in activity against Gram-positive bacteria,28-30 Gram-negative bacte- patients undergoing hemodialysis. Ann Intern Med 1997 ; 127 : 275-80.
ria30 and Candida.31 In one observational study, the use of tauroli- Mermel LA. Prevention of intravascular catheter-related infections. Ann dine as an antimicrobial lock solution in patients hemodialyzed through intravascular catheters was associated with a low inci- Anonymous. NKF-DOQI clinical practice guidelines for vascular access.
dence of catheter-related bloodstream infections.32 In a prospec- National kidney foundation-dialysis outcomes quality initiative. Am J Kid- tive, clinical trial, hemodialysis catheters randomized to have the ney Dis 1997 ; 30 (Suppl. 3) : S150-S191.
lumen flushed with a solution containing minocycline and EDTA Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone- had a significantly reduced incidence of bacterial catheter colo- iodine, alcohol, and chlorhexidine for prevention of infection associatedwith central venous and arterial catheters. Lancet 1991 ; 338 : 339-43. nization compared with catheters flushed with standard heparinsolution (8% and 69%, respectively, p = 0.005).33 However, due Sheehan G, Leicht K, O'Brien M, Taylor G, Rennie. Chlorhexidine versuspovidone-iodine as cutaneous antisepsis for prevention of vascular-cathe- to the risk of the development of resistance, this strategy is less ter infection [abstract]. In : Program and Abstracts of the 33rd Inter- appealing since it would involve widespread use of therapeutic science Conference on Antimicrobial Agents and Chemotherapy ; 17-20 antibiotics for the prevention of hemodialysis catheter-related October 1993 ; New Orleans, Louisiana. Washington, DC : American session III 450
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14. Raad II, Hohn DC, Gilbreath J, Suleiman N, Hill LA, Bruso PA, et al. Preven- tion of central venous catheter-related infections by using maximal sterile 27. Bambauer R, Mestres P, Schiel R, Scheidewind JM, Goudjinou R, Latza R, Inniger R, Bambauer S, Sioshansi P. Surface treated large bore catheters barrier precautions during insertion. Infect Control Hosp Epidemiol 1994 ; with silver based coatings versus untreated catheters for extracorporeal detoxification methods. ASAIO J 1998 ; 44 : 303-8.
15. Oliver MJ, Schwab SJ. Infections related to hemodialysis and peritoneal 28. Mermel LA, Magill N, Zinner S. Taurolidine activity against vancomycin- dialysis. In : Waldvogel FA and Bisno AL eds. Infections Associated with intermediate susceptibility Staphylococcus aureus and methicillin-resis- Indwelling Medical Devices. 3rd ed. Washington, D.C. : ASM Press ; 2000 : tant Staphylococcus aureus [abstract]. In : Program and Abstracts of the 38 th Interscience Conference on Antimicrobial Agents and Chemothe- 16. Levin A, Mason AJ, Jindal KK, Fong IW, Goldstein MB. Prevention of rapy ; 24-27 September 1998 ; San Diego, CA. Washington, DC : Ameri- hemodialysis subclavian vein catheter infections by topical povidone- can Society for Microbiology, 1998 ; 281. iodine. Kidney Int 1991 ; 40 : 934-8.
29. Mermel LA, Magill N, Zinner S. Taurolidine activity against vancomycin- 17. Fong IW. Prevention of haemodialysis and peritoneal dialysis catheter resistant enterococci [abstract]. In : Program and Abstracts of the 38th related infection by topical povidone-iodine. Postgrad Med J 1993 ; 69 : Interscience Conference on Antimicrobial Agents and Chemotherapy ; 24-27 September 1998 ; San Diego, CA. Washington, DC : AmericanSociety for Microbiology, 1998 ; 281. 18. Sesso R, Barbosa D, Leme IL, Sader H, Canziani ME, Manfredi S, Draibe S, 30. Torres-Viera C, Thauvin-Eliopoulos C, Souli M, DeGirolami P, Farris MG, Pignatari AC. Staphylococcus aureus prophylaxis in hemodialysis patients Wennersten CB, Sofia RD, Eliopoulos GM. Activities of taurolidine in vitro using central venous catheter : Effect of mupirocin ointment. J Am Soc and in experimental enterococcal endocarditis. Antimicrob Agents Che- 19. Rao SP, Oreopoulos DG. Unusual complications of a polyurethane PD 31. Johnston DA, Phillips G, Perry M, McAlpine H, Richards J, Pennington CR.
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