The following "3 Key Facts Regarding Catheter-Related Bacteremia" are taken from Eliot Heher's "MGH Nephrology Handbook" distributed to nephrology fellows every year which I find very helpful:Fact #1: Fever and chills are highly predictive of positive blood cultures in dialysis patients with tunneled cuffed catheters: In this article by Krishnasami et al, 76% of the time blood cultures end up being positive in this instance.
Implication: All dialysis patients presenting with fever and a tunneled dialysis catheter should receive empiric antibiotic therapy while blood cultures are cooking in the lab.
Fact #2: A significant minority of catheter-related bacteremia episodes result from GNRs (30-40%), with the majority arising from Staph species which are often methicillin-resistant. Mixed bacterial and fungal infection are much less common.
Implication: Empiric antibiotic therapy must include coverage for both GPCs and GNRs (e.g., vancomycin 1gm iv x 1 & gentamicin 1mg/kg iv x 1 given towards the end of dialysis).
Fact #3: Systemic antibiotic therapy without additional catheter management fails to clear infection in about 70% of cases, according to this 1997 AIM article by Marr et al.
Implication: Some type of catheter management for catheter-related bacteremia should be attempted in addition to antibiotics. Options include (a) removing the catheter (the safest option in terms of preventing bacteremic complications such as endocarditis), (b), changing the catheter over a guidewire, (c) or attempting catheter preservation using the "antibiotic lock" technique.
My thinking was that "b) Changing over a guide wire" is not effective at all (critical care, TLC data).
ReplyDeleteI could not find definition of fever in the Krishnasami et al.
ReplyDeleteOften times they may have low grade fever (<100.2). I wonder if all were included or not.
loading dose of gentamicin in that article was 1.5 mg/kg f/b 1 mg/kg p HD
Nishant,
ReplyDeleteChanging over a guidewire is actually the preferred method, per K/DOQi as it sacrifices the line while preserving the site which is important for long-term survival of the dialysis patient.
I often battle with the ID docs about this treatment strategy because it is different than TLCs.
Fevers in ESRD patients are not typical fevers. Due to their more-or-less uremic state, the majority often have normal temperatures of 95-98 degrees farenheit. Standards seem to be such that an ESRD patient with a temperature 2 degrees above their normal average are said to have a fever.
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