1. Preven&on
of
catheter
related
infec&ons
in
hemodialysis
Maurizio
Gallieni

2. Disclosure
Director, Nephrology and Dialysis Unit
San Carlo Borromeo Hospital, Milano, Italy
President Elect, the Vascular Access Society
Coordinating Editor – the Journal of Vascular Access
Consultant, NICAST (dialysis grafts), Israel

3. the
Vascular
Access
Society
http://www.vas2013.org/
http://www.vascularaccesssociety.com/

4. Background
• Central
venous
catheters
(CVCs)
are
increasingly
used
as
vascular
access
for
hemodialysis,
but
infec=ous
complica=ons
remain
a
major
clinical
problem.
• Catheter-­‐related
bloodstream
infec=ons
affect
survival,
hospitaliza=on,
mortality,
and
the
overall
cost
of
care,
poin=ng
out
the
importance
of
preven=on.

5. Ideal
Dialysis
Catheter
• Easy
to
insert
and
remove
• Inexpensive
• Free
of
infec&on
• Free
of
fibrin
sheath
(“invisible
to
body”)
• Does
not
cause
venous
thrombosis
or
stenosis
• Delivers
high
flow
(>400
ml/min)
reliably
• Durable
• Does
not
presently
exist
Scott Trerotola - Radiology 2000; 215:651-658

6. Mechanisms
of
infec&on

7. Risk of CVC-related infection in
hemodialysis
Mayo
Clinics
Proceedings
September
2006

8. Risk of CVC-related infection in
hemodialysis (16 studies)
HD CVC non tunneled 4.8/1000 catheter days
HD CVC tunneled 1.6/1000 catheter days

9. Risk of CVC-related infection in
hemodialysis
Beathard GA, Urbanes A. Infection associated with tunneled
hemodialysis catheters. Semin Dial. 2008;21(6):528-38.

10. Guidelines - 1

11. Guidelines - 2
Vanholder et al. NDT Plus 2010; 3: 234–246

12. Review - 3
2011; 7: 257–265

13. Temporary vs tunnelled catheters
• If
temporary
access
is
needed
for
dialysis,
a
tunneled
cuffed
catheter
is
preferable
to
a
non-­‐cuffed
catheter,
even
in
the
ICU
seRng,
if
the
catheter
is
expected
to
stay
in
place
for
>
3
weeks

14. Tunneled CVCs reduce EXTRALUMINAL, not
INTRALUMINAL route infections

15. Preven&on
of
catheter
related
infec&ons
in
hemodialysis
• Preven&ve
approaches
– Universal
precau&ons
– Sutureless
aGachment
devices
– Topical
ointments
and
dressings
– Locking
solu&ons
– Needle
free
connectors
– Coated
catheters

16. Hand
washing

17. FaUori
di
rischio
• Inesperienza
dell’operatore
• Colonizzazione
baUerica
del
sito
di
inserzione
• Colonizzazione
baUerica
del
catetere
• Frequen=
manipolazioni
del
catetere
• Rapporto
infermiere-­‐paziente
• Tipo
di
catetere
• U=lizzo
della
nutrizione
parenterale
• CaraUeris=che
del
paziente
• Contaminazione
del
materiale
• Scarsa
cura
del
catetere
come
mancata
compliace
alle
linee
guida
(Queensland
Goverment)

18. Pa&ent’s
skin
cleansing
Use a 2% chlorhexidine wash for daily skin
cleansing to reduce CRBSI. Category II
Bleasdale SC, et al. Effectiveness of chlorhexidine bathing to reduce catheter-
associated bloodstream infections in medical intensive care unit patients.
Arch Intern Med 2007; 167:2073–9.
No published data have addressed this same question in studies
with hemodialysis patients

19. Vanholder et al. NDT Plus 2010; 3: 234–246

20. Preven&on
of
catheter
related
infec&ons
in
hemodialysis
• Preven&ve
approaches
– Universal
precau&ons
– Sutureless
aGachment
devices
– Topical
ointments
and
dressings
– Locking
solu&ons
– Needle
free
connectors
– Coated
catheters

21. Sutureless attachment devices
Catheter Securement Devices
Use a sutureless securement device to reduce the risk of
infection for intravascular catheters *. Category II
* Yamamoto AJ, Solomon JA, Soulen MC, et al. Sutureless securement
device reduces complications of peripherally inserted central venous
catheters. J Vasc Interv Radiol 2002; 13:77–81.

22. Sutureless attachment devices
Teichgräber et al. JVA 2011;12:17-20

23. Sutureless attachment devices
Teichgräber et al. JVA 2011;12:17-20

24. Sutureless attachment devices
72 dialysis patients with cuffed tunneled CVC.
Study group (n=36): CVC secured with a sutureless
StatLock attachment device.
Control group (n=36): CVC secured with sutures.
Mean use of the tunneled CVC: 42 ± 7 days (until use
of the AV fistula).
Results:
No infections in both groups
Four local irritations at the CVC entry site were seen
only in the control group
Teichgräber et al. JVA 2011;12:17-20

25. Preven&on
of
catheter
related
infec&ons
in
hemodialysis
• Preven&ve
approaches
– Universal
precau&ons
– Sutureless
aGachment
devices
– Topical
ointments
and
dressings
– Locking
solu&ons
– Needle
free
connectors
– Coated
catheters

26. Topical ointments
• Do
not
use
topical
an=bio=c
ointment
or
creams
on
inser=on
sites,
except
for
dialysis
catheters,
because
of
their
poten=al
to
promote
fungal
infec=ons
and
an=microbial
resistance.
Category
IB

27. Topical ointments
• Use
povidone
iodine
an=sep=c
ointment
or
bacitracin/gramicidin/
polymyxin
B
ointment
at
the
hemodialysis
catheter
exit
site
a]er
catheter
inser=on
and
at
the
end
of
each
dialysis
session
only
if
this
ointment
does
not
interact
with
the
material
of
the
hemodialysis
catheter
per
manufacturer’s
recommenda=on.
Category
IB

28. Posi&on
statement
of
European
Renal
Best
Prac&ce
(ERBP)
Use of antibiotic ointments at the exit site
Vanholder et al. NDT Plus 2010; 3: 234–246

29. Topical ointments and dressings
• Chlorhexidine-­‐impregnated
dressings
and
sponges
are
available,
but
the
evidence
of
their
efficacy
in
preven=ng
infec=on
(as
compared
to
appropriate
skin
cleansing
with
2%
chlorhexidine
in
alcohol
solu=ons)
is
not
convincing.
An
RCT
in
pa=ents
on
hemodialysis
with
CVCs
did
not
show
that
these
dressings
(BIOPATCH)
conferred
any
addi=onal
benefit.
Camins, BC et al. A crossover intervention trial evaluating the efficacy of a
chlorhexidine-impregnated sponge in reducing catheter-related bloodstream
infections among patients undergoing hemodialysis. Infect. Control Hosp.
Epidemiol. 2010; 31: 1118–1123.
Betjes Nat Rev Nephrol 2011; 7: 257–265

30. INTERVENTION CONTROL

31. Topical ointments and dressings
Camins, BC et al. A crossover intervention trial evaluating the efficacy of a
chlorhexidine-impregnated sponge in reducing catheter-related bloodstream
infections among patients undergoing hemodialysis. Infect. Control Hosp.
Epidemiol. 2010; 31: 1118–1123.

32. Preven&on
of
catheter
related
infec&ons
in
hemodialysis
• Preven&ve
approaches
– Universal
precau&ons
– Sutureless
aGachment
devices
– Topical
ointments
and
dressings
– Locking
solu&ons
– Needle
free
connectors
– Coated
catheters

33. Antimicrobial lock
• Use
prophylac=c
an=microbial
lock
solu=on
in
pa=ents
with
long
term
catheters
who
have
a
history
of
mul=ple
CRBSI
despite
op=mal
maximal
adherence
to
asep=c
technique.
Category
II

34. Antimicrobial lock
Antimicrobial lock solutions
substantially reduce the risk of
CRBSI (relative risk 0.23).
Labriola
L
et
al.
Preven=ng
haemodialysis
catheter
related
bacteraemia
with
an
an=microbial
lock
solu=on:
a
meta-­‐analysis
of
prospec=ve
randomized
trials.
Nephrol
Dial
Transplant
2008;
23:1666–1672
Rabindranath, K. S. et al. Systematic review of antimicrobials for the
prevention of haemodialysis catheter-related infections. Nephrol. Dial.
Transplant 2009; 24: 3763–3774
Jaffer Y et al. A meta-analysis of hemodialysis catheter locking solutions in the
prevention of catheter-related infection. Am J Kidney Dis 2008; 51:233-241

35. Allon M. AJKD 2008; 51: 165-9

36. European
Renal
Best
Prac&ce
(ERBP)
Vanholder et al. NDT Plus 2010; 3: 234–246

37. Preven&on
of
catheter
related
infec&ons
in
hemodialysis
• Preven&ve
approaches
– Universal
precau&ons
– Sutureless
aGachment
devices
– Topical
ointments
and
dressings
– Locking
solu&ons
– Needle
free
connectors
– Coated
catheters

38. Needle
free
connectors
A
needle
free
connector
creates
a
mechanically
and
microbiologically
closed
system
when
aUached
to
the
hub
of
a
catheter,
elimina=ng
open
catheter
hubs
and
lowering
the
chance
of
contamina=on
and
infec=on

39. Needle
free
connectors
One FDA approved device
• No clear evidence of a benefit (possible benefit: in
patients with mulfunctioning catheters, needing line
inversions?)
• No recommendations in guidelines

40. Preven&on
of
catheter
related
infec&ons
in
hemodialysis
• Preven&ve
approaches
– Universal
precau&ons
– Sutureless
aGachment
devices
– Topical
ointments
and
dressings
– Locking
solu&ons
– Needle
free
connectors
– Coated
catheters

41. Prevention of tunnell infections

42. Silvergard
Trial
–
the
only
available
RCT
in
dialysis
• RCT,
adequate
number
of
pa=ents
(n=100)
• Two
groups
with
same
CVC
(one
silver
coated)
• All
CVC
in
the
right
internal
jugular
vein
• Follow-­‐up
with
venography
(evalua=on
of
thrombosis
and
infec=on)
• Colture
of
CVC
=p
upon
removal
Trerotola et al, Radiology 1998;207:491-496

43. Silvergard
trial
-­‐
Results
• No
significant
difference
in
the
number
of
infec&ons
– (indeed,
infec=on/coloniza=on
more
common
in
the
silver
coated
group,
p=NS)
• 4%
vein
thrombosis
/
stenosis
• 2
pa=ents
with
permanent
skin
lesions
in
the
silver
coated
group
Trerotola et al, Radiology 1998;207:491-496

44. Heparin
Coa&ng
and
Silver
Ion
An&microbial
Sleeve
«The xxx Heparin Coated and Silver Ion
Antimicrobial Dialysis Catheter is the first
chronic catheter to provide dual protection
against clotting and microbial
colonization»

45. Heparin
Coa&ng
and
Silver
Ion
An&microbial
Sleeve
The antimicrobial silver ions in the sleeve work to
reduce the colonization of clinically relevant
microbes on the external surface of the catheter
in the subcutaneous tunnel tract.
The unique silver-polymer system delivers a
controlled release of silver ions, which have been
tested against a broad spectrum of recent clinical
isolates and is specifically designed for the
dialysis catheter environment.

46. From
the
manufacturer
web-­‐site:
Is
there
a
clinical
study
to
show
efficacy
of
the
xxx
–
Heparin
Coated
and
Silver
Ion
An&microbial
Dialysis
Catheter?
The silver ion sleeve was tested against recent
clinical isolates including S. Aureus, coagulase-
negative Staphylococcus, C. Albicans and E. Coli.
In vitro testing demonstrated a statistically significant
reduction of microbial colonization by 99.2%–
99.999%.
In vivo testing resulted in a statistically significant
reduction of microbial colonization by 99.7%–
99.999% in Staphylococcus aureus.

47. Poten&al
problems
of
coated
CVCs
– Coa=ng
has
been
used
mainly
in
short-­‐term
catheters
– Coa=ng
usaully
limited
to
the
external
surface
(beUer
protec=on
from
skin
bacteria,
not
from
intraluminal
contamina=on)
– Higher
cost:
cost-­‐effec=veness
should
be
demonstrated
– Possibility
of
allergies
or
induc=on
of
an=bio=c
resistance
• Anaphylaxis
to
chlorhexidine-­‐impregnated
central
venous
catheter.
(Kluger,
Anaesth
Intensive
Care
2003)
– Transient
an=microbic
effect
(days
to
week?)
– No
RCT
avalable,
besides
Silvergard
trial.

48. Conclusions
• Various
interven=ons
aimed
at
reducing
the
incidence
of
CRBSI
are
available.
Preven=on
of
intraluminal
contamina=on
of
the
CVC
is
pivotal
and
of
proven
efficacy,
as
are
strict
asep=c
CVC
inser=on
and
handling
protocols,
use
of
chlorhexidine
in
alcohol
solu=ons
for
skin
cleansing,
topical
applica=on
of
an=microbial
ointments,
and
an=microbial
lock
solu=ons.

49. Conclusions
• .

50. WoCoVA
abstracts
in
the
Journal
of
Vascular
Access

51. the
Journal
of
Vascular
Access
Volunteers to participate as
reviewers and subsequently
as Editorial Board members
are welcome
Home page:
http://www.vascular-access.info/
Article submission:
http://www.editorialmanager.com/jva/