Marina Almenara Tejederas
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Wenceslao Aguilera Morales
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María Ángeles Rodríguez-Perez
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Salia Virxinia Pol Heres
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Mercedes Salgueira Lazo
Abstract
Background and Aims
Tunneled catheter-related bacteremia (TCRB) is a common and severe cause of bacteremia among hemodialysis (HD)-dependent patients. TCRB have reported incidence of 0.5 to 5.5 events per 1000 catheter days and are associated with increased morbidity and death. The main objetive of our study is determinate the incidence of TCRB in our hospital and, secondarily, to analyze our microbiology, recurrence and reinfection rates.
Method
The study is an observational retrospective evaluation of medical records of patients in whom a TC for HD was implanted in the period from January 1, 2005, to December 31, 2018. The TC were implanted by nephrologists, following a preimplantation and management protocol agreed with the Infectious Diseases Unit.
Patients were followed up from TC insertion until the study end date or first of recovery kidney function, kidney transplantation, transition to peritoneal dialysis or death. CRB definition was according Spanish Clinical Guidelines on Vascular Access for Haemodialysis: positive blood culture accompanied by fever or clinical signs of sepsis, without another posible site of infection. We recorded demographic, clinical and TC-related variables (conditions of catheter insertion, site of catheter insertion and duration of use, etc.). Exclusion criteria for our study were the lack of clinical follow-up due to belonging to a different hospital area.
Results
A total of 393 TC were implantated over a period of 13 years. After applying exclusion criteria, we investigated 341 TC implanted in 279 patients: 265 into the intern jugular vein, 71 into the subclavian and 5 in femoral vein. The mean age of the included patients was 63 (range 19-93 years). Fifty-one percent of catheter was implanted in male patients. Forty-six percent of the patients suffered from diabetes mellitus. In 55% of the cases, the cause of CT implantation was the difficulty of creating an internal vascular access.
In total there were 91 CRB in 58 patients, with a rate of 0.48 infections per 1000 catheter days (figure 1), occurring at median 461 days (range 143-443 days) after catheter insertion. Within that group, 82.4% occurred after 6 months from the implementation of the CPT. Only 6 (6.59%) took place in the 30 days after implantation. Gram-positive organisms accounted of 85%, with a predominance of Staphylococcus epidermidis (47%) followed by Staphylococcus aureus (25%). A broad spectrum of Gram-negative bacteria accounts for 14% of patients. Nineteen TC were removed by CRB, with a rate of 5.5% of total functioning TC. CRB was the cause of death in 7 of the 279 patients (2.5%). During the study, 12 (13% of CRB) recurrences and 30 (32% of CRB) reinfections events have been identified.
Conclusion
The incidence of CRB in our population was found to be lower that previous studies. It usually appears in the long term, with Gram-positive germs as the most frequently involved. The temporality and low recurrence rate suggest that our protocol has been effective.
The high rate of reinfection orients a certain individual predisposition to suffer from CRB. Identification of potential predicting risk factors could reduce the morbimortality of these patients.
An Alternative Vascular Access Technique for Haemodialysis; The Loop Mid-Thigh Graft