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• W1989975324 abstract "Treatment of infected tunneled venous access hemodialysis catheters with guidewire exchange. Cuffed venous access catheters have become commonplace for hemodialysis access. The major complications of these catheters are catheter thrombosis, catheter fibrin sheathing and infection. When catheter associated bacteremia occurs treatment with antimicrobial therapy alone has been unsuccessful in providing acceptable cure rates. Failed antimicrobial therapy exposes the patient to the risks of prolonged bacteremia, while the alternative, catheter replacement at a new site can lead to central venous stenosis and compromise future long-term upper extremity access. Catheter guidewire exchange when the tunnel tract is clinically not infected theoretically allows the preservation of future access sites and yields a higher treatment success rate while avoiding temporary non-cuffed access placement. We report a series of 23 cases of hemodialysis patients with tunneled cuffed catheters and bacteremia related to the catheter who were treated with the exchange of a new catheter over a guidewire combined with three weeks of systemic antibiotics. Patients eligible for the study required no evidence of tunnel tract infection and defervescence within 48 hours of antimicrobial therapy. Technique failure was defined as repeat infection from any organism within 90 days of catheter exchange. Four patients (18%) redeveloped bacteremia within 90 days of the exchange. The bacteremias developed at 4, 19, 63 and at 74 days days after the exchange. Guidewire exchange in combination with intravenous antibiotics in cases of catheter related bacteremia has an acceptable rate of treatment success and is a viable treatment option in a carefully selected patient population. Treatment of infected tunneled venous access hemodialysis catheters with guidewire exchange. Cuffed venous access catheters have become commonplace for hemodialysis access. The major complications of these catheters are catheter thrombosis, catheter fibrin sheathing and infection. When catheter associated bacteremia occurs treatment with antimicrobial therapy alone has been unsuccessful in providing acceptable cure rates. Failed antimicrobial therapy exposes the patient to the risks of prolonged bacteremia, while the alternative, catheter replacement at a new site can lead to central venous stenosis and compromise future long-term upper extremity access. Catheter guidewire exchange when the tunnel tract is clinically not infected theoretically allows the preservation of future access sites and yields a higher treatment success rate while avoiding temporary non-cuffed access placement. We report a series of 23 cases of hemodialysis patients with tunneled cuffed catheters and bacteremia related to the catheter who were treated with the exchange of a new catheter over a guidewire combined with three weeks of systemic antibiotics. Patients eligible for the study required no evidence of tunnel tract infection and defervescence within 48 hours of antimicrobial therapy. Technique failure was defined as repeat infection from any organism within 90 days of catheter exchange. Four patients (18%) redeveloped bacteremia within 90 days of the exchange. The bacteremias developed at 4, 19, 63 and at 74 days days after the exchange. Guidewire exchange in combination with intravenous antibiotics in cases of catheter related bacteremia has an acceptable rate of treatment success and is a viable treatment option in a carefully selected patient population. Cuffed tunneled venous access catheters are commonly used for temporary and permanent access for hemodialysis patients[1SCHWAB S.J. BULLER G.L. MCCANN R.L. BOLLINGER R.R. STICKEL D.L. Prospective evaluation of a Dacron cuffed hemodialysis catheter for prolonged use.Am J Kidney Dis. 1988; 11: 166-169Abstract Full Text PDF PubMed Scopus (215) Google Scholar, 2MOSS A.H. VASILAKIS C. HOLLEY J.L. FOULKS C.J. PILLAI K. MCDOWELL D.E. Use of a silicone dual lumen catheter with a Dacron cuff as long-term vascular access for hemodialysis.Am J Kidney Dis. 1990; 16: 211-215Abstract Full Text PDF PubMed Scopus (181) Google Scholar, 3FAN P.Y. SCHWAB S.J. Vascular access; Concepts for the 1990’s.J Am Soc Nephrol. 1992; 3: 1-11PubMed Google Scholar, 4WINDUS D. Hemodialysis Vascular access: A nephrologists view.Am J Kidney Dis. 1993; 21: 457-471Abstract Full Text PDF PubMed Scopus (278) Google Scholar]. These catheters serve an essential role providing hemodialysis access to patients awaiting the maturation or placement of permanent arteriovenous (AV) access and providing permanent access in patients in whom all other access options have been exhausted. The predominant complications with the use of these tunneled catheters are catheter thrombosis, catheter fibrin sheathing and infection[1SCHWAB S.J. BULLER G.L. MCCANN R.L. BOLLINGER R.R. STICKEL D.L. Prospective evaluation of a Dacron cuffed hemodialysis catheter for prolonged use.Am J Kidney Dis. 1988; 11: 166-169Abstract Full Text PDF PubMed Scopus (215) Google Scholar, 2MOSS A.H. VASILAKIS C. HOLLEY J.L. FOULKS C.J. PILLAI K. MCDOWELL D.E. Use of a silicone dual lumen catheter with a Dacron cuff as long-term vascular access for hemodialysis.Am J Kidney Dis. 1990; 16: 211-215Abstract Full Text PDF PubMed Scopus (181) Google Scholar, 3FAN P.Y. SCHWAB S.J. Vascular access; Concepts for the 1990’s.J Am Soc Nephrol. 1992; 3: 1-11PubMed Google Scholar, 4WINDUS D. Hemodialysis Vascular access: A nephrologists view.Am J Kidney Dis. 1993; 21: 457-471Abstract Full Text PDF PubMed Scopus (278) Google Scholar, 5SUHOCKI P. CONLON P.J. KNELSON M. HARLAND R. SCHWAB S.J. Silastic cuffed catheters for hemodialysis vascular access: Thrombolytic and mechanical correction of malfunction.Am J Kidney Dis. 1996; 28: 379-386Abstract Full Text PDF PubMed Scopus (164) Google Scholar, 6MARR K.A. SEXTON D. CONLON P. SCHWAB S.J. KIRKLAND K. Bacteremia in patients with central venous catheters used for hemodialysis: Lack of efficiency of catheter salvage.Ann Int Med. 1997; 127: 275-280Crossref PubMed Scopus (449) Google Scholar]. Catheter dysfunction caused by thrombosis has been shown to respond to a series of therapeutic techniques[5SUHOCKI P. CONLON P.J. KNELSON M. HARLAND R. SCHWAB S.J. Silastic cuffed catheters for hemodialysis vascular access: Thrombolytic and mechanical correction of malfunction.Am J Kidney Dis. 1996; 28: 379-386Abstract Full Text PDF PubMed Scopus (164) Google Scholar,7The NKF Dialysis Outcomes Quality Iniative “DOQI”.Am J Kidney Dis. 1997; 30 (NKF clinical practice guidelines for vascular access.): S150-S191PubMed Google Scholar], and in our experience thrombotic episodes, although frequent, are treatable. Catheter mediated bacteremia and catheter tunnel infection, however, are currently the primary reasons for catheter access failure[5SUHOCKI P. CONLON P.J. KNELSON M. HARLAND R. SCHWAB S.J. Silastic cuffed catheters for hemodialysis vascular access: Thrombolytic and mechanical correction of malfunction.Am J Kidney Dis. 1996; 28: 379-386Abstract Full Text PDF PubMed Scopus (164) Google Scholar,6MARR K.A. SEXTON D. CONLON P. SCHWAB S.J. KIRKLAND K. Bacteremia in patients with central venous catheters used for hemodialysis: Lack of efficiency of catheter salvage.Ann Int Med. 1997; 127: 275-280Crossref PubMed Scopus (449) Google Scholar]. In a study from our institution, the mean catheter life in catheters intended for permanent use was 12.7 months with almost all catheters lost due to infection[5SUHOCKI P. CONLON P.J. KNELSON M. HARLAND R. SCHWAB S.J. Silastic cuffed catheters for hemodialysis vascular access: Thrombolytic and mechanical correction of malfunction.Am J Kidney Dis. 1996; 28: 379-386Abstract Full Text PDF PubMed Scopus (164) Google Scholar]. In a prospective study by Marr and colleagues at Duke University, we demonstrated an infection rate of 3.9 infections per 1000 catheter days of use[6MARR K.A. SEXTON D. CONLON P. SCHWAB S.J. KIRKLAND K. Bacteremia in patients with central venous catheters used for hemodialysis: Lack of efficiency of catheter salvage.Ann Int Med. 1997; 127: 275-280Crossref PubMed Scopus (449) Google Scholar], which was consistent with the cuffed hemodialysis catheter infection rates at other centers[8BLAKE P.G. HURAIB S. WU G. The use of dual lumen jugular venous catheters as definitive long term access for hemodialysis.Int J Artif Organs. 1990; 13: 26-31PubMed Google Scholar]. Complication from these infections ranged from minimal systemic signs to endocarditis, septic arthritis, and epidural abscess. In the study by Marr and colleagues using the same patient base as the current study, there were no differences in systemic complications between those patients in whom catheter salvage was attempted and in those it whom it was not[6MARR K.A. SEXTON D. CONLON P. SCHWAB S.J. KIRKLAND K. Bacteremia in patients with central venous catheters used for hemodialysis: Lack of efficiency of catheter salvage.Ann Int Med. 1997; 127: 275-280Crossref PubMed Scopus (449) Google Scholar]. However, Kovalik and colleagues noted an increased frequency of epidural abscesses and bacterial endocarditis when these catheters were used chronically when compared to AV access[9KOVALIK E. ALBERS F. RAYMOND J. CONLON P. A clustering of cases of spinal epidural abscess in hemodialysis patients.J Am Soc Nephrol. 1996; 7: 2264-2267PubMed Google Scholar]. Thus, infectious complications have emerged as the dominant problem with long-term chronic cuffed catheter use. Cuffed catheter related bacteremia has been treated by attempted salvage with intravenous antibiotics or removal of the catheter. As reported by Marr et al, the successful rate of salvage with antimicrobial therapy alone was only 32%[6MARR K.A. SEXTON D. CONLON P. SCHWAB S.J. KIRKLAND K. Bacteremia in patients with central venous catheters used for hemodialysis: Lack of efficiency of catheter salvage.Ann Int Med. 1997; 127: 275-280Crossref PubMed Scopus (449) Google Scholar]. The alternate clinical approach to attempted catheter salvage has been catheter removal, with use of temporary access for a period of time followed by catheter replacement at a new site. With repeated new sites of access there is an increased risk for the development of central venous stenosis compromising the longevity of upper extremity AV access. Several studies have shown that in the intensive care unit (ICU) setting, guidewire exchange of non-cuffed catheters may be successfully performed without any increased risk of infection compared to placement of a new catheter at a new site[12BOZETTI F. TERNO G. BONFANTI G. SCARPA D. SCOTTI A. AMMATUNA M. BONALUMI M.G. Prevention and treatment of central venous catheter sepsis by exchange via a guidewire. A prospective controlled trial.Ann Surg. 1983; 198: 48-52Crossref PubMed Scopus (81) Google Scholar, 13PORTER K.A. BISTRIAN B.R. BLACKBURN G.L. Guidewire exchange with triple culture technique in the management of catheter sepsis.J Parenter Enteral Nutr. 1988; 12: 628-632Crossref PubMed Scopus (30) Google Scholar, 14ARMSTRONG C.W. MAYHALL C.G. MILLER K.B. NEWSOME H.H. SUGERMAN H.J. DALTON H.P. HALL G.O. BENNINGS C. Prospective study of catheter replacement and other risk factors for infection of hyperalimentation catheters.J Infect Dis. 1986; 154: 808-816Crossref PubMed Scopus (107) Google Scholar, 15PETTIGREW R.A. LANG S.D. HAYDOCK D.A. PARRY B.R. BREMNER D.A. HILL G.L. Catheter related sepsis in patients on intravenous nutrition: A prospective study of quantitative catheter cultures and guidewire changes for suspected sepsis.Br J Surg. 1985; 72: 52-55Crossref PubMed Scopus (136) Google Scholar, 16CARLISLE E.J. BLAKE P. MCCARTHY F. VAS S. ULDALL R. Septicemia in long-term jugular hemodialysis catheters; Eradicating infection by changing the catheter over a guidewire.Int J Artif Organs. 1991; 14: 150-153PubMed Google Scholar, 17SHAFFER D. Catheter-related sepsis complicating long-term, tunnelled central venous dialysis catheters: Management by guidewire exchange.Am J Kidney Dis. 1995; 25: 593-596Abstract Full Text PDF PubMed Scopus (106) Google Scholar]. This approach, however, has not been universally recommended[15PETTIGREW R.A. LANG S.D. HAYDOCK D.A. PARRY B.R. BREMNER D.A. HILL G.L. Catheter related sepsis in patients on intravenous nutrition: A prospective study of quantitative catheter cultures and guidewire changes for suspected sepsis.Br J Surg. 1985; 72: 52-55Crossref PubMed Scopus (136) Google Scholar]. Carlisle et al reported a series of patients with hemodialysis catheter related sepsis who underwent catheter exchange over a guidewire who had treatment failures only in the presences of purulence at the exit site[16CARLISLE E.J. BLAKE P. MCCARTHY F. VAS S. ULDALL R. Septicemia in long-term jugular hemodialysis catheters; Eradicating infection by changing the catheter over a guidewire.Int J Artif Organs. 1991; 14: 150-153PubMed Google Scholar]. Shaffer reported a series of thirteen patients with cuffed tunneled catheter related sepsis who were treated with antimicrobial therapy and guidewire exchange[17SHAFFER D. Catheter-related sepsis complicating long-term, tunnelled central venous dialysis catheters: Management by guidewire exchange.Am J Kidney Dis. 1995; 25: 593-596Abstract Full Text PDF PubMed Scopus (106) Google Scholar]. We report here a cohort of patients with systemic infections associated with cuffed tunneled catheters who were treated with guidewire exchange in addition to intravenous antibiotic therapy. Patients seen at Duke University Medical Center (DUMC) with clinically suspected catheter related sepsis were evaluated for potential guidewire exchange. These patients were seen over the period of July 1, 1996 though September 30, 1997. Requirement for consideration for guidwire exchange were: (1) end-stage renal disease (ESRD), (2) bacteremia without an identifiable source except the catheter, (3) defervescence with intravenous antibiotics within forty-eight hours, and (4) no sign of catheter tunnel tract infection. Patients with purulence at the exit site were ineligible for guidewire exchange. Patients who underwent guidewire exchange were continued on antibiotic therapy for three to four weeks at the discretion of the clinician. Patients who presented with fever and leukocytosis without an identifiable infection source except the catheter underwent blood cultures and received an initial empiric antibiotic therapy of vancomycin and gentamicin. Patients with positive cultures were then entered into the study. After culture results, antibiotic therapy was based on susceptibilities. A treatment failure was considered any bacteremia within 90 days after exchange. Patients who met eligibility criteria were taken to the interventional radiology suite for the catheter exchange. The catheters used in this study were of a single type (Perm Cath™; Quinton Instrument Co., Seattle, WA, USA). The catheter and skin site were prepped with a betadyne scrub (×3) and the betadyne was allowed to dry and draped in sterile fashion. Fentanyl and Versed were administered intravenously for conscious sedation; 10 cc was aspirated from each catheter port and discarded. Each port was flushed with 10 cc of heparinized saline (1,500 Units of heparin in 500 cc normal saline). Using fluoroscopic guidance, a stiff shaft hydrophilic guidewire (Glidewire SS, Medi-tech; Boston Scientific Corporation, Watertown, MA, USA) 0.035 inches in diameter, 150 cm in length, was passed through each of the two catheter lumens to the level of the right atrium. The Dacron cuff was bluntly dissected from the subcutaneous tissue via the tunnel. Catheters were placed in such a manner that the cuff could be reached with forceps inserted via the tunnel. The catheter was exchanged for a new catheter over the guidewires into the same tunnel. The guidewires were removed and 5 cc were aspirated from each lumen. Five thousand units of heparin were injected into each lumen and caps placed on the ports; 2-0 silk was used to anchor the catheter to the skin for 10 days. During the study 40 catheter-related infection episodes (fever, chills, leukocytosis without an identifiable infection source except the catheter) were evaluated for possible guidewire exchange. Patients not entered into the study had their catheter removed either because they were judged clinically unstable (hypotension), had a possible infected catheter tunnel tract, or failed to become afebrile within 48 hours of initiation of antibiotic therapy (Table 1).Table 1Catheter infection outcomes There were 23 catheter exchanges in 21 patients. The patient population included 10 men and 11 women with a mean age of 59 years. Seventeen of the catheters were right internal jugular insertion and 6 were left internal jugular. Catheters had been in place for a range of one month to 1.6 years. Organisms isolated from blood cultures were staphylococcus aureus (8 cases), enterococcus sp. (3 cases), staphylococcus Coagulase negative (3 cases), and one case each of diptheroids, serratia marcescans, streptococcus viridans, E. coli, and hemophilus parainfluenzae, respectively. One patient had a polymicrobial infection with four organisms. Two patients had positive catheter tip cultures but negative blood cultures (both staphylococcus Coagulase negative). One patient who was initially culture negative later redeveloped fever and grew Xanthomonas maltophia, which resulted in catheter removal and treatment failure (Table 2).Table 2Causes of bacteremia There were four treatment failures, defined as bacteremia from any organism within 90 days of catheter exchange. These failures occurred at 4, 19, 63, and 78 days post-catheter exchange. The treatment failure at four days was associated with recurrent fever and staphylococcus aureus bacteremia. The technique failure at 19 days was with xanthomonas maltophilia in a patient who was initially blood culture negative. The treatment failure at 63 days occurred in a patient who initially grew enterococcus but developed staphylococcus aureus bacteremia at 63 days. The treatment failure at 78 days was a recurrence of Coagulase negative staphylococcus. In addition, the patient with a polymicrobial infection with E. coli, streptococcus viridans, staphylococcus coagulase negative, and enterococcus sp. bacteremia, developed staphylococcus Coagulase negative bacteremia and L4-L5 discitis 144 days after the catheter exchange. It is our belief that this infection represents new and not recurrent infection, as this patient had developed sacral decubiti prior to the event. There were no discernable correlations between organism and treatment failure. This prospective observational series supports the finding by Shaffer that guidewire exchange of cuffed venous hemodialysis catheters is a reasonable approach to catheter related bacteremia in the clinical setting of defervescence within 48 hours after the administration of intravenous antibiotics in the absence of exit site infection[9KOVALIK E. ALBERS F. RAYMOND J. CONLON P. A clustering of cases of spinal epidural abscess in hemodialysis patients.J Am Soc Nephrol. 1996; 7: 2264-2267PubMed Google Scholar]. Data reported by Marr et al from our institution in the study that preceded our study documented a very low (32%) rate of successful catheter salvage with intravenous antibiotics alone[6MARR K.A. SEXTON D. CONLON P. SCHWAB S.J. KIRKLAND K. Bacteremia in patients with central venous catheters used for hemodialysis: Lack of efficiency of catheter salvage.Ann Int Med. 1997; 127: 275-280Crossref PubMed Scopus (449) Google Scholar]. Although patient selection is different in these studies, (no exclusion of tunnel tract infections in the study by Marr et al), the results of our study and the study by Shaffer support the finding that in the correct clinical setting guidewire exchange can be done safely. Due to the high incidence of bacteremia associated with cuffed venous access catheters, it is unreasonable to expect that there will be no repeat infections at follow-up. The infection rate 90 days after exchange in this series is comparable to the rate in de novo catheter use. Only four of the 23 cases (17%) had a repeat infection 90 days post-exchange. The series of patients reported by Shaffer had 3 of 13 cases with repeat bacteremia ranging from 2.5 months to 13 months, with two of three recurrences being with the originally cultured organism. In our study only one of the four bacteremias was with the original cultured organism, while one original culture failed to grow an organism. It is possible that our treatment failures may represent either a new infection or an infection introduced at the time of catheter exchange rather than failure to eradicate the original infection. Regardless of the cause, all represent a catheter exchange technique failure and are reported in this manner. This study is also in agreement with the observations of Beathard (personal communication) that in the correct setting that catheters can be successfully salvaged by the use of guidewire exchange. In conclusion, preservation of access sites is in the best long-term interest of the dialysis patient. When used in the proper clinical situation, guidewire catheter exchange can be performed with a low likelihood of treatment failure. Successful guidewire exchange can preserve sites of access while allowing the patient to avoid temporary non-cuffed hemodialysis access placement. We believe when the conditions of clinical improvement after 48 hours of intravenous antibiotics and absence of tunnel tract infection are met, then guidewire exchange is a viable treatment option." @default.
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• W1989975324 title "Treatment of infected tunneled venous access hemodialysis catheters with guidewire exchange" @default.
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