FEASIBILITY OF SALVAGING TCC WITH CRBSI

Introduction:

Do I always have to remove my infected hemodialysis (HD) catheter? Can it be saved? How? Long term HD catheter related blood stream infection (CRBSI) requires immediate attention, and salvage of tunnelled cuffed HD catheter (TCC) becomes a challenge for those patients who have no alternative access for HD and their survival is totally dependent on the TCC. Indications to remove TCC include severe sepsis with or without hemodynamic instability, complicated or metastatic infection, fungal infection etc. When there is severe infection and it is not feasible to remove TCC, systemic antibiotics plus antibiotic lock therapy (ALT) is used for salvage, which is defined as continued use of the same catheter throughout an episode of CRBSI.

Methods:

This is prospective observational study of 36 patients over past 2 years from a tertiary care hospital in metropolis city. They were all having TCC as a last access for HD after having multiple failed vascular access (VA) for HD and peritoneal dialysis had either failed or non-feasible. They had TCC inserted at our hospital but were undergoing HD at other centres. The presentation was with rigors on HD in 100% patients. Besides, 10 patients presented with daily fever (on HD and non-HD days). Malaise, lethargy, lack of appetite, generalised weakness and weight loss were the other associated symptoms.

Once the clinical evaluation was suggestive of CRBSI, complete blood count, C-reactive protein, and two sets of blood cultures (one set from HD circuit when no other site available to draw blood) were performed. The results of the culture reports are depicted in Figure 1. Once the diagnosis was confirmed, they were treated with ALT or 70% industrial grade ethanol or no ALT. Majority of patients also received parenteral antibiotics. The decision to choose ALT alone or combine with systemic antibiotics was based on severity of CRBSI, whether patient was admitted and the type of parenteral antibiotic used (whether post HD dosing alone is possible or one needs to give daily one or more doses).

Results:

The details of organisms, ALT agent, anticoagulation, parenteral drug and outcome of TCC is depicted in Table 1. TCC were salvaged in 28/36 (77.7%) patients. Three patients with mixed infection (Psudomonas aeruginosa + Bacillus cereus, Psudomonas luteola + Bacillus cereus, Klebsiella pneumonia + Acinetobacter baumannii) were also salvaged. The median survival of these TCCs post treatment has been 339 days.

Conclusions:

TCC was salvaged due to close involvement of HD team. TCC salvage may be considered in HD patients with limited vascular access and uncomplicated bacteremia. If attempted, systemic antibiotics and an adjunctive antibiotic lock should both be used. Using tri-sodium citrate helps, as anticoagulant, as anti-bacterial and for combining with antibiotic like gentamycin which is not compatible with heparin. Our study showed majority of organisms to be gram negative as against common occurrence of gram positive organisms. Our series had one patient of MRSA, which is not consistent with literature. TCC with infections due to fungi, Burkholderia cepacia, Pseudomonas, Bacillus spp. were also treated and TCC was salvaged, when usual dictum is to remove TCC in such situations. CRBSI due to Micrococcus species, Propionibacteria or mycobacteria were not seen in our series. 

AV fistula remains the preferred mode of vascular access for HD.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.