09.30 10.00 maurizio gallieni - publiceren

Preven&on of catheter related infec&ons in hemodialysis

Maurizio Gallieni

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

the Vascular Access Society

http://www.vascularaccesssociety.com/ http://www.vas2013.org/

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.

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

Mechanisms of infec&on

Mayo Clinics Proceedings September 2006

Risk of CVC-related infection in hemodialysis

HD CVC non tunneled 4.8/1000 catheter days HD CVC tunneled 1.6/1000 catheter days

Risk of CVC-related infection in hemodialysis (16 studies)

Risk of CVC-related infection in hemodialysis

Beathard GA, Urbanes A. Infection associated with tunneled hemodialysis catheters. Semin Dial. 2008;21(6):528-38.

Guidelines - 1

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

Guidelines - 2

2011; 7: 257–265

Review - 3

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

Tunneled CVCs reduce EXTRALUMINAL, not INTRALUMINAL route infections


•  Preven&ve approaches – Universal precau&ons – Sutureless aGachment devices

– Topical ointments and dressings – Locking solu&ons – Needle free connectors – Coated catheters

Hand washing

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)

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


•  Preven&ve approaches – Universal precau&ons

– Sutureless aGachment devices – Topical ointments and dressings – Locking solu&ons – Needle free connectors – Coated catheters

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.


Teichgräber et al. JVA 2011;12:17-20



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


•  Preven&ve approaches – Universal precau&ons – Sutureless aGachment devices

– Topical ointments and dressings – Locking solu&ons – Needle free connectors – Coated catheters

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

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

Posi&on statement of European Renal Best Prac&ce (ERBP)


Use of antibiotic ointments at the exit site

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.

Betjes Nat Rev Nephrol 2011; 7: 257–265

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.

CONTROL INTERVENTION

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.


•  Preven&ve approaches – Universal precau&ons – Sutureless aGachment devices – Topical ointments and dressings

– Locking solu&ons – Needle free connectors – Coated catheters

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

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

Antimicrobial lock solutions substantially reduce the risk of CRBSI (relative risk 0.23).

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

Antimicrobial lock

Allon M. AJKD 2008; 51: 165-9

European Renal Best Prac&ce (ERBP)



•  Preven&ve approaches – Universal precau&ons – Sutureless aGachment devices – Topical ointments and dressings – Locking solu&ons

– Needle free connectors – Coated catheters

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

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


•  Preven&ve approaches – Universal precau&ons – Sutureless aGachment devices – Topical ointments and dressings – Locking solu&ons – Needle free connectors – Coated catheters

Prevention of tunnell infections

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

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

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»

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.

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.

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.

•  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.

Conclusions

•  .

Conclusions

WoCoVA abstracts in the Journal of Vascular Access

the Journal of Vascular Access

Home page: http://www.vascular-access.info/

Article submission: http://www.editorialmanager.com/jva/

Volunteers to participate as reviewers and subsequently as Editorial Board members

are welcome

09.30 10.00 maurizio gallieni - publiceren

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