Antibiotic Prophylaxis in Chronic Renal Failure Hemodialysis

Gregory A. Chambers, PA-SLock Haven University

February 25, 2009

Causes of End-Stage Renal Disease:

•Diabetic Nephropathy

•Hypertension

•Glomerulonephritis

•HIV Nephropathy

•Renal Artery Stenosis

•Polycystic Kidney Disease

•Others

The first three causes account for nearly 75% of all end stage renal

disease!

•Diabetic Nephropathy (25-40%)

•Hypertension

•Glomerulonephritis

Diabetic Nephropathy

Leading Cause: Obesity(AKA: Hypernutrition)

Obesity in the United States

Percent of Obese (BMI > 30) in U.S. Adults

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Obesity in the United States2007 State Obesity Rates

State % State % State % State %

Alabama 30.3 Illinois 24.9 Montana 21.8 Rhode Island 21.4

Alaska 27.5 Indiana 26.8 Nebraska 26.0 South Carolina 28.4

Arizona 25.4 Iowa 26.9 Nevada 24.1 South Dakota 26.2

Arkansas 28.7 Kansas 26.9 New Hampshire 24.4 Tennessee 30.1

California 22.6 Kentucky 27.4 New Jersey 23.5 Texas 28.1

Colorado 18.7 Louisiana 29.8 New Mexico 24.0 Utah 21.8

Connecticut 21.2 Maine 24.8 New York 25.0 Vermont 21.3

Delaware 27.4 Maryland 25.4 North Carolina 28.0 Virginia 24.3

Washington DC 21.8 Massachusetts 21.3 North Dakota 26.5 Washington 25.3

Florida 23.6 Michigan 27.7 Ohio 27.5 West Virginia 29.5

Georgia 28.2 Minnesota 25.6 Oklahoma 28.1 Wisconsin 24.7

Hawaii 21.4 Mississippi 32.0 Oregon 25.5 Wyoming 23.7

Idaho 24.5 Missouri 27.5 Pennsylvania 27.1    

Obesity in the United States

(BMI > 30)

•1997 – 19.4% of adults

•2004 – 24.5% of adults

•2007 – 26.6% of adults

As a Result:

End-stage renal disease will increase dramatically in the next several years as a result of the

deconditioning of America!

Hemodialysis:

Hemodialysis:

Hemodialysis:

•Outpatient procedure

•Attach catheter to Hemodialysis equipment

•Blood passes through chambers with semi-permeable membranes

•Dialysis solutions on opposite side of membranes

•Simple diffusion – toxins, excess water out – electrolytes and nutrients in

•Anticoagulation achieved with heparin

What is Missing

Antibiotic Therapy

Hemodialysis Complications:

•Hypotension - frequent

•Fatigue - frequent

•Nausea - frequent

•Headache - frequent

•Sepsis – 1-2 % of all dialysis hours

•Endocarditis – small percent of sepsis cases

•Stroke – small percent of endocarditis cases

Let’s Do The Math………

•Hemodialysis 3 times per week………

•Total times per year (52 weeks X 3 times per week)

•156 trips to the dialysis center………

•Average time per dialysis session = 4 hours………

•Annual time in dialysis = 624 hours………

•Rate to infection = 1 – 2%.........

•Total infections per year = 6.2 – 12.4………

Research

In all the sources used, prophylaxis use of either topical or intra-luminal antibiotics decreased the rates of infection by 0.22 – 0.46%.

Research

While this may not see to be a significant amount, it would reduce the incidence of infection by nearly 25.0%!

Research:

Antibiotics Tested:

•Gentamicin (aminoglycoside)

•Cefazolin (1st generation cephalosporin)

•Cefotaxime (3rd generation cephalosporin)

•Vancomycin (glycopeptide)

•Minocycline (tetracycline)

•Taurolidine (antimicrobial properties and stimulates leucocytes)

Futures Studies:

Although the research showed significant rates of infection with antibiotic prophylaxis, the study sizes were very small (n=70 – 6)

and were mostly conducted outside the United States.

Future Studies:

In addition, many of the studies revealed bias in either the design of the study or in the

interpretation of the results.

Future Studies:

A large cohort, double blinded, randomized study conducted in the United States is needed

to truly identify the efficacy of antibiotic prophylaxis in hemodialysis patients.

Bibliography:

•James, M., Conley, J., Tonelli, M., Manns, B., MacRae, J., Hemmelgarn, B. (2008). Meta-analysis: antibiotics for prophylaxis against hemodialysis catheter-related infections. Annals of Internal Medicine. 148,596-605.

•Saxena, A., Panhotra, B., Sundaram, D., Al-Hafiz, A., Naguib, M., Venkateshappa, C., et. al. (2006). Tunneled catheters’ outcome optimization among diabetics on dialysis through antibiotic-lock placement. Kidney International. 70, 1629-1635.

•Tacconelli, E., Carmeli, Y., Aizer, A., Ferreira, G., Foreman, G., D’Agata, M. (2003). Mupirocin prophylaxis to prevent staphylococcus aureus infection in patients undergoing dialysis: a meta-analysis. Clinical Infectious Diseases. 37, 1629-1638.

Bibliography Continued:

•Allon, M. (2003). Prophylaxis against dialysis catheter-related bacteremia with a novel antimicrobial lock solution. Clinical Infectious Diseases. 36, 1539-1544.

•Stippoli GFM, Tong A, Johnson D, Schena FP, Craig JC. Antimicrobial agents for preventing peritonitis in peritoneal dialysis patients. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD004679. DOI: 10.1002/14651858.CD004679.pub2.

GO BUCKS!!!