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1. Catheter Related Blood
Stream Infection (CRBSI)
Diagnosis & Management Step-Wise
Practical Approach in HD Patients
Mohammed Abdel Gawad
Nephrology Specialist
Kidney & Urology Center (KUC)
Alexandria – EGY
drgawad@gmail.com
1st Annual Interventional Nephrology Meeting – ESNT
Mansoura, 26-27/Oct/2017

2. Talk Outline
• Diagnosis
• Management
• Prevention

3. Talk Outline
• Diagnosis
• Management
• Prevention

4. Paired Blood Cultures
Peripheral
vein
From the
catheter
Culture of the
catheter tip
(distal 5 cm)
or

5. Paired Blood Cultures
or
When a peripheral blood sample
cannot be obtained
From the
catheter
From
Dialysis
circuit
2 quantitative blood cultures of
samples obtained through
2 catheter lumens

6. Culture Results
Results Diagnosis
Same organism from both samples CRBSI Confirmed
Both negative CRBSI Unlikely
Negative peripheral blood culture
BUT
Positive central blood culture
Probably contamination
(don’t treat EXCEPT if
Staph. Aureus)

7. Talk Outline
• Diagnosis
• Management
• Prevention

8. Talk Outline
• Diagnosis
• Management
• Prevention

11. Start Empirical Antibiotics
+ Antibiotic Lock Therapy
Reassess after 2-3 days: Clinically (fever) &
Lab (WBC, CRP)
Improving?
Yes
Continue antibotics,
then:
Pathway 3:
Surveillance
No
Pathway 4:
Catheter removal
Pathway 1:
Catheter Salvage

12. Start Empirical Antibiotics
+ Antibiotic Lock Therapy
Reassess after 2-3 days: Clinically (fever) &
Lab (WBC, CRP)
Improving?
Yes
Continue antibotics,
then:
Pathway 3:
Surveillance
No
Pathway 4:
Catheter removal
Pathway 1:
Catheter Salvage

13. Empirical Antibiotics
Antibiotic To cover Condition
Vancomycin MRSA for institutions in with preponderance of MRSA
Gentamycin
(if absolutely
contraindicated use
Quinolones)
Gram –ve
---------------------
Meropenem, Imipenem
or Etrapenem
or
Piperacillin/Tazobactam
in community with low
incidence of antibiotic
resistance
MDR Gram –ve In neutropenic patients, severely ill patients with
sepsis, or patients
known to be colonized with such pathogens
Fluconazole or
Echinocandin
Candidemia total parenteral nutrition, prolonged use of
broad-spectrum antibiotics, hematologic
malignancy, receipt of bone marrow or solid-
organ transplant, femoral catheterization,
or colonization due to Candida species at
multiple sites

14. Alternatives to vancomycin as a first
choice broad spectrum
Condition Alternative
the preponderance of MRSA
isolates have vancomycin
minimum inhibitory
concentration (MIC) values 12
mg/mL
Daptomycin

15. Antibiotic Doses: VANCOMYCIN
2017

16. Antibiotic Doses: GENTAMICIN
2017

17. Dialyziability & Residual Renal
Function Effect
• Vancomycin is not removed by HD; gentamicin
is.
• Measure gent levels daily (levels will decrease
sooner in patients with significant residual
function).
• Monitor predialysis trough levels if possible
2017

18. Antibiotic Doses: MEROPENEM
2017

19. Antibiotic Doses: IMIPENEM
2017

20. Antibiotic Doses: ERTAPENEM
2017

21. Antibiotic Doses:
PIPERACILLIN/TAZOBACTAM
2017

22. Antifungal Doses: FLUCONAZOL
2017

23. Start Empirical Antibiotics
+ Antibiotic Lock Therapy
Reassess after 2-3 days: Clinically (fever) &
Lab (WBC, CRP)
Improving?
Yes
Continue antibiotics,
then:
Pathway 3:
Surveillance
No
Pathway 4:
Catheter removal
Pathway 1:
Catheter Salvage

26. Start Empirical Antibiotics
+ Antibiotic Lock Therapy
Reassess after 2-3 days: Clinically (fever) &
Lab (WBC, CRP)
Improving?
Yes
Continue antibiotics,
then:
Pathway 3:
Surveillance
No
Pathway 4:
Catheter removal
Pathway 1:
Catheter Salvage
Duration of
Systemic and
Antibiotic
Lock

27. Duration of Systemic and
Antibiotic Lock
Pathway 1:
Catheter Salvage
If catheter is retained for a
patient with S. aureus CRBSI
Continue systemic and antibiotic
lock therapy for 4 weeks

28. Duration of Systemic and
Antibiotic Lock
Pathway 1:
Catheter Salvage
If catheter is retained for a
patient with any other organism
No clear data for systemic and
antibiotic lock therapy salvage
duration

29. Antibiotic Lock Special Situation
Multiple positive catheter blood culture
BUT concurrent negative peripheral
blood cultures
Antibiotic lock therapy without systemic
therapy for 10–14 days

31. guide wire
Start Empirical Antibiotics
as in salvage pathway
Reassess after 2-3 days:
Clinically (fever) & Lab (WBC, CRP)
Improving?
Yes
Exchange on
guide wire
Continue antibiotics
Pathway 3:
Surveillance
No
Pathway 4:
Catheter removal
Pathway 2:
Exchange on guide wire

32. guide wire
Start Empirical Antibiotics
as in salvage pathway
Reassess after 2-3 days:
Clinically (fever) & Lab (WBC, CRP)
Improving?
Yes
Exchange on
guide wire
Continue antibiotics
Pathway 3:
Surveillance
No
Pathway 4:
Catheter removal
Pathway 2:
Exchange on guide wire
Duration of
Systemic and
Antibiotic
Lock

33. Duration of Systemic and
Antibiotic Lock
If catheter is exchanged for a
patient with any organism
No clear data for systemic and
antibiotic lock therapy salvage
duration
Pathway 2:
Exchange on guide wire

35. Pathway 3:
Surveillance
bloodstream infection that continues
despite >72 h of antimicrobial therapy
to which the infecting microbes are
susceptible
2 sets of blood cultures obtained on a
given day

36. Pathway 3:
Surveillance If the catheter has been retained
Surveillance blood cultures 1 week after
completion of an antibiotic course
If blood cultures +ve →
the catheter should be removed
New, long term dialysis catheter after
additional –ve blood cultures

38. Pathway 4:
Catheter removal
Remove catheter and
culture tip (5 cm)
Start empirical antibiotics as
in salvage pathway
Is access is needed urgently for dialysis?
Yes
Insert
temporary
catheter in
another site
for short
period of time
No
Continue antibiotics
Insert long term catheter
ONLY if:
1- afebrile for 48-72 hours
2- CRP is normal
3- Blood cultures are -ve

39. Pathway 4:
Catheter removal
Remove catheter and
culture tip (5 cm)
Start empirical antibiotics as
in salvage pathway
Is access is needed urgently for dialysis?
Yes
Insert
temporary
catheter in
another site
for short
period of time
No
Continue antibiotics
Insert long term catheter
ONLY if:
1- afebrile for 48-72 hours
2- CRP is normal
3- Blood cultures are -ve
Duration?

40. Pathway 4:
Catheter removal

41. Persistent fungemia or
bacteremia >72 h after catheter
removal
4 to 6 weeks of
antibiotic therapy
should be administered
Additional TEE should
be obtained
Catheter Removal Special Situation (1)

42. Catheter Removal Special Situation (2)
Catheter tip grows S. aureus
but
Initial peripheral blood cultures -ve
5–7-day course of antibiotics
Close monitoring for signs and symptoms of ongoing infection,
including additional blood cultures, as indicated

43. Talk Outline
• Diagnosis
• Management
• Prevention

44. Talk Outline
• Diagnosis
• Management
• Prevention

45. Prevention - Catheter
• Strict aseptic circumstances.
• Avoid as much as possible:
– using non-tunneled catheters.
– using femoral
• Monitor the catheter:
– visually when changing the dressing
– or by palpation through an intact dressing on a
regular basis.

46. Prevention – Exit Site
• Application of antibiotic ointment at the exit
site until the insertion site has healed
• The catheter exit site should be covered by a
dressing as long as the catheter remains in
place.

47. Prevention – Antimicrobial Lock
• Its use is debated.
• Its use may be saved to patients with:
– history of multiple CRBSI
– those with high risk of severe sequelae (patients
with pacemakers, prosthetic valve or IV devices).
• Citrate locks have, for the time being, most
extensively been studied. (The 4% solution seems
to offer at present the best benefit/risk ratio).

48. Prevention – Staphylococcus
• Eradication of Staphylococcus carriage (nasal
mupirocin cream).
• Consider IV antibiotics at insertion for patients
with Staphylococcal skin colonisation.

49. Always re-evaluate for alternative access
(AVF or AVG).

50. Thank You