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FREQUENCY OF HEMODIALYSIS CATHETER RELATED INFECTIOUS COMPLICATIONS IN PATIENTS WITH END STAGE RENAL DISEASE.

Byline: Uzma Shehzadi, Naureen Akhtar, Muhammad Aamir Usman, Adeela Chaudhry, Faiza Noor and Nazia Rafique

Keywords: Blood stream infections, Complications, End stage renal disease, Frequency, Hemodialysis.

INTRODUCTION

Hemodialysis is associated with considerable morbidity and mortality. Infections are major cause of death in these patients. The requirement of renal replacement therapy (RRT) in the form of hemodialysis has increased in the last decade and it is expected that it will continue to do so over the next 10 years. Hemodialysis is the mainstay of therapy in end stage renal disease (ESRD) and it needs effective and long term vascular access. Arteriovenous (AV) fistula is the access of choice1. Despite the efforts to secure early permanent vascular access, catheters remain an essential access in large number of ESRD patients. About 20%-60% of patients treated with hemodialysis worldwide use grafts or catheters at least in part because their vessels are not suitable for fistula creation2,3. The hemodialysis catheters can be used in virtually any patient as they are easily inserted and are suitable for immediate use following insertion.

The catheter access is even more economical as compared to AV fistula by about five folds4,5. Though the catheter access some benefits, the rate of complications associated with it make it a less preferred choice. One of the major complications associated with catheter access is infection in the form of rampant bacteremia. According to a recent study the incidence of tunneled catheter related bacteremia is as high as one episode per 252 catheter days6,7. Similarly, may studies have also reported development of infective endocarditis in these patients8,9.

The study was conducted with the rationale to determine frequency of various types of catheter related infections in tertiary care centers from our country. The results of the study are expected to create awareness among clinicians to prevent and treat these complications at an early stage to increase mean survival of the patients in whom the catheter use is inevitable.

PATIENTS AND METHODS

This was a cross-sectional study conducted from October 2016 to September 2017. The study was conducted at the Department of Nephrology of the Children's Hospital and Institute of Child Health, Lahore after approval of its synopsis from the Ethical Review Board of the same institution. The sample size was calculated using WHO Sample size calculator. Taking a previous reported frequency of catheter related infections to be 7.3%, a sample size of 104 patients was calculated with 95% confidence interval and 7% margin of error11. The patients were recruited following nonprobability, consecutive sampling. Patients aged 5-15 years, belonging to either gender diagnosed with end stage renal disease and on hemodialysis via temporary non-cuffed catheters were included in the study. Patients with end stage renal disease undergoing dialysis using arteriovenous fistula were excluded. One hundred and four patients fulfilling the criteria were included in the study.

Demographic information like age, gender, duration of ESRD, and details about etiology of ESRD, number of days catheter remained in situ, difficult catheter insertion and infectious complications related to catheter were recorded in a predesigned proforma. We used Duke's criteria for diagnosis of infective endocarditis. All the collected data was analyzed using SPSS software version 20.0. Age, number of days catheter remained in situ were presented as mean and SD. Complications were presented as frequency and percentages. Post stratification, chi-square test was applied with p-value a$?0.05 considered as statistically significant.

Table-I: Demographic and clinical profile of the study population.

Variable###Mean###S.D

Age (years)###11.1###2.7

Female to Male Ratio###1 : 1.48

Duration of CVC (days)###74.9###26.1

TLC (x106/uL)###16.90###6.442

Difficult catheterization n(%)###67 (64.4)

Catheterization (%)

Internal jugular vein###85.6

Femoral###7.7

Table-II: Various types of hemodialysis related blood infections in the study population.

Infection###Present (n, %)###Absent (n,%)###Total

Exit site infection###17, 16.3###87, 83.7###104, 100.0

Tunnel infection###8, 7.7###96, 92.3###104, 100.0

Blood stream infection###54, 52.9###48, 47.1###102, 98.1a

Infective endocarditis###36, 34.6###68, 65.4###104, 100.0

Echo vegetations###35, 34.0###68, 66.0###103, 99.0a

Table-III: Organisms found in blood and catheter tip cultures of hemodialysis patients.

Organism###Blood Culture###Catheter Tip Culture

###n###%###n###%

Escherichia coli###17###16.3###19###18.3

Enterobacter species###11###10.6###6###5.8

Klebsiella pneumonia###14###13.5###14###13.5

Pseudomonas aeruoginosa###9###8.7###20###19.2

Staphylococcus aureus###33###31.7###25###24.0

Staphylococcus epidermidis###2###1.9###4###3.8

Others###2###1.9###2###1.9

Culture negative###16###15.4###14###13.5

Total###104###100.0###104###100.0

Table-IV: Effect of gender on various blood infections in hemodialysis patients.

Type of Infection###Gender###Total###p-value

###Male(%)###Female(%)

Exit site###Yes###n(%)###6(5.8)###11(10.6)###17(16.3)

infection###No###n(%)###56(53.8)###31(29.8)###87(83.7)###0.025

Total###n(%)###62(59.6)###42(40.4)###104(100)

Tunnel###Yes###n(%)###6(5.8)###2(1.9)###8(7.7)

Infection###No###n(%)###56(53.8)###40(38.5)###96(92.3)###0.356

Total###n(%)###62(59.6)###42(40.4)###104(100)

Blood Stream###Yes###n(%)###36(35.3)###18(17.6)###54(52.9)

Infections###No###n(%)###26(25.5)###22(21.6)###48(47.1)###0.197

Total###N(%)###62(60.8)###40(39.2)###102(100)

Infective###Yes###n(%)###20(19.6)###16(15.4)###36(34.6)

Endocarditis###No###n(%)###42(40.4)###26(25)###68(65.4)###0.539

Total###n(%)###62(59.6)###42(40.4)###104(100)

Table-V: Effect of etiology of end stage renal disease on various types of blood infections in hemodialysis patients.

###Etiology of ESRD

###Nephro-###Posterior###Reflux###Neurogenic###Nephrono-###Glomerulo-###Congenital

###lithiasis###Urethral###Nephropathy###Bladder###phthisis###pathies###hypoplastic###Total###p-value

###Valves###kidneys

Exit###Yes###n,%###6, 5.8%###0, 0.0%###0, 0.0%###4, 3.8%###0, 0.0%###7, 6.7%###0, 0.0%###17, 16.3%

Site###No###n,###22,###15,14.4%###16,15.4%###11,10.6%###6, 5.8%###15, 14.4%###2, 1.9%###87, 83.7%###0.040

Infection###%###21.2%

Total###N###28,###15,14.4%###16,15.4%###15,14.4%###6, 5.8%###22, 21.2%###2, 1.9%###104, 100%

###26.9%

###Yes###n,###0, 0.0%###4, 3.8%###2, 1.9%###0, 0.0%###2, 1.9%###0, 0.0%###0, 0.0%###8, 7.7%

Tunnel###%

Infection No###n,###28,###11, 10.6%###14, 13.5%###15, 14.4%###4, 3.8%###22, 21.2%###2, 1.9%###96, 92.3%###0.004

###%###26.9%

Total###N###28,###15,14.4%###16,15.4%###15,14.4%###6, 5.8%###22, 21.2%###2,1.9%###104, 100%

###26.9%

###Yes###n,###13,###11, 10.8%###8, 7.8%###7, 6.9%###2, 2.0%###11, 10.8%###2, 2.0%###54, 52.9%

CRBSI###%###12.7%

###No###n,###15,###4, 3.9%###6, 5.9%###8, 7.8%###4, 3.9%###11, 10.8%###0, 0.0%###48, 47.1%###0.412

###%###14.7%

Total###N###28,###15, 14.7%###14, 13.7%###15, 14.7%###6, 5.9%###22, 21.6%###2,2.0%###102, 100%

###27.5%

Infective Yes###n,###13,###2, 1.9%###4, 3.8%###6, 5.8%###2, 1.9%###9, 8.7%###0, 0.0%###36, 34.6%

###%###12.5%

Endo-###n,###15,

carditis###No###%###14.4%###13, 12.5%###12, 11.5%###9, 8.7%###4, 3.8%###13, 12.5%###2, 1.9%###68, 65.4%###0.319

Total###N###28,###15, 14.4%###16, 15.4%###15, 14.4%###6, 5.8%###22, 21.2%###2, 1.9%###104, 100%

###26.9%

RESULTS

There were 104 patients in the study with mean age 11.1 +- 2.7 (range: 5 - 15) years. The female to male ratio was 1.48 with 62 males (59.6%) and 42 females (40.4%). The internal jugular was the commonest site of central venous catheter (CVC) insertion with 89 (85.6%) of the patients undergoing venous catheterization through this route. Difficult catheter insertion was experienced by 67 (64.4%) of the patients and the mean number of days patients had venous catheter in place was 74.9 +- 26.1 days (table-I). All patients presented with fever >38AdegC and no source of infection could be found except for an infected central venous catheter. The frequency of catheter related exit site infection, tunnel infection, blood stream infection was found to be 16.3%, 7.7% and 52.9% respec- tively. The frequency of infective endocarditis complicating the course of the disease was found to be 34.6%.

All of them had vegetations on echocardiography except one. with 34.0% developing subsequent echo vegetations (table-II). The mean total leukocyte count was found to be 16.9 +- 6.4 x 103/uL. Analysis of the culture reports showed that Staphylococcus aureus, Escherichia coli and Klebsiellapneumoniae were the commonest etiological pathogens in blood culture with their presence observed in 33 (31.7%), 17 (16.3%) and 14 (13.5%) of the cases respectively. Whereas, Staphylococcus aureus, Pseuodmonasaeuroginosa and Escherichia coli were the commonest organisms found in the catheter tip cultures (table-III). We analyzed the effect of gender, site of catheter insertion and etiology of end stage renal disease on exit site, tunnel and blood stream infections. The results showed that the differences in the male and female population were statistically significant for exit site infections (p-value: 0.025) (table-IV).

Similarly, etiology of ESRD significantly affected exit site and tunnel infections (p-value: 0.040 and 0.004 respectively) with most prevalence seen in cases of nephrolithiasis (26.9%) and glomerulopathies (21.2%) (table-V). The site of CVC insertion significantly affected blood stream infections (p-value: 0.019). Catheterization in the internal jugular vein was significantly related to infective endocarditis (pvalue: 0.015).

DISCUSSION

The primary objective of the study to find the frequency of hemodialysis related blood infections was successfully achieved. There are multiple complications seen with the venous catheterization in hemodialysis patients which can be broadly categorized into anatomic, thrombotic and infective. During placement of a catheter patient may develop bleeding, hematoma formation, arterial puncture, atrial puncture, thromboembolic event, pneumothorax, hemothorax etc. But the most common and distressing complications associated with catheter are blood infections. In a study by Napalkov et al, incidence rate of complications/1000 in patients with hemodialysis catheters were described. They reported an incidence of thrombosis: 0.8; mechanical catheter-related complications (MCRCs): 0.7; embolism: 0.5; major bleed: 0.3; and intracranial hemorrhage (ICH), 0.1 complications10.

In another study by Wang et al, done at a single center in China, on Cuffed-tunneled hemodialysis catheter survival and complications in pediatric patients, the overall rate of catheter-related infections, thrombosis and malposition was 7.3, 23.4 and 3.4 episodes/1000 catheter days, respectively11.

A study conducted by investigators in Sudan reported that the rate of catheter related sepsis was 69.2% and 30.8% in jugular and femoral catheters. They also reported that exit site infections were co-existent with sepsis in majority (85.3%) of the cases12. Another group researchers showed that catheter related tunnel infections were seen in three out of nine hemodialysis patients13. Our results showed that catheter related blood stream infections were the commonest form of hemodialysis related infections seen in 52.9% of the patients with exit site and tunnel infections seen in 16.3% and 7.7% of the patients respectively. In the current study, we also presented the organisms found on blood and catheter tip cultures which were not reported by the afore mentioned study. The commonest organism was found to be Staphylococcus aureus that was obtained both in blood and catheter tip cultures most frequently.

There is a significant increase in metastatic infection in patients with dialysis catheters versus AV grafts8. Furthermore the incidence of infective endocarditis is much higher in patients with catheters as opposed to patients with AV access9. Investigators have noted four episodes of endocarditis in patients with cuffed tunneled catheters followed for 16,000 catheter days14,15. We found a prevalence of 34.6% of infective endocarditis in our patients with 34.0% developing detectable echo vegetations. Our patients had internal jugular catheterization in 85.6% of the cases which is in agreement with an earlier study that showed similar catheterization in 83% of the cases12. In our study, the femoral route was used in 7.7% of the cases which is relatively less than an earlier report of 17% (12) but slightly higher than an earlier published report of 2%16.

Our study showed that catheterization in internal jugular vein was significantly associated with bacteremia which is in disagreement with some earlier reports that showed that anatomic site did not affect bacterial infections17. However, there have been certain randomized trials that proved that jugular venous catheterization did not reducethe incidence of bacteremia as compared to femoral access18. To the best of our knowledge, this is the first study from Pakistan to report various infectious complications related to hemodialysis catheters in children with end stage renal disease. The highest frequency was of catheter related blood stream infections followed by exit site and catheter tunnel infections. It is recommended to adopt absolute aseptic techniques while passing hemodialysis catheters and especially every time the medical staff handles the catheters during dialysis.

Besides, local disinfectant should be applied when handling during session and antibiotic lock with heparin may be of great help to decrease rate of infection19. If need arises, then local antibiotics like mupirocin ointment have also shown to be effective in controlling localized infections. For more disseminated infections systemic antibiotics are recommended20,21. Our study is limited by the fact that it was a single center study and the sample size was small. Larger sample size would be required to establish stronger association between hemodialysis and associated blood stream infections. Secondly, we could not keep a long term follow up of our patients to see any life threatening complications later in life emerging from these blood stream infections.

CONCLUSION

Hemodialysis catheter useis inevitable in patients who await establishment of permanent vascular access for hemodialysis. This central venous catheterization puts patients at risk of developing various infections that range from exit site and tunnel infections to sepsis and infective endocarditis. The commonest organisms involved include S. aureus, E. coli, K. pneumonia and P. aeuroginosa. Selection of internal jugular vein does not prove to offer any additional benefit in reducing the risk of such complications. However, proper catheter insertion technique and disinfection can help reduce burden of such complications. Besides, timely management, once these infections have set in, can lead to prevention of life threatening complications. The clinicians should be well equipped with managing such complications to reduce the burden of morbidity and mortality in hemodialysis patients.

CONFLICT OF INTEREST

This study has no conflict of interest to be declared by any author.

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Publication:Pakistan Armed Forces Medical Journal
Date:Jun 30, 2019
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