Haemodialysis Catheter-related Infections (CRIs)

Transcription

1 Haemodialysis Catheter-related Infections (CRIs) 1. Introduction: Some haemodialysis patients rely on central venous catheters (CVCs) for their dialysis treatment. CVCs are required when emergency haemodialysis treatment is needed, or whilst patients are waiting for creation or maturation of their arteriovenous fistula (AVF) or graft (AVG). There are two types of CVCs used for haemodialysis: non-tunnelled catheters which provide short-term access usually for emergency haemodialysis and/ or plasma exchange, and tunnelled catheters that are used as a medium- or long-term vascular access. Thrombosis and infection are the two most common complications related to CVCs use. Catheter-related infections (CRIs) are regarded as the most serious complication of CVCs with a significant increase in morbidity and mortality, and substantial cost implications. CRIs are classified into local infections such as exit-site and tunnel infections, and systemic infections referred to as catheter-related blood stream infections (CRBSI). 2. Prevention: 2.1 Minimise catheter use: Arterio-venous fistula is the preferred vascular access for haemodialysis due to their better flow rates and lower risk of dysfunction (thrombosis) and infection compared to catheters and grafts. All patients should have definitive vascular access (AV fistula or graft) before initiation of haemodialysis where possible. Patients who start haemodialysis without definitive access should have this formed as a matter of urgency. 2.2 Limit duration of non-tunnelled catheters: Femoral catheters should be removed after a maximum of 7 days. Jugular and subclavian catheters should be removed after a maximum of 3 weeks. Where it is anticipated that dialysis will be required for longer than this, a tunnelled CVC should be sited as soon as is practicable. 2.3 Minimise risk of contamination: Follow sterile technique at the time of catheter insertion and every time the catheter is accessed. Gowns, Hats and Masks must be worn for catheter insertion. Haemodialysis CVCs should not be used for other venous access purposes except in emergency situations. 2.4 Regular surveillance of catheter exit site using the catheter exit site visual scores (Appendix 1). 3. Clinical manifestations: Clinical manifestations of CRIs are dependent on whether the infection is localised or systemic. It is important to remember that patients with chronic kidney disease have impaired immunity and therefore may not mount the full inflammatory response. 3.1 Exit-site infection: Redness or Pain around exit site purulent discharge at the exit site

2 Fever or rigors may/ may not be present. 3.2 Tunnel infection (Tunnelled catheters only): Redness or pain extending >2cm from exit-site along the subcutaneous tunnel. Purulent discharge at exit site +/- fluctuant collection along the subcutaneous tunnel. Fever or rigors may be present. 3.3 Catheter-related blood stream infections (CRBSI): All or some of these signs may be present: Fever with no other obvious source of infection. Rigors (especially during dialysis) Unexplained hypotension and/or the patient is unwell or acutely confused. Signs suggestive of exit-site infection is usually present in non-tunnelled catheters but may be absent in patients with tunnelled catheters. Signs suggestive of deep seeding infections (Endocarditis, Osteomyelitis, Septic arthritis, 4. Management: 4.1 General Measures: Remember ABCDE approach in all unwell patients. Examine the patient: o Assess the catheter exit site for signs of infection using the visual scores below in Appendix 1. o Look for signs of systemic sepsis (low blood pressure, confusion, poor peripheral perfusion, raised early warning score). o Look for other source of infection (chest, urine, skin ulcers, etc.) o Look for signs of metastatic infection (back pain, joints pain/ swelling, new murmurs) Initial investigations: o Obtain blood for FBC, U&Es, LFTs, CRP, and paired blood culture (Three sets- One from each catheter lumen and one from a peripheral vein) if signs of tunnel infection or CRBSI (Patients with uncomplicated exit site infection and with no systemic signs, do not require blood culture). Patients who develop rigors during haemodialysis, one set of blood culture obtained from the dialysis tubing by nursing staff is adequate. Repeat paired blood culture should be performed if the patient spiked temperature after dialysis. PLEASE REMEMBER WHEN OBTAINING BLOOD CULTURES TO APPLY ASEPTIC TECHNIQUE TO AVOID FLASE POSITIVE RESULTS DUE TO CONTAMINATION, AND TO LABEL BC BOTTLES AND REQUEST FORMS CORRECTLY INCLUDING WHERE THE BLOOD WAS OBTAINED FROM (This will help the microbiology lab. to relate the episode of bacteraemia to the catheter)

3 o Consider CXR, MSU, Ulcer swabs if present, etc. Consider admission to ward 32 for IV anti-biotic treatment and consideration of catheter removal if: o The patient has signs of sepsis (hypotension, tachycardia, tachyponea, confusion, temperature 38 C or 35 C). AND/ OR o The patient has a tunnelled catheter with features of tunnel infection and subcutaneous pus collection. Send catheter tip for culture when removed. 4.2 Treatment: Treatment of CRIs consists of antibiotic treatment with or without catheter removal. Several factors are taken into account when deciding to remove or salvage a catheter, and therefore discussion with senior medial staff and microbiologist is recommended Indications for catheter removal: Non-tunnelled catheters: Any of the following: Catheter has been in situ for 7days (femoral catheters), or 21 days (Jugular or subclavian catheters), Pus is present at exit site, Patient has signs of systemic infection (Rigors, temperature 38 C with no other obvious source of infection, hypotension, or patient is unwell). Microbiology confirmed exit site infection or CRBSI. Tunnelled catheters: Any of the following Patient is haemodynamically unstable. Persistent pyrexia despite treatment with the appropriate antibiotics for >48 hours. Tunnel infection with evidence of subcutaneous pus collection. Confirmed CRBSI with organisms which are difficult to eradicate (Meticillin- sensitive Staphylococci aureus MSSA, MRSA, Gram-ve organisms, Fungi). Attempted salvage of tunnelled catheters infected with MSSA or a Gramve organism other than Pseudomonas aeruginosa can only be considered if: 1 st episode, the patient is responding to treatment, alternative vascular access is difficult, and the decision is authorised by the patient s consultant. Evidence of seeding infections such as osteomyelitis, endocarditis, abscess formation, etc. Persistent signs of exit site or tunnel infection despite a complete course of antibiotic treatment. Relapse of CRI defined as positive exit site culture or positive blood culture with the same organism within 2 weeks after stopping antibiotic treatment. Recurrent CRI defined as episode CRI with the same organism more than 2 weeks after stopping antibiotic treatment.

4 4.2.2 Antibiotic treatment: Uncomplicated exit site infection (Tunnelled catheters only): Prescribe oral Flucloxacillin 500mg qds (Clarithromycin 500mg bd for patients with Penicillin allergy) for 7 days. Adjust antibiotic treatment according to sensitivities. If symptoms persist despite 7 days on treatment with antibiotics to which the organism is sensitive, the catheter has to be removed unless other course of action is recommended by the patient s consultant. Continue antibiotics for a maximum of 5 days after catheter removal unless advised otherwise by the consultant microbiologist. Tunnel infection: Admit patient to ward 32 for treatment with IV Flucloxacillin 1g qds pending culture results, and for catheter removal. Adjust antibiotic according to sensitivity and continue for a total of 7 days after catheter removal if blood culture was negative or yielded gram ve organism or Coagulase-negative staphylococci, and for 14 days if blood culture yielded MSSA or MRSA. Catheter-related blood stream infection (CRBSI): Non-tunnelled catheters: Commence IV Flucloxacillin 1g qds after catheter removal pending culture results. Consider adding Gentamicin IV 1mg/kg (max. 80 mg) if patient is hypotensive or gram ve bacteria is suspected Duration of treatment should be guided by the type of micro-organism as per protocol for tunnelled catheters below. Tunnelled catheters: Follow Flow chart- Appendix 2 5. Prescribing Vancomycin and Gentamicin: 5.1 Vancomycin: An initial dose of 1g IV should be given during the last hour of dialysis, or immediately if the patient is not dialysing that day. Subsequent doses are determined by pre-dialysis Vancomycin levels (Refer to guidance on prescribing and monitoring Vancomycin levels- Appendix 3). Level Vancomycin dose < 10 1g g > 15 None

5 5.3 Gentamicin Discuss indication with a senior medical staff. An initial loading dose of 1mg/kg (max. 80 mg) IV at the end of dialysis should be given. Subsequent doses should be 1mg/kg (max. 80 mg) at the of each dialysis session if pre-dialysis gentamicin level is < 2mg/l. 6. Catheter replacement: 6.1 Non-tunnelled catheters: Assess indication for catheter replacement. NEVER REPLACE SUPECTED INFECTED/ INFECTED CATHETER OVER A GUIDWIRE. Ideally, catheter replacement should be delayed until the patient is afebrile for 48 hours. New venotomy site should be used especially if there was an exit site infection. If urgent haemodialysis treatment is required whilst the patient remains febrile, an in/out femoral catheter approach should be adopted (Discuss with a senior medical staff). 6.2 Tunnelled catheters: Catheter replacement should be deferred until the patient is afebrile for 48hours after commencing treatment. New venotomy site should be used and new tunnel track should be created if the patient had exit site infection. In patients with tunnel infection, a new anatomical site should be used for catheter replacement. If urgent haemodialysis treatment is required whilst the patient remains febrile, an in/out femoral catheter approach should be adopted (Discuss with a senior medical staff).

6 Appendix 1- Visual scores for detection and management of CRIs

7 Appendix 2: Flow chart for management of CRBSI in patients with tunnelled haemodialysis catheter. Appendix 3 DOCTORS GUIDE FOR PRESCRIBING INTRAVENOUS VANCOMYCIN FOR HAEMODIALYSIS PATIENTS DETERMINE LENGTH OF TREATMENT (Discuss with patient s consultant and/or microbiologist) AND PRESCRIBE VANCOMYCIN ON JAC (only if inpatient), EMED, AND PATIENTS S DRUG CHART ON WARD 28 JAC (If inpatient) 1. Log into JAC 2. Click Add order 3. Type Vancomycin and choose Vancomycin injection during dialysis from the drop-down menu 4. Go to the next screen and type 1 in the Dose box 5. In the Frequency box choose the option which reflects the patient s dialysis days from the drop-down menu 6. Complete start date and enter the number of treatment days in the Stop medication after box Emed 1. Log into emed 2. Go to current medication 3. Click Add drug 4. Uncheck Indefinite and enter start and finish dates 5. Type Vancomycin in the Drug box 6. Choose 1g injection in the Preparation box. 7. Choose IV in the Route box 8. Choose 1 g in the Dose box 9. Choose Variable as advised in the Regime box 10. Tick the HD box and press OK Patient s drug chart on ward 28 First Vancomycin dose is 1g Subsequent doses are determined according to Vancomycin level. When Vancomycin level is available, the dialysis nurses will contact you to prescribe Vancmycin on the patient s drug chart. Level Dose <10 1g g >15 None