Management of hemodialysis catheter-related bacteremia with an adjunctive antibiotic lock solution.
BACKGROUND
Tunneled dialysis catheters are complicated by frequent systemic infections. Standard therapy of catheter-associated bacteremia involves both systemic antibiotics and catheter replacement. Recent data suggest that biofilms in the catheter lumen are responsible for the bacteremia, and that instillation of an antibiotic lock (highly concentrated antibiotic solution) into the catheter lumen after dialysis sessions can eradicate the biofilm.


METHODS
We analyzed prospectively the efficacy of an antibiotic lock protocol, in conjunction with systemic antibiotics, for treatment of patients with dialysis catheter-associated bacteremia without catheter removal. Protocol success was defined as resolution of fever and negative surveillance cultures one week following completion of the protocol. Protocol failure was defined as persistence of fever or surveillance cultures positive for any pathogen. In addition, infection-free catheter survival was compared to that observed in institutional historical control patients treated with catheter replacement.


RESULTS
Blood cultures were positive in 98 of 129 of episodes (76%) in which patients dialyzing with a catheter had fever or chills. Protocol success occurred in 40 of 79 infected patients (51%) treated with the antibiotic lock. Protocol failure occurred in 39 cases (49%): 7 had persistent fever, 15 had positive surveillance cultures (9 for Candida and 6 for bacteria), and 17 required catheter removal due to malfunction. Each of the pathogens in the surveillance cultures was different from the original pathogen in that patient. Eight of the 9 secondary Candida infections and all 6 secondary bacterial infections resolved after catheter exchange and specific antimicrobial treatment. Overall catheter survival with the antibiotic lock protocol was similar to that observed among patients managed with catheter replacement (median survival, 64 vs. 54 days, P = 0.24).


CONCLUSIONS
Use of an antibiotic lock, in conjunction with systemic antibiotic therapy, can eradicate catheter-associated bacteremia while salvaging the catheter in about one half of cases. Moreover, this management approach offers clinical advantages over routine catheter exchange.
Krishnasami
Zipporah
Z
Division of Nephrology, Department of Pharmacy, University of Alabama at Birmingham, 1900 University Boulevard, Birmingham, AL 35294, USA.
Carlton
Donna
D
Bimbo
Lisa
L
Taylor
Maria E
ME
Balkovetz
Daniel F
DF
Barker
Jill
J
Allon
Michael
M
D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D016470:Bacteremia / Q000188:drug therapy* / Q000209:etiology*; D018441:Biofilms / Q000187:drug effects*; D002404:Catheterization / Q000009:adverse effects*; D004359:Drug Therapy, Combination; D005260:Female; D016905:Gram-Negative Bacterial Infections / Q000178:diet therapy / Q000209:etiology; D016908:Gram-Positive Bacterial Infections / Q000188:drug therapy / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D006435:Renal Dialysis / Q000009:adverse effects*; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents