title: Comparative effectiveness of two catheter locking solutions to reduce catheter-related bloodstream infection in hemodialysis patients.
abstract: OBJECTIVE
  Infection is the second leading cause of death in hemodialysis patients. Catheter-related bloodstream infection and infection-related mortality have not improved in this population over the past two decades. This study evaluated the impact of a prophylactic antibiotic lock solution on the incidence of catheter-related bloodstream infection and mortality.
  
  
  METHODS
  This prospective, multicenter, observational cohort study compared the effectiveness of two catheter locking solutions (gentamicin/citrate versus heparin) in 555 hemodialysis patients dialyzing with a tunneled cuffed catheter between 2008 and 2011. The groups were not mutually exclusive. Rates of catheter-related bloodstream infection and mortality hazards were compared between groups.
  
  
  RESULTS
  The study population (n=555 and 1350 catheters) had a median age of 62 years (interquartile range=41-83 years), with 50% men and 71% black. There were 427 patients evaluable in the heparin period (84,326 days) and 322 patients evaluable in the antibiotic lock period (71,192 days). Catheter-related bloodstream infection in the antibiotic lock period (0.45/1000 catheter days) was 73% lower than the heparin period (1.68/1000 catheter days; P=0.001). Antibiotic lock use was associated with a decreased risk of catheter-related bloodstream infection compared with heparin (risk ratio, 0.23; 95% confidence interval, 0.13 to 0.38 after multivariate adjustment). Cox proportional hazards modeling found that antibiotic lock was associated with a reduction in mortality (hazard ratio, 0.36; 95% confidence interval, 0.22 to 0.58 in unadjusted analyses; hazard ratio, 0.32; 95% confidence interval, 0.14 to 0.75 after multivariate adjustment). The rate of gentamicin-resistant organisms decreased (0.40/1000 person-years to 0.22/1000 person-years) in the antibiotic lock period (P=0.01).
  
  
  CONCLUSIONS
  The results of this study show that the use of a prophylactic, gentamicin/citrate lock was associated with a substantial reduction in catheter-related bloodstream infection and is the first to report a survival advantage of antibiotic lock in a population at high risk of infection-related morbidity and mortality.
authors: Divisions of Nephrology and Hypertension, Department of Pharmacy Services, and manierski@wayne.edu.
authors: Carol L
authors: CL
authors: Moore
authors: Stanford University, Palo Alto, California; and.
authors: Anatole
authors: A
authors: Besarab
authors: Infection Prevention, and.
authors: Marie
authors: M
authors: Ajluni
authors: Divisions of Nephrology and Hypertension.
authors: Vivek
authors: V
authors: Soi
authors: Public Health Sciences, Henry Ford Health System, Detroit, Michigan;
authors: Edward L
authors: EL
authors: Peterson
authors: Infection Prevention, and Infectious Diseases.
authors: Laura E
authors: LE
authors: Johnson
authors: Infection Prevention, and Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan.
authors: Marcus J
authors: MJ
authors: Zervos
authors: Divisions of Nephrology and Hypertension.
authors: Elizabeth
authors: E
authors: Adams
authors: Divisions of Nephrology and Hypertension.
authors: Jerry
authors: J
authors: Yee
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D000925:Anticoagulants / Q000627:therapeutic use; D016470:Bacteremia / Q000175:diagnosis / Q000382:microbiology / Q000517:prevention & control; D055499:Catheter-Related Infections / Q000175:diagnosis / Q000382:microbiology / Q000401:mortality / Q000517:prevention & control*; D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000295:instrumentation / Q000401:mortality; D002408:Catheters, Indwelling / Q000009:adverse effects*; D062905:Central Venous Catheters / Q000009:adverse effects*; D002951:Citrates / Q000627:therapeutic use*; D057186:Comparative Effectiveness Research; D018592:Cross-Over Studies; D005260:Female; D005839:Gentamicins / Q000627:therapeutic use*; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D016016:Proportional Hazards Models; D011446:Prospective Studies; D006435:Renal Dialysis; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D000925:Anticoagulants; D002951:Citrates; D005839:Gentamicins; C514290:trisodium citrate; D006493:Heparin
keywords: hemodialysis; hemodialysis access; vascular access