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Table of Contents
BRIEF REPORT
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 22-25

Catheter-related blood stream infections among children on hemodialysis over 7 years: A single-center experience


Department of Paediatric Nephrology, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates

Date of Submission16-Sep-2020
Date of Decision31-Jan-2021
Date of Acceptance24-Mar-2021
Date of Web Publication30-Jun-2021

Correspondence Address:
Gurinder Kumar
Department of Paediatrics, Sheikh Khalifa Medical City, Al Karamah Street, Abu Dhabi
United Arab Emirates
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajpn.ajpn_31_20

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  Abstract 


Patients with end-stage kidney disease frequently require hemodialysis (HD) through central venous catheters (CVCs) as a bridge to renal transplantation. However, longevity of CVCs is affected by the occurrence of CVC-related bloodstream infections (CVC-RBI). This retrospective study evaluated the outcomes of CVCs inserted for HD, with specific attention to rates and etiology of CVC-RBI. Over 7 years between January 2010 and December 2016, 39 patients, aged 2–15 years, were admitted for HD for ESRD in the Department of Pediatric Nephrology, Sheikh Khalifa Medical City, Abu Dhabi, UAE. The most etiology for ESRD was renal dysplasia (28.2%). Tunneled cuffed CVC was inserted most commonly in the right internal jugular vein (40.2%). The most common reason for change of CVC was CVC-RBI (28.9%). The estimated rate of CVC-RBIs was 1.72/000 CVC days. Staphylococcus aureus was the most common (28.6%) etiology. CVC longevity was significantly influenced by the occurrence of CVC-RBI (P < 0.001), and the rates of CVC-RBI were significantly different between patients with less or more than 200 CVC days (P = 0.002). Most patients either continued on HD (48.7%) or underwent kidney transplantation (28.2%). This study highlights that rates of CVC-RBI were low but were associated with prolonged CVC use.

Keywords: Catheter-related bloodstream infections, central venous catheters, end-stage renal disease, hemodialysis


How to cite this article:
Kumar G. Catheter-related blood stream infections among children on hemodialysis over 7 years: A single-center experience. Asian J Pediatr Nephrol 2021;4:22-5

How to cite this URL:
Kumar G. Catheter-related blood stream infections among children on hemodialysis over 7 years: A single-center experience. Asian J Pediatr Nephrol [serial online] 2021 [cited 2021 Dec 2];4:22-5. Available from: https://www.ajpn-online.org/text.asp?2021/4/1/22/320185




  Introduction Top


Globally, the incidence of end-stage kidney disease (ESKD) requiring kidney replacement therapy (KRT) is increasing.[1] Hemodialysis (HD), the most frequently used modality for KRT, is often conducted using central venous catheter (CVC), particularly when vascular access is placed urgently. However, CVC is associated with high rates of infections, termed CVC-related bloodstream infections (CVC-RBI). CVC-RBI is the second most common cause of death in these patients and lead to high health-care costs and morbidity.[2],[3] Tunneled CVC is associated with CVC-RBI in 1.6 (1.1–5.5) patients per 1000 CVC days.[3],[4] Information on rates of CVC-RBI in pediatric patients with tunneled cuffed CVC is lacking. This retrospective study was planned to evaluate the incidence, etiology, and outcomes of CVC-RBI in pediatric patients undergoing HD for ESKD and the outcomes of CVC at a single center in the United Arab Emirates.


  Methods Top


This retrospective study involved the review of records of 39 patients, 2–15 years old, who underwent HD for ESKD using tunneled CVC in the Department of Pediatric Nephrology, Sheikh Khalifa Medical City, Abu Dhabi, UAE, over 7 years between January 2010 and December 2016. No patient had an arteriovenous (AV) fistula because of personal preference. Patients on HD with TC-CVC were included, while those on peritoneal dialysis (PD) were excluded. Study protocol was approved by the Institutional Ethics Committee. The double-cuffed tunneled CVC (Medcomp, 8 F, 12-cm length; Medical Components, Inc., Harleysville, PA) was inserted by either the surgical (n = 22) or angiographic (n = 17) route. HD was performed using the AK200S® machine (Gambro, Lund, Sweden) by qualified pediatric dialysis nursing staff. under supervision of experienced pediatric nephrologist.

The treatment of CVC infection was as per the protocol outlined by National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guidelines.[5] The routine management of HD-CVC comprised strict sterile use and daily care of CVC. The parents were adequately trained to take care of the child at home. Prophylactic antibiotic therapy, in form of topical application, as catheter lock, or systemically, was not used. Identification of microorganisms and susceptibility testing for antibiotics was done using the automated MicroScan system (DADE Behring, Sacramento, CA, USA). Bacterial growth curves were evaluated with the help of BacT/ALERT®3D (bioMérieux, Inc., Durham, NC), an automated microbial detection system.

Statistical analysis

Data were collected in Microsoft Excel Sheet 2013 (Microsoft, Redmond, Washington) and analyzed using SPSS Version 23.0 for Windows statistical package (SPSS Inc., Chicago, IL, USA). Variables were summated as number (percentage) and median (range or interquartile range). The rate of CVC-RBI was calculated as incidence per 1000 CVC days. Chi-square test was used to assess association between CVC days >200 with occurrence of infection, with P <0.05 considered significant.


  Results Top


A total of 93 CVCs were inserted in 39 boys. Over half (53.8%) of the patients were boys. Median age of the patients was 9 years; 53.8% were aged >8 years [Table 1]. The most common reason for kidney failure requiring CVC placement was renal dysplasia (28.2%) and the most common site of insertion was the right internal jugular vein (40.2%) cases. The total CVC days were 20341 days and the median (interquartile range; range) of CVC days was 199 (85–779; 23–2556) days [Table 1]. While 56.4% of CVCs were present for over 6 months, the CVC with longest survival lasted 2556 days.
Table 1: Baseline characteristics

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Infection was the most common single reason for the change in CVC (28.9%), followed by removal after successful kidney transplantation (11.8%). Overall, 28.0% of the CVC were infected and the rate of CVC-RBI was estimated at 1.72/1000 CVC days. The most common organism responsible for infection was Staphylococcus aureus (28.6%) [Table 2].
Table 2: Details of central venous catheter related bloodstream infection (CVC RBI)

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Overall, there were three (7.7%) deaths during the study period; none were attributed to CVC-RBIs. The most common insertion site for CVC-RBI was the subclavian vein (50%), followed by internal jugular (35.7%) and femoral (4.3%) veins. Continued HD (48.7%), followed by renal transplant (28.2%) was the most common outcomes. The median time to renal transplantation after initiating the HD was 198 (41–1084) days.

There was no significant difference in the age of patients with CVC-RBI and those without CVC-RBI (P = 0.10) [Table 3]. As compared to patients without CVC-RBI, patients with CVC-RBI had prolonged CVC duration (P < 0.0001). Nine patients with CVC duration 200 or more days had CVC-RBI, compared to only one in those with CVC duration <200 CVC days (P = 0.002).
Table 3: Association of parameters with central venous catheter infection

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  Discussion Top


The current study shows that prolonged use of CVC is associated with a significantly increased risk of contracting CVC-RBI. Prolonged use of CVC is described as a major risk factor for infections in HD patients.[6] A study reported that CVC duration more than 10 days is associated with risk of CVC-RBI.[7] Right internal jugular vein was the most common site of CVC insertion, similar to findings in other studies.[8],[9] The most common cause of kidney failure in our patients was renal dysplasia (28.2%), and similar findings are reported by others.[9],[10] We found the subclavian vein as the most common site of CVC-RBI infection, in agreement with reports in literature.[5],[11] Since all our patients had tunneled CVC, we could not comment on the type of CVCs that are associated with higher risk of CVC-RBIs. Available studies suggest that nontunneled CVCs are associated with 2–3 times greater risk of CVC-RBIs than TC-CVC.[12] Infections (28.9%) and poor flow (16.5%) were common reasons for changing CVC, both of which might relate to the prolonged duration of CVC placement. Similar findings are reported by others.[13],[14]

Data from US indicate that the most commonly encountered microorganisms for CVC-RBIs are coagulase-negative staphylococci (32-45%), Staphylococcus aureus (22%–29%), and enterococci (9%–13%); 21%–30% of cases have Gram-negative bacteria.[15] Patients on HD are at increased risk of infection with multi-resistant organisms such as methicillin-resistant S. aureus.[16] Our findings are consistent with these results. The CVC-RBI rate was found to be 1.72 per 1000 CVC days. This finding is consistent with rates reported by other studies (1.3–1.5 per 1000 CVC days).[8],[9] One study has reported CVC-RBI rate as 0.52 per 1000 CVC days, and that infection did not result in removal of CVCs.[17]

In the current study, the median (interquartile range) for CVC survival was 199 (85-779) days. Two studies reported median CVC survival of 110 and 320 days;[9],[18] in the former study, the maximum catheter survival was for 586 days. In the current study, the CVCs remained active in 19 patients, 11 patients underwent renal transplantation, 5 were shifted to PD, and three patients died, and AV fistula was created in one patient. A study on nine patients reported transplantation in four patients, continued HD in 3 and shift to PD in two patients.[17] Similarly, another study reported that five of 11 patients enrolled underwent transplantation, CVCs remained active in two patients, two were shifted to PD, one had AV fistula created, and one died due to sepsis.[9]

As compared to AV fistula, CVCs are associated with increased risk of infection and morbidity.[8],[19] Hence, experts recommend attempting to create an AV fistula as the first choice for vascular access in those patients weighing >20 kg in whom renal transplantation appears to be unlikely in the coming 1 year.[5]


  Conclusion Top


This study highlights that prolonged duration of CVC use is associated with significantly increased risk of CVC-RBIs. The overall rate of infection associated with the use of CVC was low and continued HD was the most common outcome.

Acknowledgments

The authors acknowledge the support of Maverick Medicorum Medical Communications Pvt. Ltd., India, toward medical writing and data analysis services.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hassanien AA, Al-Shaikh F, Vamos EP, Yadegarfar G, Majeed A. Epidemiology of end-stage renal disease in the countries of the Gulf Cooperation Council: A systematic review. JRSM Short Rep 2012;3:38.  Back to cited text no. 1
    
2.
United States Renal Data System. 2018 USRDS Annual Data Report. Volume 2: End-Stage Renal Disease in the United States. Available from: https://www.usrds.org/2018/download/2018_Volume_2_ESRD_in_the_US.pdf. [Last accessed on 2019 May 30].  Back to cited text no. 2
    
3.
Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: A systematic review of 200 published prospective studies. Mayo Clin Proc 2006;81:1159-71.  Back to cited text no. 3
    
4.
Miller LM, Clark E, Dipchand C, et al. Hemodialysis tunneled catheter-related infections. Can J Kidney Health Dis. 2016;3:2054358116669129.  Back to cited text no. 4
    
5.
Kidney Disease Outcomes Quality Initiative (KDOQI) Work Group. Clinical practice recommendation 8: Vascular access in pediatric patients. Am J Kidney Dis 2006;48 S1:S274-6.  Back to cited text no. 5
    
6.
Wang K, Wang P, Liang X, Lu X, Liu Z. Epidemiology of haemodialysis catheter complications: A survey of 865 dialysis patients from 14 haemodialysis centres in Henan province in China. BMJ Open 2015;5:e007136.  Back to cited text no. 6
    
7.
Sahli F, Feidjel R, Laalaoui R. Hemodialysis catheter-related infection: Rates, risk factors and pathogens. J Infect Public Health 2017;10:403-8.  Back to cited text no. 7
    
8.
Borzych-Duzalka D, Shroff R, Ariceta G, Yap YC, Paglialonga F, Xu H, et al. Vascular access choice, complications, and outcomes in children on maintenance hemodialysis: Findings from the International Pediatric Hemodialysis Network (IPHN) Registry. Am J Kidney Dis 2019;74:193-202.  Back to cited text no. 8
    
9.
Lopez PJ, Troncoso B, Grandy J, Reed F, Ovalle A, Celis S, et al. Outcome of tunnelled central venous catheters used for haemodialysis in children weighing less than 15 kg. J Pediatr Surg 2014;49:1300-3.  Back to cited text no. 9
    
10.
Shroff R, Rees L, Trompeter R, Hutchinson C, Ledermann S. Long-term outcome of chronic dialysis in children. Pediatr Nephrol 2006;21:257-64.  Back to cited text no. 10
    
11.
Briones L, Diaz Moreno A, Sierre S, Lopez L, Lipsich J, Adragna M. Permanent vascular access survival in children on long-term chronic hemodialysis. Pediatr Nephrol 2010;25:1731-8.  Back to cited text no. 11
    
12.
Weijmer MC, Vervloet MG, ter Wee PM. Compared to tunnelled cuffed haemodialysis catheters, temporary untunnelled catheters are associated with more complications already within 2 weeks of use. Nephrol Dial Transplant 2004;19:670-7.  Back to cited text no. 12
    
13.
Chawla PG, Nevins TE. Management of hemodialysis catheter-related bacteremia–A 10-year experience. Pediatr Nephrol 2000;14:198-202.  Back to cited text no. 13
    
14.
Onder AM, Chandar J, Saint-Vil M, Lopez-Mitnik G, Abitbol CL, Zilleruelo G. Catheter survival and comparison of catheter exchange methods in children on hemodialysis. Pediatr Nephrol 2007;22:1355-61.  Back to cited text no. 14
    
15.
Böhlke M, Uliano G, Barcellos FC. Hemodialysis catheter-related infection: Prophylaxis, diagnosis and treatment. J Vasc Access 2015;16:347-55.  Back to cited text no. 15
    
16.
Patel PR, Kallen AJ, Arduino MJ. Epidemiology, surveillance, and prevention of bloodstream infections in hemodialysis patients. Am J Kidney Dis 2010;56:566-77.  Back to cited text no. 16
    
17.
Quinlan C, Bates M, Sheils A, Dolan N, Riordan M, Awan A. Chronic hemodialysis in children weighing less than 10 kg. Pediatr Nephrol 2013;28:803-9.  Back to cited text no. 17
    
18.
Pollack S, Eisenstein I, Tarabeih M, Shasha-Lavski H, Magen D, Zelikovic I. Long-term hemodialysis therapy in neonates and infants with end-stage renal disease: A 16-year experience and outcome. Pediatr Nephrol 2016;31:305-13.  Back to cited text no. 18
    
19.
Valentini RP, Chand DH. Catheter craze continues for pediatric hemodialysis vascular access: The need to move from catheter first to catheter last. Am J Kidney Dis 2019;74:155-7.  Back to cited text no. 19
    



 
 
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