Catheter Related Bacteremia

Catheters are associated with a high prevalence of catheter-related bacteremia (CRB) and significant morbidity and mortality in hemodialysis (HD) patients1,2,3,4. According to the 2008 United States Renal Data System (USRDS) report, hospital admissions for bacteremia/septice¬mia in end stage renal disease (ESRD) patients fell in the early part of the decade, but are now at a level 31% higher than in 19935. HD vascular access, and in particular dialysis catheters, has emerged as a major risk factor for infection and bacteremia with numerous reports implicating HD vascular access in 48 to 73% of all bacteremias in the HD population6.

Catheter patients have a greater relative risk (RR) of death than patients with arteriovenous fistula (AVF) or arteriovenous graft (AVG). Analysis of data from the USRDS Dialysis Morbidity and Mortality Study Wave I indicates that non-diabetic patients dialyzing with a catheter had a significantly higher mortality risk when compared with AVF (RR 1.70, p<0.001)7. In a recent retrospective cohort study of 7497 prevalent HD patients, the proportion of patients who died was higher among those who dialyzed with a cuffed catheter (15.2%) as compared to those who dialyzed with either an AVG (9.1%) or an AVF (7.3%)8. This marked difference remains despite demographic and comorbidity adjustments. In the most fully adjusted model, data from the Dialysis Outcomes and Practice Patterns Study I and II demonstrate that the mortality risk for patients using a catheter or graft remained substantially greater (RR 1.32 and RR 1.15, respectively; p<0.001) when compared with an AVF9.

Using results from different epidemiologic studies and assuming a mortality rate of approximately 5 to 10% for each CRB event, there are approximately 2750 to 5500 HD patient deaths per year as a result of CRB1. This increased mortality risk from catheters also explains a significant portion of the lower mortality rate in Europe when compared to the US9.

Several studies have attempted to define the risk factors involved in CRB. Site of insertion, duration of use and influence of comorbidity have been reported to impact the risk of developing CRB. The subclavian location is associated with the highest risk for developing catheter associated central venous stenosis6,10 and femoral catheters are more susceptible to infections than thoracic catheters6,11. The duration of catheter use is also important because the risk of infection increases linearly with time6,12,13. A recent study by Mazonakis et al. demonstrated that patients dialyzing through a tunneled central venous catheter (compared with an AVF) have a significantly higher risk of access-related bacteremia, irrespective of comorbidity14. Among local factors, poor personal hygiene, use of occlusive transparent dressing, and accumulation of moisture around the exit site have been described as risk factors for CRB6,10,15. Nasal and skin colonization with Staphylococcus aureus, as well as bacterial colonization of HD catheters, have also been reported as risk factors for systemic infection6.

The initial management of CRB is through the use of systemic antibiotic therapy. The initial choice of antibiotics is empiric and requires knowledge of the most frequent organisms prevalent in the area and their pattern of sensitivities16. Typically, this includes initial coverage for both gram positive and negative organisms. Once the organism and its sensitivities are known, specific antimicrobial therapy should replace empiric therapy, in order to limit the emergence of highly resistant infections6,16.

The second aspect of CRB management is immediate catheter removal or catheter exchange over a guidewire. Some investigators have demonstrated that infection-free survival for patients with CRB treated with systemic antibiotics alone was inferior to that obtained with either immediate catheter removal or catheter exchange17. However, limited published reports provide a direct comparison of clinical outcomes of CRB managed by means of different treatment strategies17. While various approaches of catheter removal and exchange have been studied, each has resulted in a significantly compromised quality of life for the patient and substantial costs to the healthcare system. Catheter removal with delayed placement of a new catheter involves 3 separate procedures totaling approximately $650/patient in professional fees17. Routine exchange of infected catheters over a guidewire costs approximately $250/patient17. This economic analysis does not include facility fees or miscellaneous expenses incurred for such items as patient transportation.

Another option to decrease catheter morbidity and mortality is the development of antibiotic or antibiotic-anticoagulant catheter lock solutions to decrease the risk of catheter related sepsis and thrombosis18. Catheter biofilm is frequently associated with thrombus or fibrin in the catheter17. Pharmacological eradication of bacteria in the biofilm may permit definitive treatment of the source of CRB while salvaging the dialysis catheter; however, there are striking differences in the likelihood of success depending on the type of pathogen17. These solutions remain under investigation and are not FDA approved for use in the US.

The clinical presentation of the typical patient who develops CRB suggests that the major source for the infection is contamination of the catheter hub at the time of use in the dialysis facility19. Thus, one can presume, the best option to prevent catheter related bacteremia, other than choosing an alternative access type, is implementation and strict adherence to a CRB prophylaxis protocol. In one 24 month study, in which 932 tunneled cuffed dialysis catheters were placed in 402 patients, the incidence of CRB fell from an average of 6.97 per 1000 catheter days during the control period to an average of 1.68 during the study period through the implementation of a strict catheter management program19. More importantly, the decreased infection rate was sustained with an average incidence of 1.28 per 1000 catheter days during the last 18 months of the study period19. Guideline 3 of KDOQI’s Clinical Practice Guidelines for Vascular Access provides a sample protocol for catheter care which is based on the Centers for Disease Control standard practice for accessing catheters and cleansing catheter exit sites20.

Research continues to address not only problems related to CRB, but also catheter tip clotting, catheter fibrous sheathing and central venous stenosis. Until solutions to these issues are found, “fistula first and catheters last21” will remain the best option to provide excellent outcomes and minimize patient complications.


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  20. Clinical Practice Guidelines and Clinical Practice Recommendations
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Another topic of interest: Change in vascular access and mortality in maintenance hemodialysis patients. Click here to view.