HDCN Article Review/Hyperlink

Marr KA, Sexton DJ, Conlon PJ, Corey GR, Schwab SJ, Kirkland KB

Catheter-related bacteremia and outcome of attempted catheter salvage in patients undergoing hemodialysis

Ann Int Med (Aug) 127:275-280 1997

Before the onset of cuffed internal jugular (IJ) hemodialysis catheters, catheter related bacteremia was a clear indication for removal of the catheter. However, in some patients with cuffed IJ catheters the catheter may be the last available form of access (although admittedly, one can usually temporize with an uncuffed femoral catheter). It has become acceptable practice, based on some preliminary published results supportive of the practice, to attempt a limited trial of antibiotics to treat suspected catheter related infection in such patients.

In this paper by Marr et al, a retrospective review was performed of dual lumen cuffed hemodialysis catheters in 102 patients between 1995 and 1996. Forty percent of patients developed 62 episodes of bacteremia. 24 catheters were removed immediately, whereas in 38, catheter salvage was attempted. In 24 of these, treatment failed, defined as repeated positive blood culture or continued fever with negative blood cultures, and the catheter was removed. 12 catheters were salvaged successfully, although only 6 of these survived an additional 3 months; the other 6 had to be removed for dysfunction or some other reason not related to infection. Recurrent bacteremia with the same organism was 68% in patients subjected to salvage attempts, vs. 17% in patients in whom the catheter was immediately removed.

Of the patients with bacteremic episodes, 9/41 (22%) had complications: 6 osteomyelitis, 1 septic arthritis, 4 endocarditis, and 2 died. All complications occurred in patients infected with Gram positive organisms.

Comment: The authors conclude that catheter salvage has a low success rate (32% initially), but was not associated with a higher complication rate. There was not a higher morbidity associated with catheter salvage attempt, but this was a retrospective study, and the authors point out that a selection bias (less severe infections leading to salvage attempts) may have been present. It is easy to say that catheters should be immediately removed, but in many difficult patients, catheter salvage attempts may be required. An additional complication not mentioned that has been associated with catheter salvage attempts is spinal epidural abscess. (John T. Daugirdas, M.D., University of Illinois at Chicago)