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Article Review/Hyperlink
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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)
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