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Eman anan
A. Hemodialysis patients with catheters have a 2-3 fold increased risk of infection and death compared to patients with arteriovenous fistulas or grafts. B. Catheter-related bloodstream infections (CRBSIs) in hemodialysis patients can be treated with broad-spectrum antibiotics targeting gram-positive and gram-negative organisms. The catheter should be removed to treat CRBSIs, with the exception of salvaging certain catheters using antibiotic lock therapy along with systemic antibiotics. C. Treatment duration depends on the infecting organism but is typically 10-14 days after symptoms and blood cultures resolve, up to 4-6 weeks for infections like endocarditis. Catheter
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Eman anan
- 2. Hemodialysis patients witha catheter have a 2- to 3-fold increased risk of for infection and death compared with patients with an arteriovenous fistula or graft.
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- 5. -Definition 1-Hyperemia, induration,and/or tenderness ≤2 cm from catheter exit site. 2-May be associated with fever and purulent drainage from the exit site . 3-It may or may not be associated with bacteremia -If there is purulent drainage It should be collected and sent for Gram staining and culture before antibiotic administration . Draw blood sample for blood culture -The patient should be investigated for nasal carriage of Staphylococcus If present, treated with intranasal mupirocin cream Twice a day to each nostril for 5 days
- 6. Empiric antibiotic -Exit site withoutfever -Topical antibiotic +/ - systemic antibiotic -Modify the antibiotic regimen once culture and sensitivity result available -Duration 7 to 14 days Depending on the microorganism isolated .
- 7. If the infection persistsafter an initial course of systemic antibiotics
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- 9. Definition 1-Tenderness, hyperemia,and/or induration that extends >2 cm from the exit site and along the subcutaneous tunnel. 2-It may or may not be associated with bacteremia . If there is purulent drainage It should be collected and sent for Gram staining and culture . Draw blood sample for blood culture
- 10. Empiric Treatment Start broadspectrum empiric antibiotics to cover both gram-positive and negative organisms . Modify antibiotic regimen when culture and sensitivity results are available. Duration In the absence of a concurrent CRBSI Are typically treated for 10 to 14 days Depending on the microorganism isolated and local practice. Duration If a CRBSI is also present The duration of therapy will be as CRBSI
- 11. Catheter removal The catheter should always beremoved, without exchange over a guidewire A new catheter should be inserted at a separate site.
- 12. 3-Catheter related blood streaminfection (CRBSI )
- 13. 1-Suspect CRSBI inpatient with -Fever and/or chills -Hemodynamic instability, altered mental status, and other symptoms and/or signs of sepsis , such as hypothermia, acidosis, and hypotension Not related to another infection site . 2- Paired Blood Culture ( prior to antibiotic initiation ) therapy ) 1- Peripheral + central from catheter hub ( if catheter retained ) 2-Centeral from the catheter + dialysis circuit ( from hemodialysis line ) in case of peripheral vein absent 3- Peripheral + catheter tip if catheter removed ( distal 5 cm from tip )
- 14. Consideration for bloodsample 1-Obtain samples for blood culture prior to the initiation of antibiotic therapy 2-Marke the bottles to reflect the site from which the samples were obtained (catheter and peripheral vein ) . 3- For percutaneously drawn blood samples Skin preparation with use of alcohol or alcoholic chlorhexidine( 10.5%) (allow adequate skin contact and drying times to mitigate blood culture contamination ) 4-Peripheral blood samples should be from vessels that are not intended for future use in creating a dialysis fistula (e.g., hand veins) 5-If a blood sample is obtained through a catheter Clean the catheter hub with either alcohol or tincture of iodine or alcoholic chlorhexidine (10.5%) 6-The volume of the locking solution should be removed prior to blood culture collection .
- 15. 3-Empiric antimicrobial therapyfor hemodialysis catheter related blood stream infection CRBSI result from a broad array of Gram positive and Gram negative organism Gram +ve microorganisms -Staphylococcus aureus ( MSSA or MRSA) -Enetrococci - Coagulase negative Staphylococci Gram -ve bacill -Pseudomonas species and others Fungi -Candida species Polymicrobial -------------------------------------------------- Others --------------------------------------------------
- 16. -Choice of antimicrobialagent for CRBSI based on coverage of Gram +ve bactria + Gram -ve bactria +/- fungal infection M.O Antimicrobial agent For Gram +ve M.O - Cefazolin ( MSSA ) - Vancomycin or teicoplanin (if risk of MRSA ) For Gram -ve M.O - 3rd generation cephalosporin :Ceftazidim - 4th generation cephalosporin :Cefepime - Beta lactam / Beta lactamase inhibitor :Piperacillin /Tazobactam - Carbapenem : (Imipenem / cilastatin )-Meropenem Fungal infection Fluconazole ( if risk for C.glabarata – C .Krusei is low ) (If no previous exposure in the last 3 months ) Amphotericin Indication for fungal infection Septic patient with following risk factor 1- Prolonged use of broad spectrum antibiotic 2-Femoral catheter 3- Hematological malignancy 4-Bone marrow or organ transplant 5-TPN 6-Colonization of candida at multiple site
- 17. -Fever -Chills -Hemodynamic instability -Or alteredmental status Resolve within 2-3 days and there is no metatstatic infection or exit siteinfection or tunnel infection . The catheter can be retained, and an antibiotic lock can be used as adjunctive therapy after each dialysis session for 10–14 days The infected catheter can be exchanged over a guidewire for a new, longterm hemodialysis catheter
- 18. Definitive diagnosis ofdialysis catheter-induced bacteremia requires one of -Concurrent positive blood cultures of the same organism from the catheter and a peripheral vein. -Culture of the same organism from both the catheter tip and at least one percutaneous blood culture CRSBI diagnosis unlikely Booth sets of initial blood cultures have negative results If there is no other identified source of infection and signs and symptoms of bacteremia have resolved Stopping empiric therapy
- 19. 1-De- escalation tosingle antibiotic once culture available. 2-Patients who receive empirical vancomycin or teicoplanin and who are found to have CRBSI due to methicillin-susceptible S. aureus should be switched to cefazolin . 3-Patients who have CRBSI due to vancomycin- resistant enterococci can be treated with oral linezolid .
- 20. If peripheral bloodculture –ve and catheter culture +ve Antibiotic are not generaly recommended The exception is patients whose catheter tips grow S. aureus and have negative blood culture These patients should receive 5–7 days of antibiotic
- 21. Complicated Infection -Port abscess -Osteomyelitis -Septic arthritis -Endocarditis Tunnel infection Sever sepsis Hemodynamic instability If feverand bacterimia persist 48 -72 hr after initiaition of antibiotic to which the organism is susceptible S. aureus Pseudomonas species Candida species MDR organism
- 22. Catheter salvage Cultures should be collected after72 hours of adequate antibiotic therapy catheter should be removed if the blood culture results remain positive
- 23. A-Placement of atemporary non-tunneled catheter is typically the best alternative option for short-term dialysis access. B- A temporary nontunneled catheter should be inserted into another anatomical site . C- If absolutely no alternative sites are available for catheter insertion, then exchange the infected catheter over a guidewire. D-After a hemodialysis catheter is removed for CRBSI, a long-term hemodialysis catheter can be placed once blood cultures with negative results are obtained.
- 24. Table 1 :Treatmentduration for CRBSI Gram –ve bacilli 10 – 14 days Coagulase -ve Staphylococcus species Catheter is remove Treat wih antibiotic for 5-7 days Catheter retained Treat for 10 -14 day Enterococcus Catheter retained (Treat with antibiotic for 7-10) days Staphylococcus auerus 1-Antibiotic for 4-6 weeks unless patient have exception recommended in 2 2- Short duration of antimicroibial ( minimum 14 days) If patient -Not diabetic -Not immune suppressed ( not receiving systemic steroid or other immune suppressive drugs , and is non neutropenic) -IF catheter removed,if patient has no prosthetic intravascular device (e.g pacemaker or recently placed vascular graft ) -If fever and bacteremia resolve within 72 hr after initiation of antimicrobial therapy
- 25. Table 1 :Treatmentduration for CRBSI Candida SPP 14 days after 1st –ve blood culture Endocarditis 4–6-week Septic thrombophlebitis 4–6-week Osteomyelitis 6–8 weeks of therapy
- 26. (ALT) involves instillationof a highly concentrated antibiotic solution into an intravascular catheter lumen For CRBSI, antibiotic lock should not be used alone; instead, it should be used in conjunction with systemic antimicrobial therapy . Antibiotic lock is indicated for patients with CRBSI involving long-term catheters with no signs of exit site or tunnel infection for whom catheter salvage is the goal The antibiotic/heparin lock solution is prepared immediately before instillation into the catheter lumen The antibiotic lock should be replaced every 48 hours, after each HD session This mixture of antibiotic and anticoagulant is then instilled ("locked") into each catheter lumen at the end of each dialysis session, in place of standard heparin locks, for the duration of the systemic antibiotic ( 10- 14 days ).
- 28. Catheter Salvage Blood culture should be obtained1 week after completion of antibiotic treatment If the result positiveThe catheter should be removed
- 29. 1-Blood culture :Obtainblood cultures from catheter and peripheral vein or bloodline if peripheral vein not feasible 2- Empiric antibiotic Blood culture -ve Stop ABX Resolution of bactremia and fungemia in 2-3 days and fever Presistant bacteremia / fungmia and fever Coagulase –ve Staphylococci Gram –ve bacilli S.aureus Candida albican Remove CVC Retain CVC Antibiotic for 10 -14 day ,Continue ABL Or guidewire exchange Retain CVC Antibiotic for 10 -14 day ,Continue ABL Or guidewire exchange Remove CVC And Antibiotic x 3 weeks If TEE –ve Guidewire CVC exchange Antifungal for 14 day after 1st -ve blood culture Antibiotic x4-6 and look of metastatic Infection
- 30. Antibiotic Dose Cefazolin 20mg/kg (actual body weight), rounded to the nearest 500-mg increment, after dialysis Ceftazidim 500 mg to 1gm q 24 hr or 1- 2 gm q 48 – 72 hr after dialysis Cefepime 1 gm on day 1 then 0.5 -1 gm q 24 hr or 1-2 gm q 48 - 72 ( after dialysis ) Piperacillin/ Tazobactam 2.25 gm q 12 hr after heamodialysis session Vancomycin 20 mg/ kg loading dose infused during last hr of Dialysis session Then 500 mg during the last 30 min of the following dialysis session Meropenem 500 mg every 24 hr after hemodialysis Assume 3 times weekly and complete IHD sessions Imipenem / cilastatin 250 mg to 500 mg q 12 hr after hemodialysis session Linezolide 600 mg every 12 hr after hemodialysis
- 31. Antifungal Dose Fluconazole iv100 – 200 q 24 hr Or 200 – 400 q 48 – 72 hr Amphotericin B Caspofungin 70 mg iv loading dose followed by 50 mg iv daily Micafungin 100 mg iv daily
- 32. References 1. MermelLA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection update by the infectious disease society of america. Clin Infec Dis.( 2009 ) 2-O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. CDC 2011. Accessed: 6/6/2014. http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines (2011) 3-UpToDate 4- NKF KDOQI Vascular access guideline. ( 2006 ) 5- Diagnosis, prevention and treatment of haemodialysis catheter-related bloodstream infections (CRBSI): a position statement of European Renal Best Practice (ERBP) NDT Plus (2010) 6-Canadian Journal of Kidney Healthand DiseaseVolume 3: 1–11 ( 2016 ) 7 - Hand book of dialysis 5th edition 8-Johns Hoppikens antimicrobial guidline (2015 – 2016 )