Original Investigation
Dialysis
Treatment of Dialysis Catheter–Related Enterococcus Bacteremia With an Antibiotic Lock: A Quality Improvement Report

https://doi.org/10.1053/j.ajkd.2008.06.033Get rights and content

Background

Catheter-related bacteremia (CRB) is a frequent complication of tunneled dialysis catheters, and Enterococcus is a common infecting organism. CRB may be treated by instilling an antibiotic lock into the catheter lumen in conjunction with systemic antibiotics. The efficacy of this approach in Enterococcus bacteremia is unknown.

Design

Quality improvement report.

Setting & Participants

64 catheter-dependent hemodialysis outpatients with vancomycin-sensitive Enterococcus bacteremia treated with a uniform antibiotic lock protocol. Clinical outcomes were tracked prospectively.

Quality Improvement Plans

Patients received intravenous vancomycin for 3 weeks in conjunction with a vancomycin lock instilled into both catheter lumens after each dialysis session.

Measures

Treatment failure was defined as persistent fever 48 hours after initiation of antibiotic therapy or recurrent Enterococcus bacteremia within 90 days. A clinical cure was defined as fever resolution without recurrent bacteremia. Major infection-related complications within 6 months were documented.

Results

Treatment failure occurred in 25 patients (39%) because of persistent fever in 10 and recurrent bacteremia in 15. Treatment success occurred in 39 patients (61%). A serious complication of Enterococcus CRB occurred in 4 of 64 patients (6%); endocarditis in 1 and osteomyelitis in 3. The frequency of serious complications was 16% (4 of 25 patients) in those with treatment failure compared with 0% (0 of 39 patients) in those with treatment success (P = 0.01).

Limitations

This was a single-center study. We did not measure serum vancomycin.

Conclusions

An antibiotic lock protocol permits catheter salvage in 61% of hemodialysis patients with Enterococcus CRB. Serious complications occur in 6% of patients and are more common in those with treatment failure.

Section snippets

Setting

The University of Alabama at Birmingham (UAB) provides medical care for approximately 450 hemodialysis patients under the supervision of 10 full-time clinical nephrologists. About 25% of these patients are catheter dependent at any given time. More than 95% of all hospitalizations of our dialysis patients occur at UAB Hospital, allowing for comprehensive follow-up of any complications. Two full-time access coordinators schedule all access procedures and maintain a prospective computerized

Situation Analysis

All dialysis patients with CRB were treated by using a uniform protocol with objective outcome measures. Use of a consistent protocol and prospective documentation of outcomes permitted us to perform a formal analysis of the success and complication rates in the subset of patients with Enterococcus bacteremia.

Outcomes

Of 64 patients with Enterococcus CRB treated with an antibiotic lock, fever persisted in 16% of patients, and their infected catheters were removed promptly (Fig 1). In an additional 23%

Discussion

The present study found a relatively high success rate (61%) of vancomycin lock treatment in salvaging the infected catheter in a large population of hemodialysis patients with Enterococcus CRB. This cure rate was less than that previously observed at our institution for gram-negative CRB (87%) and S epidermidis CRB (75%), but greater than that for S aureus CRB (41%).6, 8 The reason for the treatment failures cannot be determined from the present study. Two potential explanations are a biofilm

Acknowledgements

Portions of this report were presented in abstract form at the Clinical Meeting of the National Kidney Foundation; April 2 to 6, 2008, Dallas, TX.

Support: This research was supported in part by Grant No. 1 K24 DK59818-01 from the National Institute of Diabetes and Digestive and Kidney Diseases to Dr Allon.

Financial Disclosure: None.

Cited by (25)

  • Hemodialysis vascular access complications: Recognition and management

    2014, Hospital Medicine Clinics
    Citation Excerpt :

    The success rate varies considerably by organism, with 87% cure rate for gram-negative infections, 75% for Staphylococcus epidermidis infections, and 60% for Enterococcus. The success rate of salvage in the case of S aureus is low (∼40%) and therefore should be considered only in problematic cases.56–58 What can be done to reduce incidence of infection?

  • Optimizing future treatment of enterococcal infections: Attacking the biofilm?

    2012, Trends in Microbiology
    Citation Excerpt :

    Of these treatments, only silver [61] and antimicrobial lock therapy were found to be effective against enterococcal infections in the clinic. Vancomycin–heparin lock therapy seems to be a promising method for preventing bacterial growth associated with dialysis catheters; nevertheless antibiofilm action in this observational study was not supported by imaging, and the intervention was not compared to standards of care [62]. Although C-MP-P (sodium citrate, methylene blue, methylparaben, and propylparaben) lock solution for hemodialysis catheters proved to be effective in reducing catheter-related bloodstream infections, this multi-center trial with relatively small numbers of infections was not powered to detect a significant reduction in enterococcal infections [63].

View all citing articles on Scopus

Originally published online as doi:10.1053/j.ajkd.2008.06.033 on October 13, 2008.

View full text