Study Makes a Case for AVF Use in Pediatric Hemodialysis Patients

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BOSTON—Central venous catheters (CVCs) for hemodialysis (HD) access are responsible for a high incidence of catheter-related bloodstream infections in children, according to data presented at the Infectious Diseases Society of American annual meeting. As a result, greater efforts are needed to encourage the use of arteriovenous fistulas (AVFs) in pediatric HD patients, researchers at the State University of New York Downstate Medical Center in Brooklyn, N.Y., concluded.

“With children there is reluctance for cosmetics reasons to give them a fistula,” said study investigator Margaret Hammerschlag, MD, Professor of Pediatrics and Medicine. Infection rates with AVFs are dramatically lower than with CVCs in all HD populations, she noted.

She and her colleagues reviewed data on catheter-related bloodstream infections (CRBSIs) in children on HD at their pediatric dialysis clinic. The investigators collected data on demographic characteristics, types and sites of central venous catheter, duration of catheter use, causative organisms and sensitivities.

The study included 25 children aged 2-21 years seen between January 2009 and April 2011. Of these, 24 used CVCs for vascular access. A total of 108 catheters were placed: 105 were tunneled and three were not tunneled. In addition, 13 were placed in femoral veins, 77 were placed in internal jugular veins, and 15 were placed in subclavian veins.

The mean duration of catheter use was 773 days (range 24-3,265 days). CRBSIs developed in 16 patients (64%) for a total of 130 episodes (mean five per patient) and an incidence of 6.9 per 1,000 catheter-days.  In addition, the incidence of CRBSIs (per 1,000 catheter-days) was 6.6 with tunneled catheters, 15.3 for non-tunneled catheters, 13.9 for femoral catheters, 6.0 for internal jugular catheters, and 6.1 for subclavian catheters.

The incidence of CRBSI during the study period for pediatric HD patients was higher than the estimated national CRBSI incidence for pediatric and adult patients, she said. In one case, repeated episodes led to removal of a child from the transplant list because of thrombosis.

In adults on HD, the incidence of CRBSIs with CVCs has been reported to be 1.05-5.5/1,000 catheter-days compared with only 0.04-0.6 in adults with AVFs, Dr. Hammerschlag said,

Coagulase-negative staphylococci were responsible for 36.4% of episodes, Staphylococcus aureus, 22%, methicillin-resistant S. aureus, 28%, Gram negative bacilli, 35%, and Candida species (5%). They also found that uncommon organisms, including Delftia acidovorans, Chryseobacterium meningosepticum, Providencia stuartii, Morganella morganii, Neisseria sicca, and Bacillus cereus.

Co-investigator Kobkul Chotikanatis, MD, a second-year pediatric infectious disease fellow, said many nephrologists may use CVC in a child because they believe the child has a chance for an early transplant and will only be on dialysis for short time. “But it turned out that could be a significant burden for the patients,” Dr. Chotikanatis said.

 

 

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