They are more likely than temporary catheters to cause serious infections.
SAN DIEGO—Cuffed catheters for hemodialysis patients are associated with a 46% higher risk of septicemia or endocarditis compared with temporary catheters, according to a study of nearly 30,000 patients.
Additionally, septicemia or endocarditis is 3.5 times more likely to develop in patients with cuffed catheters than in those with fistulas (reference group), after adjusting for case mix, baseline comorbidities, and baseline measurements of creatinine, albumin, hemoglobin, and phosphorus.
Temporary catheters were associated with a 2.5 times greater risk and synthetic grafts had a 33% higher risk, when compared to fistulas. Anna Furniss, MS, of Arbor Research in Ann Arbor, Mich., reported the findings here during Renal Week 2006, which was held by the American Society of Nephrology.
One possible explanation for the findings, Furniss said, is that temporary catheters, which are not placed as deeply in a vein as cuffed catheters, are removed as soon as a local infection is observed. If a local infection occurs in patients with a cuffed catheter, however, clinicians are likely to wait for the response to a course of antibiotics before removing it. If the infection fails to clear, it could lead to septicemia or endocarditis.
The findings suggest that clinicians should remove the catheter and perhaps place it in a different anatomical site rather than treat first with antibiotics, Furniss said.
The new findings come from the Dialysis Outcomes and Practice Patterns Study (DOPPS), a prospective observational investigation of hemodialysis patients in 12 countries. The overall rate of the first occurrence of septicemia and endocarditis was 2.5 and 0.05 episodes per 100 patient years, respectively.
Michael Allon, MD, professor of medicine in the division of nephrology at the University of Alabama in Birmingham, said the finding that cuffed, or tunneled, catheters are more likely than temporary, or untunneled, catheters to cause bacteremia is surprising.
Randomized controlled trials comparing the two catheter types have found a higher risk of bacteremia with non-tunneled catheters, and two large prospective non-randomized comparisons of the two catheter types showed a two- to threefold higher incidence of bacteremia with temporary, or non-tunneled, catheters, Dr. Allon pointed out. In his view, “the weight of the published evidence suggests using tunneled catheters for long-term use.” He said he would not recommend that nephrologists change their practice patterns in light of the new findings.
In one of two related studies presented here, investigators at the Renal Research Institute at St. Raphael’s Hospital in New Haven, Conn., found that deaths related to sepsis occur early after onset of catheter-associated bacteremia (CAB), and that deaths occurring in 60 days or less following CAB onset are due largely to cardiac events.
The researchers, Laura Troidle, PA, and Fredric Finkelstein, MD, examined the causes and chronology of death in 26 hemodialysis patients who had CAB and died. Of 10 patients who died within 14 days, three died from an acute cardiac event, two from an acute cardiac event and sepsis, and three from sepsis alone. Two died after discontinuing dialysis. Of the seven patients who died within 15-30 days, three died from an acute cardiac event alone, one from an acute cardiac event and sepsis, one from a stroke, and two stopped dialysis.
Of nine patients who died within 31-60 days, eight died from an acute cardiac event alone and one from chronic obstructive pulmonary disease. Gram-negative bacteria were involved in half of all deaths, S. aureus in 31%, and other gram-positive bacteria in 42%.
In the other study, researchers in the United Kingdom led by Charlotte Bebb, MB, of Nottingham City Hospital, concluded that universal use of nasal mupirocin in hemodialysis patients with a tunneled central venous catheter (tCVC) results in a sustained decrease in CAB. From November 2001 to April 2003, all hemodialysis patients with a tCVC received nasal 2% mupirocin ointment three times daily for five days following catheter insertion to prevent S. aureus infections. The course was repeated while the catheter was in place.
Since April 2003, all patients with tCVC received a course of mupirocin three times daily for five days following insertion followed by maintenance treatment with nasal mupirocin three times daily on one day each week. Patients self-administered the drug following instruction from nurses.
Prior to November 2001, the bacteremia rate for tCVC was 4.5 per 1,000 catheter days. The introduction of nasal mupirocin was followed by a sustained decline in bacteremia rate. It dropped to about 2.0 infections per 1,000 catheter days in 2001 to a little over 1.0 in 2004 and just below 1.0 in 2006.
Dr. Bebb and her colleagues concluded that this approach “is a practical solution requiring minimal input from nursing staff.”