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Prevention and management of catheter-related infection in hemodialysis patients

2010; Elsevier BV; Volume: 79; Issue: 6 Linguagem: Inglês

10.1038/ki.2010.471

1523-1755

Charmaine E. Lok, Michele H. Mokrzycki,

Streptococcal Infections and Treatments

Central venous catheter-related infections have been associated with high morbidity, mortality, and costs. Catheter use in chronic hemodialysis patients has been recognized as distinct from other patient populations who require central venous access, leading to recent adaptations in guidelines-recommended diagnosis for catheter-related bacteremia (CRB). This review will discuss the epidemiology and pathogenesis of hemodialysis CRB, in addition to a focus on interventions that have favorably affected CRB outcomes. These include: (1) the use of prophylactic topical antimicrobial ointments at the catheter exit site, (2) the use of prophylactic catheter locking solutions for the prevention of CRB, (3) strategies for management of the catheter in CRB, and (4) the use of vascular access managers and quality initiative programs. Central venous catheter-related infections have been associated with high morbidity, mortality, and costs. Catheter use in chronic hemodialysis patients has been recognized as distinct from other patient populations who require central venous access, leading to recent adaptations in guidelines-recommended diagnosis for catheter-related bacteremia (CRB). This review will discuss the epidemiology and pathogenesis of hemodialysis CRB, in addition to a focus on interventions that have favorably affected CRB outcomes. These include: (1) the use of prophylactic topical antimicrobial ointments at the catheter exit site, (2) the use of prophylactic catheter locking solutions for the prevention of CRB, (3) strategies for management of the catheter in CRB, and (4) the use of vascular access managers and quality initiative programs. Vascular access is not only known as the obvious ‘Achilles heel’ of hemodialysis (HD) but it is also the quiet undercurrent of trends in patient outcomes. This is apparent when one follows the growth and impact of the central venous catheter (CVC) over two decades since its introduction as a ‘permanent’ access in the mid-1980s.1.Moss A.H. McLaughlin M.M. Lempert K.D. et al.Use of a silicone catheter with a Dacron cuff for dialysis short-term vascular access.Am J Kidney Dis. 1988; 12: 492-498Abstract Full Text PDF PubMed Google Scholar, 2.Schwab S.J. Buller G.L. McCann R.L. et al.Prospective evaluation of a Dacron cuffed hemodialysis catheter for prolonged use.Am J Kidney Dis. 1988; 11: 166-169Abstract Full Text PDF PubMed Google Scholar, 3.Shusterman N.H. Kloss K. Mullen J.L. Successful use of double-lumen, silicone rubber catheters for permanent hemodialysis access.Kidney Int. 1989; 35: 887-890Abstract Full Text PDF PubMed Google Scholar At present, the prevalent CVC use has increased to ∼25% while >80% of patients initiate HD with a catheter.4.CORR 2010 CORR Report—Treatment of End-Stage Organ Failure in Canada.2010Google Scholar When such large numbers are affected, trends in patient outcomes serve to highlight the catheter’s associations with high morbidity and mortality. For example, the most recent USRDS (US Renal Data System) report observed high first- and second-month death rates after HD initiation, coincident with the increase in CVC placement rates.5.USRDS: US Renal Data SystemUSRDS 2009 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2009Google Scholar A significant cause of CVC-related morbidity and mortality is infection. For example, rates of mortality from infection in the first year of HD are now 2.4 times greater than in 1981 and is largely attributed to CVC use.5.USRDS: US Renal Data SystemUSRDS 2009 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2009Google Scholar Hospitalizations due to vascular access infections more than doubled between 1993 and 2005 in the United States6.USRDS: US Renal Data SystemUSRDS 2009 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2009Google Scholar and mirror the marked increase in CVC use during the same period, suggesting that increased hospitalization may not be solely attributable to poor CVC care but due to increased CVC use itself. Catheter-related infections encompass exit site infections, tunnel infections, and bacteremias; however, bacteremias are the most clinically important because of their common occurrence and potential to transform into sepsis. The risk of sepsis with a CVC is twofold to fivefold higher than that with arteriovenous grafts and arteriovenous fistulae.7.Thomson P.C. Stirling C.M. Geddes C.C. et al.Vascular access in haemodialysis patients: a modifiable risk factor for bacteraemia and death.QJM. 2007; 100: 415-422Crossref PubMed Scopus (67) Google Scholar After an episode of sepsis, the rate of adverse cardiovascular events increases by up to twofold. These include myocardial infarction, congestive heart failure, peripheral vascular disease, and cerebral vascular accident events.8.Ishani A. Collins A.J. Herzog C.A. et al.Septicemia, access and cardiovascular disease in dialysis patients: the USRDS Wave 2 study.Kidney Int. 2005; 68: 311-318Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar Unquestionably, CVC-related infections and sepsis are associated with high morbidity and hospitalization rates, high treatment costs, and poor survival.5.USRDS: US Renal Data SystemUSRDS 2009 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2009Google Scholar, 8.Ishani A. Collins A.J. Herzog C.A. et al.Septicemia, access and cardiovascular disease in dialysis patients: the USRDS Wave 2 study.Kidney Int. 2005; 68: 311-318Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar, 9.Engemann J.J. Friedman J. Reed S.D. et al.Clinical outcomes and costs due to Staphylococcus aureus bacteremia among patients receiving long-term hemodialysis.Infect Control Hosp Epidemiol. 2005; 26: 534-539Crossref PubMed Scopus (104) Google Scholar, 10.Marr K.A. Kong L. Fowler V.G. et al.Incidence and outcome of Staphylococcus aureus bacteremia in hemodialysis patients.Kidney Int. 1998; 54: 1684-1689Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar, 11.Maraj S. Jacobs L.E. Kung S.C. et al.Epidemiology and outcome of infective endocarditis in hemodialysis patients.Am J Med Sci. 2002; 324: 254-260Abstract Full Text Full Text PDF PubMed Google Scholar, 12.Ramanathan V. Chiu E.J. Thomas J.T. et al.Healthcare costs associated with hemodialysis catheter-related infections: a single-center experience.Infect Control Hosp Epidemiol. 2007; 28: 606-609Crossref PubMed Scopus (33) Google Scholar, 13.Mokrzycki M.H. Zhang M. Cohen H. et al.Tunnelled haemodialysis catheter bacteraemia: risk factors for bacteraemia recurrence, infectious complications and mortality.Nephrol Dial Transplant. 2006; 21: 1024-1031Crossref PubMed Scopus (86) Google Scholar, 14.Tanriover B. Carlton D. Saddekni S. et al.Bacteremia associated with tunneled dialysis catheters: comparison of two treatment strategies.Kidney Int. 2000; 57: 2151-2155Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar However, welcome relief has been observed in the USRDS 2009 data with a recent decline (2006–2007) in overall vascular access-related hospitalizations due to infection, but they are still approximately two times higher than a decade before.5.USRDS: US Renal Data SystemUSRDS 2009 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2009Google Scholar The hopeful speculation for this improved trend is of a heightened awareness of the high risks associated with catheter-related bacteremia (CRB) and the implementation of evidence-based preventative and management strategies along with other quality improvement measures. This paper will review the epidemiology and pathophysiology of CRB and emphasize evidence-based strategies to prevent and manage CRB. Given the gravity of CRB in HD patients dialyzing with a catheter access, a precise diagnosis and definition of CRB would seem crucial. However, this seemingly basic requirement has been challenging because of the unique circumstances of HD patients, whereby the rigorous standard of requiring quantitative blood cultures and/or determining differential time to positivity from a peripheral vein and catheter blood culture cannot be obtained because of logistic or other reasons.15.Mermel L.A. Allon M. Bouza E. et al.Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America.Clin Infect Dis. 2009; 49: 1-45Crossref PubMed Scopus (1428) Google Scholar For example, the priority of preserving arm veins for future fistula creation, fragile and damaged vessels, and patient refusal render venipuncture impractical. The IDSA (Infectious Disease Society of America) has recently acknowledged these significant challenges, and provision has been made to accept blood cultures obtained from the catheter and blood line connected to the CVC (instead of peripheral vein venipuncture) when peripheral vein samples are not possible. Drainage at the CVC exit site should be cultured as the diagnosis of CRB is strengthened by a positive culture of the same organism at the exit site and in the blood. However, there is often no drainage at the exit site. Therefore, when there is an absence of drainage at the exit site and alternate sources of infection cannot be found, positive blood cultures obtained from an HD catheter should be considered a possible CRB in a symptomatic patient and treated as such, with initiation of antimicrobial therapy.15.Mermel L.A. Allon M. Bouza E. et al.Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America.Clin Infect Dis. 2009; 49: 1-45Crossref PubMed Scopus (1428) Google Scholar Although this is only considered a ‘possible’ CRB by precise IDSA standards, it is an appropriate definition of HD CRB. The CDC has recently provided definitions and tools for dialysis units for the reporting of dialysis vascular access infections as ‘dialysis event/100 patient-months’ for surveillance purposes.16.CDChttp://www.cdc.gov/nhsn/PDFs/pscManual/8pscDialysisEventcurrent.pdfDate: 2010Google Scholar However, reporting of CRB as event/1000 catheter days has been recognized as the most informative measure, and can be used for benchmarking, clinical monitoring, surveillance, and investigational studies, but requires appropriate resources for accuracy.17.Maki D.G. Kluger D.M. Crnich C.J. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies.Mayo Clin Proc. 2006; 81: 1159-1171Abstract Full Text Full Text PDF PubMed Scopus (687) Google Scholar Tracking of CRB has been recognized as an important aspect of dialysis patient care18.Tokars J.I. Description of a new surveillance system for bloodstream and vascular access infections in outpatient hemodialysis centers.Semin Dial. 2000; 13: 97-100Crossref PubMed Google Scholar, 19.Taylor G. Gravel D. Johnston L. et al.Prospective surveillance for primary bloodstream infections occurring in Canadian hemodialysis units.Infect Control Hosp Epidemiol. 2002; 23: 716-720Crossref PubMed Scopus (80) Google Scholar, 20.Vascular Access Work GroupClinical Practice Guidelines for Vascular Access.Am J Kidney Dis. 2006; 48: S176-S247Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 21.Jindal K. Chan C.T. Deziel C. et al.Hemodialysis clinical practice guidelines for the Canadian Society of Nephrology. Chapter 4: vascular access.J Am Soc Nephrol. 2006; 17: S16-S23Google Scholar, 22.Vanholder R. Canaud B. Fluck R. et al.Diagnosis, prevention and treatment of haemodialysis catheter-related bloodstream infections (CRBSI): a position statement of European Renal Best Practice (ERBP).NDT Plus. 2010; 25: 1753-1756Google Scholar, 23.George A. Tokars J.I. Clutterbuck E.J. et al.Reducing dialysis associated bacteraemia, and recommendations for surveillance in the United Kingdom: prospective study.BMJ. 2006; 332: 1435Crossref PubMed Google Scholar and has been recently recommended as a clinical performance measure by a CMS clinical technical expert panel as part of monitoring dialysis access-related infections (http://www.cms.gov/CPMProject/Downloads/ESRD2010TechnicalExpertPanelReport.pdf). The incidence of CRB ranges between 0.6 and 6.5 episodes per 1000 catheter days.14.Tanriover B. Carlton D. Saddekni S. et al.Bacteremia associated with tunneled dialysis catheters: comparison of two treatment strategies.Kidney Int. 2000; 57: 2151-2155Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 24.Saad T.F. Bacteremia associated with tunneled, cuffed hemodialysis catheters.Am J Kidney Dis. 1999; 34: 1114-1124Abstract Full Text Full Text PDF PubMed Google Scholar, 25.Krishnasami Z. Carlton D. Bimbo L. et al.Management of hemodialysis catheter-related bacteremia with an adjunctive antibiotic lock solution.Kidney Int. 2002; 61: 1136-1142Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar, 26.Onder A.M. Chandar J. Simon N. et al.Comparison of tissue plasminogen activator-antibiotic locks with heparin-antibiotic locks in children with catheter-related bacteraemia.Nephrol Dial Transplant. 2008; 23: 2604-2610Crossref PubMed Scopus (0) Google Scholar, 27.Lok C.E. Stanley K.E. 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Van de Ven P.J. et al.CITRATE Study GroupRandomized, clinical trial comparison of trisodium citrate 30 and heparin as catheter-locking solution in hemodialysis patients.J Am Soc Nephrol. 2005; 16: 2769-2777Crossref PubMed Scopus (0) Google Scholar, 31.Power A. Duncan N. Singh S.K. Sodium citrate versus heparin catheter locks for cuffed central venous catheters: a single-center randomized controlled trial.Am J Kidney Dis. 2009; 53: 1034-1041Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 32.Ash S.R. Maki D.G. Lavin P.T. et al.A multi-center randomized trial of an antimicrobial and antithrombotic lock solution for hemodialysis catheters (abstract).J Am Soc Nephrol. 2009; (available at)http://www.abstracts2view.com/asn09/Google Scholar, 33.Solomon L.R. Cheesbrough J.S. 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Bokhary H.A. et al.A prospective study of hemodialysis access-related bacterial infections.J Infect Chemother. 2002; 8: 242-246Abstract Full Text PDF PubMed Scopus (0) Google Scholar The majority of CRB-associated isolates are Gram-positive organisms (52–84%), with Staphylococcus aureus accounting for between 21 and 43% in most series, and methicillin-resistant S. aureus (MRSA) reported in approximately 12–38%.14.Tanriover B. Carlton D. Saddekni S. et al.Bacteremia associated with tunneled dialysis catheters: comparison of two treatment strategies.Kidney Int. 2000; 57: 2151-2155Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 24.Saad T.F. Bacteremia associated with tunneled, cuffed hemodialysis catheters.Am J Kidney Dis. 1999; 34: 1114-1124Abstract Full Text Full Text PDF PubMed Google Scholar, 25.Krishnasami Z. Carlton D. Bimbo L. et al.Management of hemodialysis catheter-related bacteremia with an adjunctive antibiotic lock solution.Kidney Int. 2002; 61: 1136-1142Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar, 27.Lok C.E. Stanley K.E. Hux J.E. et al.Hemodialysis infection prevention with polysporin ointment.J Am Soc Nephrol. 2003; 14: 169-179Crossref PubMed Scopus (129) Google Scholar, 37.Marr K.A. Sexton D.J. Conlon P.J. et al.Catheter-related bacteremia and outcome of attempted catheter salvage in patients undergoing hemodialysis.Ann Intern Med. 1997; 127: 275-280Crossref PubMed Google Scholar Risk factors for CRB that have been identified include poor patient hygiene, previous CRB, recent hospitalization, longer duration of catheter use, inadequate dialysis, hypoalbuminemia, S. aureus nasal carriage, diabetes mellitus, immunocompromised status, atherosclerosis, and hypertension.37.Marr K.A. Sexton D.J. Conlon P.J. et al.Catheter-related bacteremia and outcome of attempted catheter salvage in patients undergoing hemodialysis.Ann Intern Med. 1997; 127: 275-280Crossref PubMed Google Scholar, 38.Taylor G. Gravel D. Johnston L. et al.Incidence of bloodstream infection in multicenter inception cohorts of hemodialysis patients.Am J Infect Control. 2004; 32: 155-160Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar, 39.Tokars J.I. Light P. Anderson J. et al.A prospective study of vascular access infections at seven outpatient hemodialysis centers.Am J Kidney Dis. 2001; 37: 1232-1240Abstract Full Text PDF PubMed Google Scholar, 40.Lemaire X. Morena M. Leray-Moragues H. et al.Analysis of risk factors for catheter-related bacteremia in 2000 permanent dual catheters for hemodialysis.Blood Purif. 2009; 28: 21-28Crossref PubMed Scopus (37) Google Scholar, 41.Jean G. Charra B. Chazot C. et al.Risk factor analysis for long-term tunneled dialysis catheter-related bacteremias.Nephron. 2002; 91: 399-405Crossref PubMed Scopus (0) Google Scholar Serious metastatic infectious complications occur in 3–44% of episodes, and include endocarditis, osteomyelitis, thrombophlebitis, septic arthritis, spinal epidural abscess, and large atrial thrombi13.Mokrzycki M.H. Zhang M. Cohen H. et al.Tunnelled haemodialysis catheter bacteraemia: risk factors for bacteraemia recurrence, infectious complications and mortality.Nephrol Dial Transplant. 2006; 21: 1024-1031Crossref PubMed Scopus (86) Google Scholar, 14.Tanriover B. Carlton D. Saddekni S. et al.Bacteremia associated with tunneled dialysis catheters: comparison of two treatment strategies.Kidney Int. 2000; 57: 2151-2155Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 25.Krishnasami Z. Carlton D. Bimbo L. et al.Management of hemodialysis catheter-related bacteremia with an adjunctive antibiotic lock solution.Kidney Int. 2002; 61: 1136-1142Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar, 34.Beathard G.A. Management of bacteremia associated with tunneled-cuffed hemodialysis catheters.J Am Soc Nephrol. 1999; 10: 1045-1049PubMed Google Scholar, 37.Marr K.A. Sexton D.J. Conlon P.J. et al.Catheter-related bacteremia and outcome of attempted catheter salvage in patients undergoing hemodialysis.Ann Intern Med. 1997; 127: 275-280Crossref PubMed Google Scholar, 42.Negulescu O. Coco M. Croll J. et al.Large atrial thrombus formation associated with tunneled cuffed hemodialysis catheters.Clin Nephrol. 2003; 59: 40-46Crossref PubMed Google Scholar, 43.Poole C.V. Carlton D. Bimbo L. et al.Treatment of catheter-related bacteraemia with an antibiotic lock protocol: effect of bacterial pathogen.Nephrol Dial Transplant. 2004; 19: 1237-1244Crossref PubMed Scopus (0) Google Scholar, 44.Kovalik E.C. Raymond J.R. Albers F.J. et al.A clustering of epidural abscesses in chronic hemodialysis patients: risks of salvaging access catheters in cases of infection.J Am Soc Nephrol. 1996; 7: 2264-2267PubMed Google Scholar (Table 1). The incidence of infectious complications is higher when catheter salvage is attempted.13.Mokrzycki M.H. Zhang M. Cohen H. et al.Tunnelled haemodialysis catheter bacteraemia: risk factors for bacteraemia recurrence, infectious complications and mortality.Nephrol Dial Transplant. 2006; 21: 1024-1031Crossref PubMed Scopus (86) Google Scholar,44.Kovalik E.C. Raymond J.R. Albers F.J. et al.A clustering of epidural abscesses in chronic hemodialysis patients: risks of salvaging access catheters in cases of infection.J Am Soc Nephrol. 1996; 7: 2264-2267PubMed Google Scholar Epidural abscess and large atrial thrombi occur uncommonly, and are usually associated with Staphylococcus isolates and with poor outcomes. These include severe neurological deficits, such as paresis and paralysis (50–72%) with epidural abscess, septic pulmonary emboli with large atrial thrombus (Figure 1, Figure 2, Figure 3, Figure 4), and high mortality rates (17–60%).42.Negulescu O. Coco M. Croll J. et al.Large atrial thrombus formation associated with tunneled cuffed hemodialysis catheters.Clin Nephrol. 2003; 59: 40-46Crossref PubMed Google Scholar, 44.Kovalik E.C. Raymond J.R. 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Amin K. et al.Routine replacement of tunneled, cuffed, hemodialysis catheters eliminates paraspinal/vertebral infections in patients with catheter-associated bacteremia.Am J Nephrol. 2003; 23: 202-207Crossref PubMed Scopus (0) Google ScholarTable 1Metastatic complications of catheter-related bacteremia (CRB)ComplicationFrequency (%)ReferencesEndocarditis3–17Engemann et al.9.Engemann J.J. Friedman J. Reed S.D. et al.Clinical outcomes and costs due to Staphylococcus aureus bacteremia among patients receiving long-term hemodialysis.Infect Control Hosp Epidemiol. 2005; 26: 534-539Crossref PubMed Scopus (104) Google Scholar; Mokrzycki et al.13.Mokrzycki M.H. Zhang M. Cohen H. et al.Tunnelled haemodialysis catheter bacteraemia: risk factors for bacteraemia recurrence, infectious complications and mortality.Nephrol Dial Transplant. 2006; 21: 1024-1031Crossref PubMed Scopus (86) Google Scholar; Tanriover et al.14.Tanriover B. Carlton D. Saddekni S. et al.Bacteremia associated with tunneled dialysis catheters: comparison of two treatment strategies.Kidney Int. 2000; 57: 2151-2155Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar; Saad24.Saad T.F. Bacteremia associated with tunneled, cuffed hemodialysis catheters.Am J Kidney Dis. 1999; 34: 1114-1124Abstract Full Text Full Text PDF PubMed Google Scholar; Marr et al.37.Marr K.A. Sexton D.J. Conlon P.J. et al.Catheter-related bacteremia and outcome of attempted catheter salvage in patients undergoing hemodialysis.Ann Intern Med. 1997; 127: 275-280Crossref PubMed Google ScholarLarge atrial thrombiRareNegulescu et al.42.Negulescu O. Coco M. Croll J. et al.Large atrial thrombus formation associated with tunneled cuffed hemodialysis catheters.Clin Nephrol. 2003; 59: 40-46Crossref PubMed Google Scholar; Ghani et al.45.Ghani M.K. Boccalandro F. Denktas A.E. et al.Right atrial thrombus formation associated with central venous catheters utilization in hemodialysis patients.Intensive Care Med. 2003; 29: 1829-1832Crossref PubMed Scopus (36) Google Scholar; Kingdon et al.138.Kingdon E.J. Holt S.G. Davar J. et al.Atrial thrombus and central venous dialysis catheters.Am J Kidney Dis. 2001; 38: 631-639Abstract Full Text Full Text PDF PubMed Google Scholar; Shah et al.139.Shah A. Murray M. Nzerue C. Right atrial thrombi complicating use of central venous catheters in hemodialysis.Int J Artif Organs. 2004; 27: 772-778Crossref PubMed Scopus (19) Google ScholarSpinal epidural abscessRareKovalik et al.44.Kovalik E.C. Raymond J.R. Albers F.J. et al.A clustering of epidural abscesses in chronic hemodialysis patients: risks of salvaging access catheters in cases of infection.J Am Soc Nephrol. 1996; 7: 2264-2267PubMed Google Scholar; Obrador and Levenson46.Obrador G.T. Levenson D.J. Spinal epidural abscess in hemodialysis patients: report of three cases and review of the literature.Am J Kidney Dis. 1996; 27: 75-83Abstract Full Text PDF PubMed Google Scholar; Philipneri et al.47.Philipneri M. Al-Aly Z. Amin K. et al.Routine replacement of tunneled, cuffed, hemodialysis catheters eliminates paraspinal/vertebral infections in patients with catheter-associated bacteremia.Am J Nephrol. 2003; 23: 202-207Crossref PubMed Scopus (0) Google ScholarSeptic pulmonary emboli0.4Mokrzycki et al.13.Mokrzycki M.H. Zhang M. Cohen H. et al.Tunnelled haemodialysis catheter bacteraemia: risk factors for bacteraemia recurrence, infectious complications and mortality.Nephrol Dial Transplant. 2006; 21: 1024-1031Crossref PubMed Scopus (86) Google ScholarSeptic emboli other organs (for example, the brain)1–2Engemann et al.9.Engemann J.J. Friedman J. Reed S.D. et al.Clinical outcomes and costs due to Staphylococcus aureus bacteremia among patients receiving long-term hemodialysis.Infect Control Hosp Epidemiol. 2005; 26: 534-539Crossref PubMed Scopus (104) Google Scholar; Tanriover et al.14.Tanriover B. Carlton D. Saddekni S. et al.Bacteremia associated with tunneled dialysis catheters: comparison of two treatment strategies.Kidney Int. 2000; 57: 2151-2155Abstract Full Text Full Text PDF PubMed Scopus (132) Google ScholarOther abscess1.5Mokrzycki et al.13.Mokrzycki M.H. Zhang M. Cohen H. et al.Tunnelled haemodialysis catheter bacteraemia: risk factors for bacteraemia recurrence, infectious complications and mortality.Nephrol Dial Transplant. 2006; 21: 1024-1031Crossref PubMed Scopus (86) Google ScholarSeptic arthritis2–5Tanriover et al.14.Tanriover B. Carlton D. Saddekni S. et al.Bacteremia associated with tunneled dialysis catheters: comparison of two treatment strategies.Kidney Int. 2000; 57: 2151-2155Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar; Marr et al.37.Marr K.A. Sexton D.J. Conlon P.J. et al.Catheter-related bacteremia and outcome of attempted catheter salvage in patients undergoing hemodialysis.Ann Intern Med. 1997; 127: 275-280Crossref PubMed Google ScholarOsteomyelitis1.5–15Engemann et al.9.Engemann J.J. Friedman J. Reed S.D. et al.Clinical outcomes and costs due to Staphylococcus aureus bacteremia among patients receiving long-term hemodialysis.Infect Control Hosp Epidemiol. 2005; 26: 534-539Crossref PubMed Scopus (104) Google Scholar; Mokrzycki et al.13.Mokrzycki M.H. Zhang M. Cohen H. et al.Tunnelled haemodialysis catheter bacteraemia: risk factors for bacteraemia recurrence, infectious complications and mortality.Nephrol Dial Transplant. 2006; 21: 1024-1031Crossref PubMed Scopus (86) Google Scholar; Marr et al.37.Marr K.A. Sexton D.J. Conlon P.J. et al.Catheter-related bacteremia and outcome of attempted catheter salvage in patients undergoing hemodialysis.Ann Intern Med. 1997; 127: 275-280Crossref PubMed Google ScholarDeath6–34Marr et al.10.Marr K.A. Kong L. Fowler V.G. et al.Incidence and outcome of Staphylococcus aureus bacteremia in hemodialysis patients.Kidney Int. 1998; 54: 1684-1689Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar; Mokrzycki et al.13.Mokrzycki M.H. Zhang M. Cohen H. et al.Tunnelled haemodialysis catheter bacteraemia: risk factors for bacteraemia recurrence, infectious complications and mortality.Nephrol Dial Transplant. 2006; 21: 1024-1031Crossref PubMed Scopus (86) Google Scholar; Lok et al.27.Lok C.E. Stanley K.E. Hux J.E. et al.Hemodialysis infection prevention with polysporin ointment.J Am Soc Nephrol. 2003; 14: 169-179Crossref PubMed Scopus (129) Google Scholar; Lentino et al.57.Lentino J.R. Baddour L.M. Wray M. et al.Staphylococcus aureus and other bacteremias in hemodialysis patients: antibiotic therapy and surgical removal of access site.Infection. 2000; 28: 355-360Crossref PubMed Scopus (55) Google Scholar; Inrig et al.58.Inrig J.K. Reed S.D. Szczech L.A. et al.Relationship between clinical outcomes and vascular access type among hemodialysis patients with Staphylococcus aureus bacteremia.Clin J Am Soc Nephrol. 2006; 1: 518-524Crossref PubMed Scopus (0) Google Scholar; Lowy140.Lowy F.D. Staphylococcus aureus infections.N Engl J Med. 1998; 339: