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Clinical Outcomes and Risk Factors for Tunneled Hemodialysis Catheter-Related Bloodstream Infections

Clinical Outcomes and Risk Factors for Tunneled Hemodialysis Catheter-Related Bloodstream Infections Downloaded from https://academic.oup.com/ofid/article-abstract/7/6/ofaa117/5818983 by DeepDyve user on 17 June 2020 applyparastyle “fig//caption/p[1]” parastyle “FigCapt” Open Forum Infectious Diseases BRIEF REPORT TCHD insertion was not within the study period, removal date Clinical Outcomes and Risk Factors could not be verified, or if the patient was not managed by the for Tunneled Hemodialysis Catheter- hospital’s dialysis network. CRBSI episodes were identified using hospital admissions (ICD-10 AM code T82.7X assigned Related Bloodstream Infections as principal or complicating discharge diagnoses) and the blood 1, 2,3 1 2 Kylie Martin, Yves S. Poy Lorenzo, Po Yee Mia Leung, Sheri Chung, 1 1 1,3 culture database. Patient demographics, comorbidities, and Emmet O’flaherty , Nuala Barker, and Francesco Ierino outcomes were extracted from admission notes. Insertions were Department of Nephrology, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia, Pharmacy Department, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia, and performed by interventional radiologists using tunneled cuffed University of Melbourne, Melbourne Medical School, Department of Medicine, Fitzroy, catheters (Palindrome chronic dialysis catheters, Medtronic, Victoria, Australia Minneapolis, MN, USA). Diabetes and left internal jugular vein insertion site were sig- e co Th ntrol was primary TCHD not associated with CRBSI. nificantly associated with increased risk of a catheter-related CRBSIs were categorized as definite, probable, and possible bloodstream infection from a tunneled hemodialysis catheter. according to the Kidney Disease Outcomes Quality Initiative Ex-smoker status was significantly associated with reduced risk. (KDOQI) guidelines [6]. Keywords: catheter; hemodialysis; infection; vascular. Categorical variables are reported as count and proportion, and continuous variables are summarized as median and inter- Challenges with timely permanent vascular access for hemodi- quartile range (IQR). Univariate logistic regression was used to alysis (HD) lead to urgent insertion of tunneled catheters for compare cases with controls for each variable, and crude odds hemodialysis (TCHD). In Australia, 15% of 10 624 prevalent ratios (ORs), 95% confidence intervals (CIs), and 2-tailed P HD patients were dialyzing via a central venous catheter in 2017 values were calculated. All variables with a P value <.1 in univar- [1]. Catheter-related bloodstream infections (CRBSIs) from iate analysis and variables identified a priori in the international TCHD use occur at rates of 1.1–6.1 episodes per 1000 catheter- literature as risk factors for CRBSI (age, diabetes, TCHD use for days internationally [2, 3]. CRBSI are associated with signifi- >90  days, hypertension [5, 7]) were included in the multivar- cant mortality, morbidity, and health care costs [4, 5]. To our iate analysis regardless of univariate parameters. Multivariate knowledge, there are no published Australian data on patient logistic regression was used to identify independent demo- factors associated with CRBSI. This study aimed to investigate graphic and clinical risk factors associated with CRBSI, with P factors associated with CRBSI in patients with a primary TCHD values <.05 considered significant. Statistical analysis was per - inserted at an Australian tertiary metropolitan hospital and re- formed using Stata 15.1 (StataCorp, College Station, TX, USA). port their microbiological and clinical outcomes. Descriptive analyses of microbiological and clinical outcomes of CRBSI were performed. METHODS RESULTS The hospital’s Human Research Ethics Committee approved the study (QA 021/19). A total of 227 patients had a primary insertion of a TCHD. Patients with primary insertion of a TCHD from January Table 1A summarizes patient demographics and comorbidities. 2013 to June 2018 were included. Patients were followed until Maintenance HD was performed for 4–5 hours, 3 times a week. the time of primary TCHD removal (documented in hospital re- Forty-two (19%) patients were on immunosuppressive therapy cords), death with a functioning TCHD, or December 31, 2018 during the study period (steroid agent equivalent to ≥16  mg (whichever came first). Patients were excluded if the primary prednisone per day for >15  days or other immunosuppressive or immunomodulatory agent). Of the 227 patients, 157 (69%) patients had a TCHD inserted Received 23 January 2020; editorial decision 30 March 2020; accepted 3 April 2020. for acute HD, and in 68 (30%) patients for maintenance renal Correspondence: Kylie Martin, MBBS, BMedSc, MPHTM, St Vincent’s Hospital Melbourne, replacement therapy (RRT) access failure, for example, mal- 41 Victoria Parade, Fitzroy, Victoria, Australia 3065 (kngu.martin@gmail.com). ® function or infection of either a peritoneal dialysis catheter or Open Forum Infectious Diseases © The Author(s) 2020. Published by Oxford University Press on behalf of Infectious Diseases arterio-venous access. TCHD was removed in 45 (20%) patients Society of America. This is an Open Access article distributed under the terms of the Creative who no longer required RRT, in 95 (42%) with established per- Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any manent RRT access, in 37 (16%) with proven or suspected medium, provided the original work is not altered or transformed in any way, and that the TCHD infections, and in 19 (8%) with a nonfunctional TCHD. work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Fifteen (7%) patients died with a functioning TCHD. Reasons DOI: 10.1093/ofid/ofaa117 BRIEF REPORT • ofid • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/7/6/ofaa117/5818983 by DeepDyve user on 17 June 2020 for removal, other than infection, could not be verified for 16 gram-negative bacteremias (2 Pseudomonas aeruginosa, 6 patients. Enterobacterales, and 2 environmental gram-negative organ- e a Th ggregate rate was 1.28 CRBSIs per 1000 catheter-days. isms), 3 (8%) fungemias (2 Candida species, 1 Cryptococcus Thirty-nine primary TCHDs were associated with a CRBSI neoformans), and 3 (8%) were culture-negative. (17%). Twenty-four were defined as definite, 11 as probable, and 4 as possible according to the KDOQI guideline definitions [6]. Infection Outcomes In univariate analysis of CRBSI risk factors (Table  1A), there Twenty-eight patients had a principal diagnosis of CRBSI on ad- was no significant association with age, diabetes, days TCHD in mission. The mean length of stay (LOS) was 14 days (±12 days). situ, and hypertension. Ex-smoker status was associated with lower Eleven patients had a CRBSI occur as a complication during odds of CRBSI (OR, 0.32; 95% CI, 0.13–0.78), and insertion into an inpatient admission with a mean LOS of 43 (±21) days fol- the left internal jugular vein was associated with higher odds (OR, lowing the onset of the CRBSI. 3.91; 95% CI, 1.60–9.53). In multivariate analysis (Table  1B), di- er Th e were 2 (5%) in-hospital deaths, 1 (2.6%) episode of abetes (OR, 2.2; 95% CI, 1.02–4.75) and TCHD inserted into the methicillin-susceptible S. aureus endocarditis, and 1 (2.6%) ep- left internal jugular vein (OR, 4.4; 95% CI, 1.65–11.72) were in- isode of Candida endophthalmitis. Seven (18%) cases had at dependently associated with increased risk of CRBSI. Ex-smoker least 1 subsequent CRBSI episode following the primary CRBSI. status was independently associated with a reduced risk of CRBSI Eight (4%) controls had a CRBSI associated with a TCHD in- compared with nonsmokers (OR, 0.32; 95% CI, 0.13–0.80). serted aer t ft he primary TCHD. Microbiology DISCUSSION There were 23 (59%) gram-positive bacteremias (4 methicillin- There was a total of 39 CRBSIs in 227 primary TCHD inser- susceptible and 9 methicillin-resistant Staphylococcus aureus, 3 tions (17%), requiring removal in 37 (16%) cases. Diabetes enterococci, and 7 coagulase-negative staphylococci), 10 (26%) Table 1A. Patient Demographics and Comorbidities and Univariate Analysis of Risk Factors for CRBSI CRBSI (n = 39) No CRBSI (n = 188) OR Univariate 95% CI P Value Age, median (IQR), y 58 (42–69) 60 (51–70) 0.98 0.96–1.00 .072 Days catheter in, median (IQR) 73 (18–204) 95 (29–178) 1.00 0.997–1.00 .890 Catheter in >90 d, No. (%) 21 (54) 88 (47) 1.33 0.66–2.65 .424 Male, No. (%) 23 (16) 123 (20) 0.76 0.38–1.54 .445 Comorbidities Diabetic, No. (%) 21 (54) 79 (42) 1.61 0.80–3.22 .178 Hypertension, No. (%) 24 (1) 124 (66) 0.83 0.41–1.68 .598 Peripheral vascular disease, No. (%) 4 (10) 16 (9) 1.23 0.39–3.90 .727 Immunosuppressive, No. (%) 9 (23) 33 (18) 1.41 0.61–3.25 .42 Autoimmune, No. (%) 5 (13) 12 (6) 2.16 0.71–6.52 .173 Oncological, No. (%) 0 11 (6) - - - Smoking status Never smoked, No. (%) 25 (64) 85 (45) 1 - - Ex-smoker, No. (%) 7 (18) 75 (40) 0.32 0.13–0.78 .012 Current smoker, No. (%) 7 (18) 27 (14) 0.88 0.34–2.26 .79 Ethnicity Caucasian, No. (%) 30 (77) 146 (78) 1 - - Asian, No. (%) 2 (5) 24 (13) 0.41 0.09–1.81 .237 Aboriginal Australian and Torres Strait Islander 1 (3) 5 (3) 0.97 0.11–8.63 .981 Pacific Islander, No. (%) 4 (10) 7 (4) 2.78 0.77–10.10 .12 Other, No. (%) 2 (5) 5 (3) 1.95 0.36–10.51 .439 Satellite-metropolitan or 11 (28) 49 (26) 1.11 0.52–2.41 .783 regional dialysis center, No. (%) Insertion site Right internal jugular vein, No. (%) 29 (74) 170 (90) 1 - - Left internal jugular vein, No. (%) 10 (26) 15 (8) 3.91 1.60–9.53 .003 Femoral/other, No. (%) 3 (8) 0 - - - Body mass index <25 kg/m , No. (%) 13 (33) 71 (38) 1 - - 25–29.99 kg/m , No. (%) 2 (5) 14 (7) 0.78 0.16–3.85 .76 ≥30 kg/m , No. (%) 24 (62) 103 (55) 1.27 0.61–2.67 .523 2 • ofid • BRIEF REPORT Downloaded from https://academic.oup.com/ofid/article-abstract/7/6/ofaa117/5818983 by DeepDyve user on 17 June 2020 Table 1B. Multivariate Analysis of Risk Factors for CRBSI reported in an Australian and New Zealand survey [12]. Our cohort of CRBSI episodes reflects primary TCHD insertions Variable OR 95% CI P Value only. Other studies included serial TCHD insertions and re- Left internal jugular vein 4.4 1.65–11.72 .003 peat CRBSI episodes. Previous CRBSI is a risk factor for sub- Diabetes 2.2 1.02–4.75 .045 sequent CRBSI [7]. In our study, fewer controls experienced a Ex-smoker 0.32 0.13–0.80 .015 subsequent episode of CRBSI when compared with cases (4% Age, y 0.98 0.95–1.00 .096 vs 18%, respectively). Tunneled dialysis catheter in situ >90 d 1.24 0.58–2.66 .574 Hypertension 1.05 0.47–2.32 .908 Almost half of the patients had a TCHD in situ for >90 days. This may reflect the 2 major reasons for TCHD insertion— Abbreviations: CI, confidence interval; CRBSI, catheter-related bloodstream infection; IQR, interquartile range; OR, odds ratio. acute start RRT or RRT access malfunction. Acute start RRT is due to late referrals and patients who do not engage in timely and left internal jugular vein insertion site were inde- permanent access for RRT. Permanent vascular access takes pendent risk factors for CRBSI. Ex-smokers were less likely to weeks to months to fully mature and be ready for regular use. acquire CRBSI. We also have a significant proportion of diabetic patients (42%), Diabetics are more susceptible to infections, including with underlying vascular disease or calcified vessels, which re- CRBSI [7, 8]. A  hyperglycemic environment may impair host sult in poor access development. Minimization of late referrals responses, namely neutrophil chemotaxis, adhesion and intra- could be addressed with stronger community chronic kidney cellular killing, and humoral immunity, increasing the likeli- disease education, follow-up, and planning. Encouraging up- hood of infection [8]. This emphasizes the need to ensure that take of acute start peritoneal dialysis could reduce the need for diabetic patients with renal impairment are carefully considered vascular access. Our CRBSI microbiology results are consistent for timely permanent RRT access. with the international literature. Most were gram-positive or- Of clinical note, TCHDs inserted into the left internal jug- ganisms, including S.  aureus and coagulase-negative staphylo- ular vein were at an increased risk of CRBSI compared with the cocci. Gram-negative bacteremia and polymicrobial bacteremia right. Forty-one (18%) primary TCHDs were inserted into the have also been reported [3, 4]. left internal jugular vein. Reasoning was not consistently docu- This is the first Australian published data using multivar - mented; however, it can be hypothesized that the contralateral iate analyses to identify intrinsic patient risk factors for CRBSI. upper limb may have been preserved for arterio-venous access Although the CRBSI rate is comparable to that reported in the creation or that the preferred right internal jugular insertion international literature, more work is needed to achieve timely site had inaccessible vascular anatomy. The left internal jugular access for patients with near-end-stage kidney disease, in- vein insertion site has a longer and variable anatomical course cluding those with diabetes, and to avoid TCHD insertion into to the right atrium compared with the right internal jugular the left internal jugular vein. vein. This larger surface area with contact to prosthetic material is liable for biofilm or clot formation and TCHD malfunction. Acknowledgments TCHD biofilms can create an altered micro-environment that Financial support. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-prot s fi ectors. facilitates slow-growing microorganisms where antibiotic pen- Author contributions. K.M.  wrote the manuscript. Y.S.P.L.  and etration is difficult [9]. F.I. contributed to the manuscript. Y.S.P.L. analyzed the data. K.M., Y.S.P.L., e de Th creased risk of CRBSI in ex-smokers is difficult to P.Y.M.L., S.C., E.O., and N.B. collected the data. explain physiologically. Tobacco smoking cessation has been shown to augment the inflammation and immunity state in the References patient, which may explain a reduction in CRBSI risk in our 1. ANZDATA Registry. 41st Report. Adelaide, Australia: Australia and New Zealand Dialysis and Transplant Registry; 2018. Available at: http://www.anzdata.org.au. cohort [10]. Accessed 9 January 2020. Risk factors for CRBSI identified in previous studies in- 2. Jean G, Charra B, Chazot C, et al. Risk factor analysis for long-term tunneled di- clude higher total intravenous iron dose, more frequent uro- alysis catheter-related bacteremias. Nephron 2002; 91:399–405. 3. Saad TF. Bacteremia associated with tunneled, cuffed hemodialysis catheters. Am kinase catheter infusion, local infection, and nasal carriage J Kidney Dis 1999; 34:1114–24. of S. aureus [5, 7, 11]. Data on these factors were incomplete 4. Lok CE, Mokrzycki MH. Prevention and management of catheter-related infec- tion in hemodialysis patients. Kidney Int 2011; 79:587–98. at our center and were therefore not assessed in our study. In 5. Fry AC, Stratton J, Farrington K, et al. Factors affecting long-term survival of tun- contrast to other studies, we found that duration of TCHD nelled haemodialysis catheters—a prospective audit of 812 tunnelled catheters. Nephrol Dial Transplant 2008; 23:275–81. in situ and hypertension did not have a significant associa- 6. National Kidney Foundation. KDOQI clinical practice guidelines and clinical prac- tion with CRBSI. This may be due to our relatively low rate tice recommendations for 2006 updates: hemodialysis adequacy, peritoneal dialysis adequacy and vascular access. Am J Kidney Dis 2006; 48(Suppl 1):S1–S322. of CRBSI compared with the international literature [2, 3]. 7. Lemaire  X, Morena  M, Leray-Moragués  H, et  al. Analysis of risk factors for A  median rate (IQR) of 0.59 (0.39–1.2) CRBSIs per 1000 catheter-related bacteremia in 2000 permanent dual catheters for hemodialysis. catheter-days (tunneled and nontunneled HD catheters) was Blood Purif 2009; 28:21–8. BRIEF REPORT • ofid • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/7/6/ofaa117/5818983 by DeepDyve user on 17 June 2020 8. Koh GC, Peacock SJ, van der Poll T, Wiersinga WJ. The impact of diabetes on the 11. Miller LM, Clark E, Dipchand C, et al; Canadian Society of Nephrology Vascular pathogenesis of sepsis. Eur J Clin Microbiol Infect Dis 2012; 31:379–88. Access Work Group. Hemodialysis tunneled catheter-related infections. Can J 9. Jones SM, Ravani P, Hemmelgarn BR, et al. Morphometric and biological characteriza- Kidney Health Dis 2016; 3:2054358116669129. tion of biofilm in tunneled hemodialysis catheters. Am J Kidney Dis 2011; 57:449–55. 12. Smyth  B, Kotwal  S, Gallagher  M, et  al; REDUCCTION Partnership Project. 10. Arnson Y, Shoenfeld Y, Amital H. Effects of tobacco smoke on immunity, inflam- Dialysis catheter management practices in Australia and New Zealand. mation and autoimmunity. J Autoimmun 2010; 34:J258–65. Nephrology (Carlton) 2019; 24:827–34. 4 • ofid • BRIEF REPORT http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Open Forum Infectious Diseases Oxford University Press

Clinical Outcomes and Risk Factors for Tunneled Hemodialysis Catheter-Related Bloodstream Infections

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Downloaded from https://academic.oup.com/ofid/article-abstract/7/6/ofaa117/5818983 by DeepDyve user on 17 June 2020 applyparastyle “fig//caption/p[1]” parastyle “FigCapt” Open Forum Infectious Diseases BRIEF REPORT TCHD insertion was not within the study period, removal date Clinical Outcomes and Risk Factors could not be verified, or if the patient was not managed by the for Tunneled Hemodialysis Catheter- hospital’s dialysis network. CRBSI episodes were identified using hospital admissions (ICD-10 AM code T82.7X assigned Related Bloodstream Infections as principal or complicating discharge diagnoses) and the blood 1, 2,3 1 2 Kylie Martin, Yves S. Poy Lorenzo, Po Yee Mia Leung, Sheri Chung, 1 1 1,3 culture database. Patient demographics, comorbidities, and Emmet O’flaherty , Nuala Barker, and Francesco Ierino outcomes were extracted from admission notes. Insertions were Department of Nephrology, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia, Pharmacy Department, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia, and performed by interventional radiologists using tunneled cuffed University of Melbourne, Melbourne Medical School, Department of Medicine, Fitzroy, catheters (Palindrome chronic dialysis catheters, Medtronic, Victoria, Australia Minneapolis, MN, USA). Diabetes and left internal jugular vein insertion site were sig- e co Th ntrol was primary TCHD not associated with CRBSI. nificantly associated with increased risk of a catheter-related CRBSIs were categorized as definite, probable, and possible bloodstream infection from a tunneled hemodialysis catheter. according to the Kidney Disease Outcomes Quality Initiative Ex-smoker status was significantly associated with reduced risk. (KDOQI) guidelines [6]. Keywords: catheter; hemodialysis; infection; vascular. Categorical variables are reported as count and proportion, and continuous variables are summarized as median and inter- Challenges with timely permanent vascular access for hemodi- quartile range (IQR). Univariate logistic regression was used to alysis (HD) lead to urgent insertion of tunneled catheters for compare cases with controls for each variable, and crude odds hemodialysis (TCHD). In Australia, 15% of 10 624 prevalent ratios (ORs), 95% confidence intervals (CIs), and 2-tailed P HD patients were dialyzing via a central venous catheter in 2017 values were calculated. All variables with a P value <.1 in univar- [1]. Catheter-related bloodstream infections (CRBSIs) from iate analysis and variables identified a priori in the international TCHD use occur at rates of 1.1–6.1 episodes per 1000 catheter- literature as risk factors for CRBSI (age, diabetes, TCHD use for days internationally [2, 3]. CRBSI are associated with signifi- >90  days, hypertension [5, 7]) were included in the multivar- cant mortality, morbidity, and health care costs [4, 5]. To our iate analysis regardless of univariate parameters. Multivariate knowledge, there are no published Australian data on patient logistic regression was used to identify independent demo- factors associated with CRBSI. This study aimed to investigate graphic and clinical risk factors associated with CRBSI, with P factors associated with CRBSI in patients with a primary TCHD values <.05 considered significant. Statistical analysis was per - inserted at an Australian tertiary metropolitan hospital and re- formed using Stata 15.1 (StataCorp, College Station, TX, USA). port their microbiological and clinical outcomes. Descriptive analyses of microbiological and clinical outcomes of CRBSI were performed. METHODS RESULTS The hospital’s Human Research Ethics Committee approved the study (QA 021/19). A total of 227 patients had a primary insertion of a TCHD. Patients with primary insertion of a TCHD from January Table 1A summarizes patient demographics and comorbidities. 2013 to June 2018 were included. Patients were followed until Maintenance HD was performed for 4–5 hours, 3 times a week. the time of primary TCHD removal (documented in hospital re- Forty-two (19%) patients were on immunosuppressive therapy cords), death with a functioning TCHD, or December 31, 2018 during the study period (steroid agent equivalent to ≥16  mg (whichever came first). Patients were excluded if the primary prednisone per day for >15  days or other immunosuppressive or immunomodulatory agent). Of the 227 patients, 157 (69%) patients had a TCHD inserted Received 23 January 2020; editorial decision 30 March 2020; accepted 3 April 2020. for acute HD, and in 68 (30%) patients for maintenance renal Correspondence: Kylie Martin, MBBS, BMedSc, MPHTM, St Vincent’s Hospital Melbourne, replacement therapy (RRT) access failure, for example, mal- 41 Victoria Parade, Fitzroy, Victoria, Australia 3065 (kngu.martin@gmail.com). ® function or infection of either a peritoneal dialysis catheter or Open Forum Infectious Diseases © The Author(s) 2020. Published by Oxford University Press on behalf of Infectious Diseases arterio-venous access. TCHD was removed in 45 (20%) patients Society of America. This is an Open Access article distributed under the terms of the Creative who no longer required RRT, in 95 (42%) with established per- Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any manent RRT access, in 37 (16%) with proven or suspected medium, provided the original work is not altered or transformed in any way, and that the TCHD infections, and in 19 (8%) with a nonfunctional TCHD. work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Fifteen (7%) patients died with a functioning TCHD. Reasons DOI: 10.1093/ofid/ofaa117 BRIEF REPORT • ofid • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/7/6/ofaa117/5818983 by DeepDyve user on 17 June 2020 for removal, other than infection, could not be verified for 16 gram-negative bacteremias (2 Pseudomonas aeruginosa, 6 patients. Enterobacterales, and 2 environmental gram-negative organ- e a Th ggregate rate was 1.28 CRBSIs per 1000 catheter-days. isms), 3 (8%) fungemias (2 Candida species, 1 Cryptococcus Thirty-nine primary TCHDs were associated with a CRBSI neoformans), and 3 (8%) were culture-negative. (17%). Twenty-four were defined as definite, 11 as probable, and 4 as possible according to the KDOQI guideline definitions [6]. Infection Outcomes In univariate analysis of CRBSI risk factors (Table  1A), there Twenty-eight patients had a principal diagnosis of CRBSI on ad- was no significant association with age, diabetes, days TCHD in mission. The mean length of stay (LOS) was 14 days (±12 days). situ, and hypertension. Ex-smoker status was associated with lower Eleven patients had a CRBSI occur as a complication during odds of CRBSI (OR, 0.32; 95% CI, 0.13–0.78), and insertion into an inpatient admission with a mean LOS of 43 (±21) days fol- the left internal jugular vein was associated with higher odds (OR, lowing the onset of the CRBSI. 3.91; 95% CI, 1.60–9.53). In multivariate analysis (Table  1B), di- er Th e were 2 (5%) in-hospital deaths, 1 (2.6%) episode of abetes (OR, 2.2; 95% CI, 1.02–4.75) and TCHD inserted into the methicillin-susceptible S. aureus endocarditis, and 1 (2.6%) ep- left internal jugular vein (OR, 4.4; 95% CI, 1.65–11.72) were in- isode of Candida endophthalmitis. Seven (18%) cases had at dependently associated with increased risk of CRBSI. Ex-smoker least 1 subsequent CRBSI episode following the primary CRBSI. status was independently associated with a reduced risk of CRBSI Eight (4%) controls had a CRBSI associated with a TCHD in- compared with nonsmokers (OR, 0.32; 95% CI, 0.13–0.80). serted aer t ft he primary TCHD. Microbiology DISCUSSION There were 23 (59%) gram-positive bacteremias (4 methicillin- There was a total of 39 CRBSIs in 227 primary TCHD inser- susceptible and 9 methicillin-resistant Staphylococcus aureus, 3 tions (17%), requiring removal in 37 (16%) cases. Diabetes enterococci, and 7 coagulase-negative staphylococci), 10 (26%) Table 1A. Patient Demographics and Comorbidities and Univariate Analysis of Risk Factors for CRBSI CRBSI (n = 39) No CRBSI (n = 188) OR Univariate 95% CI P Value Age, median (IQR), y 58 (42–69) 60 (51–70) 0.98 0.96–1.00 .072 Days catheter in, median (IQR) 73 (18–204) 95 (29–178) 1.00 0.997–1.00 .890 Catheter in >90 d, No. (%) 21 (54) 88 (47) 1.33 0.66–2.65 .424 Male, No. (%) 23 (16) 123 (20) 0.76 0.38–1.54 .445 Comorbidities Diabetic, No. (%) 21 (54) 79 (42) 1.61 0.80–3.22 .178 Hypertension, No. (%) 24 (1) 124 (66) 0.83 0.41–1.68 .598 Peripheral vascular disease, No. (%) 4 (10) 16 (9) 1.23 0.39–3.90 .727 Immunosuppressive, No. (%) 9 (23) 33 (18) 1.41 0.61–3.25 .42 Autoimmune, No. (%) 5 (13) 12 (6) 2.16 0.71–6.52 .173 Oncological, No. (%) 0 11 (6) - - - Smoking status Never smoked, No. (%) 25 (64) 85 (45) 1 - - Ex-smoker, No. (%) 7 (18) 75 (40) 0.32 0.13–0.78 .012 Current smoker, No. (%) 7 (18) 27 (14) 0.88 0.34–2.26 .79 Ethnicity Caucasian, No. (%) 30 (77) 146 (78) 1 - - Asian, No. (%) 2 (5) 24 (13) 0.41 0.09–1.81 .237 Aboriginal Australian and Torres Strait Islander 1 (3) 5 (3) 0.97 0.11–8.63 .981 Pacific Islander, No. (%) 4 (10) 7 (4) 2.78 0.77–10.10 .12 Other, No. (%) 2 (5) 5 (3) 1.95 0.36–10.51 .439 Satellite-metropolitan or 11 (28) 49 (26) 1.11 0.52–2.41 .783 regional dialysis center, No. (%) Insertion site Right internal jugular vein, No. (%) 29 (74) 170 (90) 1 - - Left internal jugular vein, No. (%) 10 (26) 15 (8) 3.91 1.60–9.53 .003 Femoral/other, No. (%) 3 (8) 0 - - - Body mass index <25 kg/m , No. (%) 13 (33) 71 (38) 1 - - 25–29.99 kg/m , No. (%) 2 (5) 14 (7) 0.78 0.16–3.85 .76 ≥30 kg/m , No. (%) 24 (62) 103 (55) 1.27 0.61–2.67 .523 2 • ofid • BRIEF REPORT Downloaded from https://academic.oup.com/ofid/article-abstract/7/6/ofaa117/5818983 by DeepDyve user on 17 June 2020 Table 1B. Multivariate Analysis of Risk Factors for CRBSI reported in an Australian and New Zealand survey [12]. Our cohort of CRBSI episodes reflects primary TCHD insertions Variable OR 95% CI P Value only. Other studies included serial TCHD insertions and re- Left internal jugular vein 4.4 1.65–11.72 .003 peat CRBSI episodes. Previous CRBSI is a risk factor for sub- Diabetes 2.2 1.02–4.75 .045 sequent CRBSI [7]. In our study, fewer controls experienced a Ex-smoker 0.32 0.13–0.80 .015 subsequent episode of CRBSI when compared with cases (4% Age, y 0.98 0.95–1.00 .096 vs 18%, respectively). Tunneled dialysis catheter in situ >90 d 1.24 0.58–2.66 .574 Hypertension 1.05 0.47–2.32 .908 Almost half of the patients had a TCHD in situ for >90 days. This may reflect the 2 major reasons for TCHD insertion— Abbreviations: CI, confidence interval; CRBSI, catheter-related bloodstream infection; IQR, interquartile range; OR, odds ratio. acute start RRT or RRT access malfunction. Acute start RRT is due to late referrals and patients who do not engage in timely and left internal jugular vein insertion site were inde- permanent access for RRT. Permanent vascular access takes pendent risk factors for CRBSI. Ex-smokers were less likely to weeks to months to fully mature and be ready for regular use. acquire CRBSI. We also have a significant proportion of diabetic patients (42%), Diabetics are more susceptible to infections, including with underlying vascular disease or calcified vessels, which re- CRBSI [7, 8]. A  hyperglycemic environment may impair host sult in poor access development. Minimization of late referrals responses, namely neutrophil chemotaxis, adhesion and intra- could be addressed with stronger community chronic kidney cellular killing, and humoral immunity, increasing the likeli- disease education, follow-up, and planning. Encouraging up- hood of infection [8]. This emphasizes the need to ensure that take of acute start peritoneal dialysis could reduce the need for diabetic patients with renal impairment are carefully considered vascular access. Our CRBSI microbiology results are consistent for timely permanent RRT access. with the international literature. Most were gram-positive or- Of clinical note, TCHDs inserted into the left internal jug- ganisms, including S.  aureus and coagulase-negative staphylo- ular vein were at an increased risk of CRBSI compared with the cocci. Gram-negative bacteremia and polymicrobial bacteremia right. Forty-one (18%) primary TCHDs were inserted into the have also been reported [3, 4]. left internal jugular vein. Reasoning was not consistently docu- This is the first Australian published data using multivar - mented; however, it can be hypothesized that the contralateral iate analyses to identify intrinsic patient risk factors for CRBSI. upper limb may have been preserved for arterio-venous access Although the CRBSI rate is comparable to that reported in the creation or that the preferred right internal jugular insertion international literature, more work is needed to achieve timely site had inaccessible vascular anatomy. The left internal jugular access for patients with near-end-stage kidney disease, in- vein insertion site has a longer and variable anatomical course cluding those with diabetes, and to avoid TCHD insertion into to the right atrium compared with the right internal jugular the left internal jugular vein. vein. This larger surface area with contact to prosthetic material is liable for biofilm or clot formation and TCHD malfunction. Acknowledgments TCHD biofilms can create an altered micro-environment that Financial support. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-prot s fi ectors. facilitates slow-growing microorganisms where antibiotic pen- Author contributions. K.M.  wrote the manuscript. Y.S.P.L.  and etration is difficult [9]. F.I. contributed to the manuscript. Y.S.P.L. analyzed the data. K.M., Y.S.P.L., e de Th creased risk of CRBSI in ex-smokers is difficult to P.Y.M.L., S.C., E.O., and N.B. collected the data. explain physiologically. Tobacco smoking cessation has been shown to augment the inflammation and immunity state in the References patient, which may explain a reduction in CRBSI risk in our 1. ANZDATA Registry. 41st Report. Adelaide, Australia: Australia and New Zealand Dialysis and Transplant Registry; 2018. Available at: http://www.anzdata.org.au. cohort [10]. Accessed 9 January 2020. Risk factors for CRBSI identified in previous studies in- 2. Jean G, Charra B, Chazot C, et al. Risk factor analysis for long-term tunneled di- clude higher total intravenous iron dose, more frequent uro- alysis catheter-related bacteremias. Nephron 2002; 91:399–405. 3. Saad TF. Bacteremia associated with tunneled, cuffed hemodialysis catheters. Am kinase catheter infusion, local infection, and nasal carriage J Kidney Dis 1999; 34:1114–24. of S. aureus [5, 7, 11]. Data on these factors were incomplete 4. Lok CE, Mokrzycki MH. Prevention and management of catheter-related infec- tion in hemodialysis patients. Kidney Int 2011; 79:587–98. at our center and were therefore not assessed in our study. In 5. Fry AC, Stratton J, Farrington K, et al. Factors affecting long-term survival of tun- contrast to other studies, we found that duration of TCHD nelled haemodialysis catheters—a prospective audit of 812 tunnelled catheters. Nephrol Dial Transplant 2008; 23:275–81. in situ and hypertension did not have a significant associa- 6. National Kidney Foundation. KDOQI clinical practice guidelines and clinical prac- tion with CRBSI. This may be due to our relatively low rate tice recommendations for 2006 updates: hemodialysis adequacy, peritoneal dialysis adequacy and vascular access. Am J Kidney Dis 2006; 48(Suppl 1):S1–S322. of CRBSI compared with the international literature [2, 3]. 7. Lemaire  X, Morena  M, Leray-Moragués  H, et  al. Analysis of risk factors for A  median rate (IQR) of 0.59 (0.39–1.2) CRBSIs per 1000 catheter-related bacteremia in 2000 permanent dual catheters for hemodialysis. catheter-days (tunneled and nontunneled HD catheters) was Blood Purif 2009; 28:21–8. BRIEF REPORT • ofid • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/7/6/ofaa117/5818983 by DeepDyve user on 17 June 2020 8. Koh GC, Peacock SJ, van der Poll T, Wiersinga WJ. The impact of diabetes on the 11. Miller LM, Clark E, Dipchand C, et al; Canadian Society of Nephrology Vascular pathogenesis of sepsis. Eur J Clin Microbiol Infect Dis 2012; 31:379–88. Access Work Group. Hemodialysis tunneled catheter-related infections. Can J 9. Jones SM, Ravani P, Hemmelgarn BR, et al. Morphometric and biological characteriza- Kidney Health Dis 2016; 3:2054358116669129. tion of biofilm in tunneled hemodialysis catheters. Am J Kidney Dis 2011; 57:449–55. 12. Smyth  B, Kotwal  S, Gallagher  M, et  al; REDUCCTION Partnership Project. 10. Arnson Y, Shoenfeld Y, Amital H. Effects of tobacco smoke on immunity, inflam- Dialysis catheter management practices in Australia and New Zealand. mation and autoimmunity. J Autoimmun 2010; 34:J258–65. Nephrology (Carlton) 2019; 24:827–34. 4 • ofid • BRIEF REPORT

Journal

Open Forum Infectious Diseases – Oxford University Press

Published: Jun 1, 2020

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