Metastatic infectious complications in tunneled dialysis catheter-associated infections: a single-center experience

Abstract

Aim: Although the guidelines recommend arteriovenous fistula (AVF) primarily as vascular access in hemodialysis patients, tunneled catheter (TC) use is gradually increasing. TCs are associated with an increased risk of infection. TC infections can cause many metastatic infectious complications such as infective endocarditis (IE), spondylodiscitis (SpD), and paravertebral abscess. This study aimed to determine the frequency, risk factors, and prognosis of metastatic infectious complications in patients admitted to our hospital with TC infections. Material and Method: Patients with TCs hospitalized to the Nephrology unit of Ondokuz Mayıs University Hospital between January 1, 2015, and January 1, 2020, with catheter infection, were included in the study. Demographic, clinical, and microbiological information was obtained from the patients' medical records retrospectively. Metastatic infectious complications were defined as IE, SpD, paravertebral or epidural abscess, and septic embolisms in any focus. Binary logistic regression analyzes were used to identify risk factors for metastatic infectious complications. Results: One hundred and forty-eight catheter episodes were included in the study. Eighty-seven (58.8%) of the patients were women. Metastatic infectious complications developed in 22 (14.9%) of the patients. Of these, ten patients had IE, ten patients had SpD, and two patients had both IE and SpD. Coagulase-negative staphylococci was obtained as pathogenic microorganism in most cases (9/22, 49%). Patients with infectious complications had higher length of hospital stay [46.5 (10-171) vs 18 (6-92); p<0.001], and higher rates of sepsis (50% vs 16.7%; p<0.001), need for intensive care unit (36.4% vs 12.7%; p=0.005), and death (36.4% vs 11.9%; p=0.003). In multivariate binary logistic regression analysis, diabetes mellitus (DM) [OR: 7,813; 95% CI (2.05–29,783); p=0.003] and catheter duration [OR: 1.002; 95% CI (1-1,003); p=0.009] were identified as risk factors associated with metastatic infectious complications. Conclusion: Metastatic infectious complications are associated with significant morbidity and mortality in hemodialysis patients. Long catheter duration and the presence of DM are risk factors for infectious complications. As recommended in international guidelines, minimizing the use of catheters and preventing the development of catheter infection by paying attention to basic hygiene rules, especially in diabetic patients, will help prevent these serious complications.

Keywords

• hemodialysis
• infective endocarditis
• spondylodiscitis
• tunnelled catheter

References

1. Türk Nefroloji Derneği Yayınları. Türkiye'de Nefroloji, Diyaliz ve Transplantasyon. Ankara, 2021. https: //nefroloji.org.tr/uploads/folders/file/REGISTRY_2020.pdf
2. Murea M, Geary RL, Davis RP, Moossavi S. Vascular access for hemodialysis: A perpetual challenge. Semin Dial 2019; 32: 527-34.
3. Ravani P, Palmer SC, Oliver MJ, et al. Associations between hemodialysis access type and clinical outcomes: a systematic review. J Am Soc Nephrol 2013; 24: 465-73.
4. Klevens RM, Edwards JR, Andrus ML, Peterson KD, Dudeck MA, Horan TC. NHSN Participants in Outpatient Dialysis Surveillance. Dialysis Surveillance Report: National Healthcare Safety Network (NHSN)-data summary for 2006. Semin Dial 2008; 21: 24-8.
5. Lukowsky LR, Kheifets L, Arah OA, Nissenson AR, Kalantar-Zadeh K. Patterns and predictors of early mortality in incident hemodialysis patients: new insights. Am J Nephrol 2012; 35: 548-58.
6. Taylor G, Gravel D, Johnston L, Embil J, Holton D, Paton S. Canadian Nosocomial Infection Surveillance Program; Canadian Hospital Epidemiology Committee. Incidence of bloodstream infection in multicenter inception cohorts of hemodialysis patients. Am J Infect Control 2004; 32: 155-60.
7. Lewis SS, Sexton DJ. Metastatic complications of bloodstream infections in hemodialysis patients. Semin Dial 2013; 26: 47-53.
8. Poinen K, Quinn RR, Clarke A, et al. Complications drom tunneled hemodialysis catheters: a Canadian observational cohort study. Am J Kidney Dis 2019; 73: 467-75.

9. Abbott KC, Agodoa LY. Hospitalizations for bacterial endocarditis after initiation of chronic dialysis in the United States. Nephron 2002; 91: 203-9.
10. Mylona E, Samarkos M, Kakalou E, Fanourgiakis P, Skoutelis A. Pyogenic vertebral osteomyelitis: a systematic review of clinical characteristics. Semin Arthritis Rheum 2009; 39: 10-7.
11. Abid S, DE Silva S, Warwicker P, Farrington K. Infective spondylodiscitis in patients on high-flux hemodialysis and on-line hemodiafiltration. Hemodial Int 2008; 12: 463-70.
12. Priest DH, Peacock JE Jr. Hematogenous vertebral osteomyelitis due to Staphylococcus aureus in the adult: clinical features and therapeutic outcomes. South Med J 2005; 98: 854-62.
13. Mokrzycki MH, Zhang M, Cohen H, Golestaneh L, Laut JM, Rosenberg SO. Tunnelled haemodialysis catheter bacteraemia: risk factors for bacteraemia recurrence, infectious complications and mortality. Nephrol Dial Transplant 2006; 21: 1024-31.
14. Madhavan K, Chieng LO, Armstrong VL, Wang MY. Spondylodiscitis in end-stage renal disease: a systematic review. J Neurosurg Spine 2019; 15: 1-9.
15. Rocha A, Castro R, Santos J. Endocarditis and spondylodiscitis associated with tunneled cuffed hemodialysis catheters: hospitalizations with poor outcomes. Int J Artif Organs 2015; 38: 173-7.
16. Engemann JJ, Friedman JY, Reed SD, Griffiths RI, Szczech LA, Kaye KS, et al. Clinical outcomes and costs due to Staphylococcus aureus bacteremia among patients receiving long-term hemodialysis. Infect Control Hosp Epidemiol 2005; 26: 534-9.
17. Koh GC, Peacock SJ, van der Poll T, Wiersinga WJ. The impact of diabetes on the pathogenesis of sepsis. Eur J Clin Microbiol Infect Dis 2012; 31: 379-88.
18. Lemaire X, Morena M, Leray-Moragués H, et al. analysis of risk factors for catheter-related bacteremia in 2000 permanent dual catheters for hemodialysis. Blood Purif 2009; 28: 21-8.
19. Guillermo-Corpus G, Ramos-Gordillo JM, Peña-Rodríguez JC. Survival and clinical outcomes of tunneled central jugular and femoral catheters in prevalent hemodialysis patients. Blood Purif 2019; 47: 132-9.
20. Shingarev R, Barker-Finkel J, Allon M. Natural history of tunneled dialysis catheters placed for hemodialysis initiation. J Vasc Interv Radiol 2013; 24: 1289-94.
21. Engstrom BI, Horvath JJ, Stewart JK, et al. Tunneled internal jugular hemodialysis catheters: impact of laterality and tip position on catheter dysfunction and infection rates. J Vasc Interv Radiol 2013; 24: 1295-302.
22. Zanoni F, Pavone L, Binda V, et al. Catheter-related bloodstream infections in a nephrology unit: Analysis of patient- and catheter-associated risk factors. J Vasc Access 2021; 22: 337-43.
23. Coker MA, Black JR, Li Y, et al. An analysis of potential predictors of tunneled hemodialysis catheter infection or dysfunction. J Vasc Access 2019; 20: 380-5.
24. Donati G, Spazzoli A, Croci Chiocchini AL, et al. Bloodstream infections and patient survival with tunneled-cuffed catheters for hemodialysis: A single-center observational study. Int J Artif Organs 2020; 43: 767-73.
25. Sepas HN, Negahi A, Mousavie SH, Vosough F, Farazmand B. Patency and outcomes of tunneled hemodialysis catheter via femoral versus jugular vein access. J Adv Pharm Technol Res 2019; 10: 81-4.
26. Kuo G, Sun WC, Lu YA, et al. Chronic dialysis patients with infectious spondylodiscitis have poorer outcomes than non-dialysis populations. Ther Clin Risk Manag 2018; 14: 257-63.
27. Kamalakannan D, Pai RM, Johnson LB, Gardin JM, Saravolatz LD. Epidemiology and clinical outcomes of infective endocarditis in hemodialysis patients. Ann Thorac Surg 2007; 83: 2081-6.
28. Rekik S, Trabelsi I, Hentati M, et al. Infective endocarditis in hemodialysis patients: clinical features, echocardiographic data and outcome: a 10-year descriptive analysis. Clin Exp Nephrol 2009; 13: 350-4.