Evaluation of Central Venous Catheter for Dialysis Associated with Bloodstream Infections

Objective: Hemodialysis (HD) catheter-related bloodstream infections (CRBSIs) are a major complication of long-/short-term catheter. Material and Methods: Patients with HD CRBSIs were identified, and their blood was taken and sent to clinical pathology for culture and sensitivity testing. The inclusion criteria were adults with end-stage renal disease who required urgent HD access in the presence of a central venous catheter (CVC) infection. Results: The most common isolates among the patients with CRBSIs were gram-positive microorganisms (57.5%) and gram-negative organisms (42.5%). Overall, in our entire study, Staphylococcus aureus was the most common pathogen isolated, accounting for 30%, followed by Pseudomonas aeruginosa (20%), coagulase-negative staphylococci (CoNS) (12.5%), Klebsiella spp. and Acinetobacter (10%), Staphylococcus epidermidis (7.5%), and methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, Staphylococcus hominis, and Enterococcus faecalis (2.5%). The commonest bacterial in femoral was S. aureus, and for subclavian was Pseudomonas aeruginosa. All S. aureus were sensitive to aminoglycosides and quinolones. P. aeruginosa was sensitive to the third generation of cephalosporins, especially cefoperazone and carbapenem. Conclusion: Nontunneled CVCs used for more than 2 weeks could increase the risk of CRBSIs. Procalcitonin and erythrocyte sedimentation rate could predict the CRBSIs in this study. This study also revealed that the gram-positive bacteria were primadonna in dialysis of CRBSIs, and most of them were sensitive to aminoglycosides.


Introduction
Increased morbidity, mortality, and healthcare expenses are linked to catheter-related bloodstream infections (CRBSIs).When these devices are required, preventing CRBSIs is a crucial goal.The kind of catheter, the purpose for which it is used, how it is used, as well as the unique traits of the patient in whom it is inserted are all elements that determine the risk of infection. 1,2)The fact that CRBSIs rates vary depending on the institution and healthcare unit under examination is not surprising.In order to enhance CRBSIs' care and prevention, this study will analyze patient characteristics, bacterial pathogen patterns, and their sensitivity to medications.
A serious clinical issue, CRBSIs, is a nosocomial infection that is always changing due to changes in the population at risk, the range of bacteria that are present, and an increase in the use of broad-spectrum antibiotics.In addition to CRBSIs, central venous catheters (CVCs) increase the risk of a patient experiencing a number of local and systemic side effects, including infection at the site of insertion, septic thrombophlebitis, endocarditis, metastatic infections, and other life-threatening conditions such as bacteremia, sepsis, and death. 3,4)Therefore, it is crucial that these infections are identified as soon as possible and diagnosed promptly using a combination of clinical signs and quantitative culture techniques, as well as their antibiotic susceptibility, which serves as a crucial tool in assisting the doctor in initiating the proper therapy. 4)he incidence of CRBSIs was 2.79 infections per 1000 catheter days in 2005, according to Lorente et al., while Objective: Hemodialysis (HD) catheter-related bloodstream infections (CRBSIs) are a major complication of long-/short-term catheter.Material and Methods: Patients with HD CRBSIs were identified, and their blood was taken and sent to clinical pathology for culture and sensitivity testing.The inclusion criteria were adults with end-stage renal disease who required urgent HD access in the presence of a central venous catheter (CVC) infection.

Original Article
CVC was involved in 2.04% of cases. 5)Singh et al. determined that the overall infection rate for CRBSIs was 0.48 per 1000 device days. 6)Parameswaran et al. found that 8.75 CRBSIs occurred for every 1000 catheter days. 7)he reported incidence of CRBSIs varies from nation to nation and even from hospital to hospital.Bloodstream infections, according to a meta-analytical study conducted at Johns Hopkins University, are the third most common reason for hospital-acquired infections.The death rate related to these infections ranges from 12% to 25%. 8)

Material and Methods
Patients with hemodialysis (HD) CRBSIs were identified, and their blood was taken and sent to clinical pathology for culture and sensitivity testing.The diagnosis of CRBSIs is based on the presence of CVC, signs of catheter infection, clinical symptoms and signs of bacteremia, and a positive blood culture.The inclusion criteria were adults with end-stage renal disease (ESRD) who required urgent HD access in the presence of a CVC infection.Patients were divided into subclavian and femoral groups.All patients were asked to provide written informed consent during the initial appointment if they were willing to allow the use of their clinical data for publications or presentations in the scientific community.The protocols were carried out in compliance with the Helsinki Declaration of 1975 and the institutional and national responsible committees' ethical standards for human experimentation.The Hasanuddin University clinical research council gave the project their blessing before it could begin (UH 22040100, May 19, 2022).
Suspected cases of CRBSIs were those patients on an indwelling central catheter who had symptoms of local phlebitis, inflammation, purulence, or both at the insertion site, along with fever, chills, hypotension, and an increased leucocyte count. 1)The findings were noted, which contained demographic details such as the ward the patient was admitted to, name, age, sex, date of admission, diagnosis, associated medical conditions, and so on.Additionally, information on the type of catheter used, its length, any prior catheterizations, and any infections that may have developed as a result of the temporary catheter were gathered.Additionally, total leucocyte count, fever, and any other pertinent laboratory test results were documented.
Two blood samples were taken from people who had CRBSI-related suspicions.The catheter was used for one and the peripheral site for the other.In our hospital, two-lumen polyurethane latex-free CVCs were inserted.We collected the sample.After carefully washing hands, a fresh pair of sterile gloves were put on.The catheter was then flushed with a 10-mL syringe of regular saline that had been prefilled.The first 3 to 5 mL of blood were taken out and thrown away.The 50-mL BACTEC bottles were then filled with the blood sample (5 mL), which would later be processed on BD BACTEC FX40 equipment.
Upon discovering bacterial growth on the bottle, a sample was taken for Gram staining and processing using a 1-mL needle that was inserted into the rubber cap of the bottle.On several culture medium plates, an aliquot was cultivated in part.For 24 hours, the plates were incubated at 37°C.Following incubation, the plates were checked for any development; the colonies (Fig. 1), if any, were stained with a Gram stain; and the organisms were identified using a variety of biochemical assays.

Results
Twenty patients were inserted with subclavian HD CVC and 20 patients were inserted with femoral CVC.The demographic study showed (Table 1) 55% were male (22/40), and the female study showed 45% (18/40) and an age of 45.5 ± 11.1 years.The duration of catheter insertion in the subclavian and femoral groups was 52.9 ± 42.6 days and 38 ± 10.5 days, respectively.The length of hospital stay in the subclavian and femoral groups was 10 ± 6.4 days and 9.4 ± 7.1 days, respectively.Based on SIRS indications, the pulse rate, respiration, temperature, and white blood cell (WBC) count for the subclavian group were 88.2 ± 7.6 x/min, 19.7 ± 3.7 x/min, 37 ± 0.6°C, and 11.4 ± 5.2 × 10 3 /µL with p values of 0.60, 0.146, 0.361,  Creatinine and urea values in the subclavian group were 7.8 ± 4.8 mg/dL and 133 ± 99 mg/dL, respectively, and these values in the femoral group were 6.6 ± 3.2 mg/dL and 91.5 ± 34.1 mg/dL, respectively.The length of treatment in the subclavian and femoral groups was 9.9 ± 6.3 and 9.3±7.1 days, respectively.The most common microorganisms found in CRBSIs were gram positive (Table 2) (57.5%) and gram negative (42.5%).Overall, Staphylococcus aureus was the most common pathogen found, with a value of 30%, followed by Pseudomonas aeruginosa (20%), coagulase-negative staphylococci (CoNS) (12.5%),Klebsiella spp.and Acinetobacter (10%), Staphylococcus epidermidis (7.5%), and methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, Staphylococcus hominis, and Enterococcus faecalis (2.5%).The most common bacteria found at the femoral level was S. aureus, and at the subclavian insertion, it was P. aeruginosa.As for antibiotic sensitivity information as shown (Table 3), S. aureus was sensitive to aminoglycosides and quinolones.P. aeruginosa was sensitive to the third class of cephalosporins, especially cefoperazone and carbapenem.CoNS Klebsiella spp. was sensitive to quinolones; Klebsiella spp. was sensitive to aminoglycosides, especially gentamicin; and Acinetobacter was sensitive to third-class cephalosporins, quinolones, and aminoglycosides.S. epidermidis was sensitive to quinolones and vancomycin, MRSA was sensitive to vancomycin, E. coli was sensitive to third-generation cephalosporins and carbapenems, S. hominis was sensitive to aminoglycosides and vancomycin, and E. faecalis was sensitive to vancomycin.We also found that there was no significant association between bacterial infections in the femoral and subclavian groups with a p value of 0.164 and no significant association between antibiotics in CRBSIs in the subclavian and femoral groups with a p value of 0.210.

Discussion
In this study, it was found that CRBSIs were mostly found at the age of 4 decades.Repeated CVC insertion and a long duration of CVC use are risk factors for CRBSIs.Based on The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) 2019, it states that nontunneled central venous catheters (NT-CVCs) can be used in emergencies with a maximum duration of 2 weeks due to the increased risk of infection, and are only used in emergencies. 1)In this study, it was found that the use of catheters with a duration that exceeds the duration that should be HD CVC insertion can be done in three places, namely, the internal jugular, femoral, and subclavian.To reduce the risk of infection, access through the internal jugular should be used, but in this study there was no insertion in the internal jugular.In this study, several insertions use ultrasound guidance, whereas based on the research of Aydin et al., the use of ultrasound guidance can reduce the risk of complications such as insertion in the artery. 8)During the study period, 40 patients presented at our institution, male 22 patients (55%) and female 18 patients (45%), with the femoral group 20 patients and the subclavian group 20 patients.The catheter duration for the femoral group was 38 ± 10.5 days and that for the subclavia group was 52.9 ± 42.6 days.Procalcitonin, lactate, and ESR in the subclavian group were 67.7 ± 64.2 μg/mL, 3.7 ± 1.4 mmol/L, and 84 ± 24.1 mm/h, respectively, and in the femoral group, they were 111 ± 47 μg/mL, 3.6 ± 0.8 mmol/L, and 105 ± 24.1 mm/h, respectively.The p values for them were 0.02, 0.68, and 0.004, respectively.
S. aureus was the most frequently isolated pathogen in this investigation, accounting for nearly 30% of infections linked to CRBSIs.The primary etiological agents of CRBSIs are staphylococci.S. aureus bacteremia is a serious illness with a high mortality rate and risk of complications. 1,2)P. aeruginosa and CoNS were the next most common isolates discovered.P. aeruginosa made up 20% and CoNS made up 12.5% in this study.According to the National Nosocomial Infections Surveillance (NNIS) system, CoNS has been the most frequently isolated pathogens, accounting for around 28% of infections caused by CRBSIs, 3) followed by Klebsiella spp. 4 cases (10%), Acinetobacter 4 cases (10%), S. epidermidis 3 cases (7.5%), MRSA 1 case (2.5%), E. coli 1 case (2.5%), and S. hominis and E. faecalis, each of them 1 case (2.5%).An interesting finding in this study was that Escheria coli was found which was not found in many other studies.Interestingly, there was a difference in the type of most bacterial colonies between femoral and subclavian.We do not have a journal to support whether there is a difference between the location of catheter insertion and the type of infecting bacteria.In our opinion, the hygiene of the patient also determines the pathogenicity of the bacteria.
Regarding this study, aminoglycosides and quinolones were effective against all strains of S. aureus.Particularly, cefoperazone, the third class of cephalosporins, and carbapenem were effective against P. aeruginosa.Acinetobacter is sensitive to third-class cephalosporins, quinolones, and aminoglycosides; Klebsiella spp. is sensitive to aminoglycosides, particularly gentamicin.E. coli was sensitive to third-generation cephalosporins and carbapenems, S. aureus was sensitive to aminoglycosides and vancomycin, and E. faecalis was sensitive to vancomycin.S. epidermidis was sensitive to quinolones and vancomycin.
were sensitive to aminoglycosides.CRBSIs are a problem that can cause significant morbidity, mortality, excess length of stay, and cost.KDOQI Guideline considers to limit the use of temporary CVC to maximun of 2 weeks due to increase risk of infection and should be considered in patients in need of emergent access.KDOQI considers reasonable tunneled CVC is the most appropriate permanent dialysis access and there is no maximum time limit to CVC use.

Fig.
Fig. 1 Plate exhibiting colonies on blood agar for diagnosis of CRBSIs.CRBSIs: catheter-related bloodstream infections

Table 1
Subgroup analyses of time to catheter colonization

Table 2
Isolated microorganism found on CRBSIs