Treatment of catheter-related bacteremia with tissue plasminogen activator antibiotic locks.

This retrospective study was completed to investigate the effectiveness of tissue plasminogen activator (TPA) antibiotic locks (ABL) along with systemic antibiotics (AB) to clear catheter-related bacteremia (CRB) in children on chronic hemodialysis. There were 76 CRBs in 37 children. CRBs were successfully cleared with AB/ABL in 63/76 (83%) cases. Ten of 76 (13%) CRBs were symptomatic at 48 h of treatment. These were seven polymicrobial, two gram-negative, and one Candida CRB. 13/76 (17%) episodes required catheter exchange, and all were wire-guided exchanges. TPA-ABL/AB cleared gram-positive and gram-negative CRBs significantly better than polymicrobial CRBs (p < 0.01). The infection-free survival and the rate of recurrence at 45 days was not statistically different between the TPA-ABL/AB group and the catheter-exchange group. If CRB was symptomatic at 48 h of treatment, recurrence at 6 weeks was more frequent with persistent use of TPA-ABL/AB (p < 0.05). There were no episodes of metastatic infections, catheter malfunction from occlusion, or catheter breakdown during the course of TPA-ABL treatments. In conclusion, TPA-ABL can be safely and effectively used in the management of CRB, increasing the probability of catheter survival and preserving the vascular access site. With the exception of polymicrobial CRB, there is no disadvantage in using TPA-ABL/AB over catheter exchange, as the infection-free survival and the rate of recurrence are comparable.

Catheter survival and comparison of catheter exchange methods in children on hemodialysis.

This retrospective study was done to compare the infection-free and overall survival of first and subsequent tunneled cuffed hemodialysis catheters in children. Subsequent catheters were exchanged by two different methods (a) removal and replacement (R&R), or (b) wire-guided exchange (WGE) using the same tunnel and vessel. The study involved 59 children (27 male, 32 female; mean age 13.9 +/- 4.6 years) undergoing maintenance hemodialysis in a pediatric unit over a period of 60 months. From a total of 175 catheters (57 first catheters, 81 WGE, 37 R&R) and 38,888 catheter days, 74/175 (42%) catheters were exchanged because of catheter-related bacteremia (CRB) and 43/175 (25%) for malfunction or cuff extrusion. One-year survival rates for first and consecutive catheters was 26% and 21%, respectively. The overall survival of first catheters, and those exchanged by WGE and R&R for both infectious and non-infectious reasons, was not statistically different. However, infection-free survival of first catheters was significantly prolonged in comparison with that of subsequent catheters (P < 0.001). The infection-free survival and the overall survival were not affected by etiology of primary disease, gender, serum albumin, or hemoglobin. Overall catheter survival increased with age >10 years. There was a significant association between gram-negative and polymicrobial CRB and requirement for R&R (P < 0.02). Our findings suggest that WGE is safe in a clinically stable child if the tunnel and the exit site are not infected and has the potential benefit of preserving the vascular access site. The shorter infection-free survival in subsequent catheters suggests a cumulative disadvantage with prolonged catheter use.