Effect of catheter-lock solutions on catheter-related infection and inflammatory syndrome in hemodialysis patients: heparin versus citrate 46% versus heparin/gentamicin.

BACKGROUND AND OBJECTIVE: Prevention strategies are emerging with the use of catheter-lock solutions (CLS) to prevent catheter-related infections. We compared 3 CLS: heparin, citrate (46%) and heparin/gentamicin (H/G). DESIGN, SETTING AND PARTICIPANTS: Three periods of 6 months using the three CLS were compared. RESULTS: 265 catheters were studied. The CRI rate per 1,000 catheter-days was 2.9 for heparin, 3.4 for citrate and 0.4 for H/G. The free-infection catheter survival tended to be higher with H/G (log-rank test, p = 0.06) and the CRP had a significant decreasing course (p = 0.03). Since 2006 H/G was used as CLS in our dialysis unit. The resistance to gentamicin of Enterobacteriaceae increased in the nephrology department and in the entire hospital. On the other hand, the resistance of Staphylococcus aureus to gentamicin dropped to nil. CONCLUSION: CLS with heparin/gentamicin tended to decrease CRI compared to citrate 46% and heparin and frankly improved the CRP course after catheter insertion. Gentamicin resistance should be monitored.

Rapid curbing of a vancomycin-resistant Enterococcus faecium outbreak in a nephrology department.

BACKGROUND AND OBJECTIVES: Vancomycin-resistant enterococci (VRE) are recovered with increasing frequency among patients with chronic renal failure, making VRE a major concern in nephrology departments, especially for patients who are treated by hemodialysis. We report herein the successful aggressive management of a VRE outbreak in a nephrology department. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: An Enterococcus faecium vanB strain was isolated from a peritoneal dialysis solution from an inpatient. Immediately, infection control measures were enforced and active screening was performed for all contact patients. Carriers were isolated, and patients were divided into three cohorts: Positive, contact, and noncontact patients. We then performed a case-control study to understand risk factors for VRE carriage comparing VRE carriers with contact patients who were negative for VRE. RESULTS: A total of 14 VRE-positive and 125 VRE-negative contact patients were identified. VRE-positive patients were more likely to receive hemodialysis and have longer hospital stays in nephrology. VRE-positive patients more often had a central venous catheter for a longer period of time and received more antibiotics than VRE-negative patients. Treatment with large-spectrum beta-lactams and number of days in the nephrology ward were significantly associated with a higher risk for VRE carriage by using multivariate analysis. CONCLUSIONS: These findings suggest that case mix, longer hospital stays, and antibiotic use are major risk factors for VRE acquisition. In addition, it demonstrates that strict enforcement of isolation precautions and cohorting associated with active screening are successful to curb the transmission of VRE in renal units despite continuous colonization pressure.

Measuring plasma conductivity to detect sodium load in hemodialysis patients.

BACKGROUND: Sodium thiosulfate therapy has been proposed for calcific uremic arteriolopathy and nephrogenic systemic fibrosis in hemodialysis patients. The treatment brings 3.7 g (161 mmol) of sodium. How to counterbalance this sodium load was studied. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Plasma conductivity (Cp) and mass balance index were compared for 20 sessions without thiosulfate and 20 sessions with thiosulfate infusion. Subsequently, the dialysate conductivity was set to 13.8 mS/cm during the entire session. Next, dialysate conductivity was set to 14 mS/cm for the first 3 h and to 13 mS/cm for the last hour of thiosulfate infusion (n = 25). RESULTS: The Cp variation between beginning and end was equal to +0.005 +/- 0.13 mS/cm without thiosulfate, +0.24 +/- 0.13 mS/cm with thiosulfate, and 14 mS/cm dialysate conductivity (P < 0.001). The decrease in dialysate conductivity at 13.8 mS/cm did not counterbalance the sodium load. The last program adequately compensated the sodium load with a Cp increase of only +0.05 +/- 0.14 mS/cm (NS versus without thiosulfate). The total of the dialyzed sodium and the sodium load for this last program was equal to 603 mmol compared with 456 mmol for the sessions without thiosulfate, the difference of 147 mmol being close to the known content of 161 mmol in 25 g of infused thiosulfate. CONCLUSIONS: Thiosulfate infusion requires a decrease of dialysate conductivity of -1 mS/cm during the infusion to counterbalance the added 3.7 g (161 mmol) sodium load.