What are the guidelines for removing a tunneled dialysis catheter?

Guidelines for Tunneled Dialysis Catheter Removal

Tunneled dialysis catheters should be removed immediately when there is evidence of tunnel infection, port abscess, or persistent bacteremia despite appropriate antibiotic therapy.

Indications for Removal

Definite Indications for Removal

• Tunnel infection or port abscess: Requires catheter removal, incision and drainage if indicated, and 7-10 days of antibiotic therapy 1
• Exit site infections with purulent drainage that fail to respond to systemic antibiotics 1
• Catheter-related bloodstream infection (CRBSI) with Staphylococcus aureus: Removal is strongly recommended due to high risk of endocarditis 1
• Persistent bacteremia or fungemia: Continued positive blood cultures despite appropriate antimicrobial therapy 1
• Septic thrombosis, endocarditis, or other metastatic infections 1
• Clinical deterioration or persistent/recurrent CRBSI in pediatric patients 1

Relative Indications for Removal

• Uncomplicated exit site infections: Initial management with topical antimicrobial agents based on culture results; if fails to resolve, systemic antibiotics should be administered and catheter removed if treatment fails 1
• Coagulase-negative staphylococcal bacteremia: May attempt catheter salvage with systemic antibiotics and antibiotic lock therapy, but removal indicated if treatment fails 1

Procedure for Removal

1. Pre-removal assessment:

   • Confirm indication for removal
   • Review patient's coagulation status
   • Obtain appropriate cultures before removal if infection is suspected

2. Technique:

   • Tunneled catheters can be safely removed at bedside by properly trained personnel 2
   • Use sterile technique with appropriate barrier precautions 1
   • Apply pressure at exit site after removal to prevent bleeding
   • For infected catheters, culture the catheter tip

Special Considerations

Catheter Exchange vs. Removal

• Guidewire exchange may be considered if:

  • No evidence of tunnel infection 3
  • Patient defervesces within 48 hours of antimicrobial therapy 3
  • Other vascular sites are unavailable or patient has bleeding diathesis 1
  • Consider using antimicrobial-impregnated catheter for exchange 1

• Complete removal with delayed replacement should be performed if:

  • Tunnel infection is present
  • Exit site infection with purulence
  • Persistent bacteremia despite appropriate therapy

Antibiotic Management

• Systemic antibiotics should be administered based on culture results:
  • For S. aureus: β-lactam antibiotics for MSSA; vancomycin for MRSA 1
  • For coagulase-negative staphylococci: 5-7 days if catheter removed; 10-14 days if catheter retained 1
  • For gram-negative bacteremia: 10-14 days of appropriate antimicrobial therapy 1

Timing of Replacement

• After removal of infected catheter, insertion of a new tunneled catheter should be postponed until:
  • Appropriate systemic antimicrobial therapy is begun
  • Repeat blood cultures yield negative results 1
  • Ideally, after completion of antibiotic course in stable patients 1

Common Pitfalls to Avoid

• Delayed removal of infected catheters, especially with tunnel infection or persistent bacteremia 4
• Using vancomycin for β-lactam-susceptible S. aureus infections 1, 4
• Failure to obtain appropriate cultures before initiating antibiotics 4
• Missing endovascular complications by not performing transesophageal echocardiography in S. aureus bacteremia 4

Conclusion

Proper management of tunneled dialysis catheter removal is essential for preventing complications and ensuring optimal patient outcomes. The decision to remove should be based on clinical presentation, type of infection, and causative organism, with immediate removal indicated for tunnel infections, port abscesses, and persistent bacteremia despite appropriate therapy.