What is the management for a patient who develops fever during dialysis?

Management of Fever During Dialysis

When a patient develops fever during dialysis, immediate assessment for infection is necessary, with particular attention to water quality, vascular access, and systemic infections, as dialysis patients with fever have high rates of bacteremia (approximately 30-60%).

Initial Assessment

• Evaluate for signs of sepsis including hypotension, tachycardia, and altered mental status 1
• Check vital signs including temperature, blood pressure, heart rate, and respiratory rate 1
• Assess vascular access site for signs of infection (redness, warmth, tenderness, purulent drainage) 1, 2
• Review recent laboratory values including complete blood count with differential, looking specifically for leukocytosis and bandemia (>5% bands is associated with increased risk of bacteremia) 2

Risk Stratification

High-risk patients for bacteremia include:

• Those with dialysis catheters (6.2 times higher risk compared to fistula/graft) 3, 2
• Prior history of bacteremia (8.9 times higher risk) 2
• Presence of fever (temperature ≥38.5°C) 3
• Leukocytosis or bandemia 2
• Hypoalbuminemia 3

Diagnostic Workup

• Obtain blood cultures from peripheral sites and from the dialysis access if it's a catheter (before antibiotic administration) 3, 2
• Consider additional cultures based on symptoms (urine, sputum, wound) 4, 2
• Check dialysis machine for blood leaks, as this may necessitate more frequent disinfection of internal pathways 1
• Review recent water quality testing results (cultures and endotoxin analysis should be performed monthly) 1
• Consider procalcitonin testing, though it has limited utility in hemodialysis patients (77% sensitivity, 59% specificity at cutoff of 1 ng/ml) 5

Immediate Management

• For patients with high-risk features (catheter access, prior bacteremia, fever, leukocytosis):

  • Start empiric broad-spectrum antibiotics after obtaining cultures 3, 2
  • Consider vancomycin plus gram-negative coverage based on local resistance patterns 2
  • Adjust antibiotic dosing for renal failure 1

• For low-risk patients (fistula/graft access, no fever, normal white blood cell count, normal albumin):

  • May consider close monitoring without immediate antibiotics while awaiting culture results 3
  • These patients have a much lower risk of bacteremia (approximately 6%) 3

Specific Interventions

• If water contamination is suspected:

  • Notify the medical director immediately 1
  • Consider stopping dialysis if bacterial or endotoxin levels exceed action levels 1
  • Implement additional disinfection measures for the water treatment system 1

• For dialysis catheter-related infection:

  • Consider catheter removal and replacement if bacteremia is confirmed 1, 2
  • Use antiseptic lock solutions for long-term catheters with history of multiple infections 1

• For influenza (if suspected during flu season):

  • Isolate patient with surgical mask and maintain 6-foot distance from other patients 1
  • Treat with oseltamivir 30 mg initially followed by 30 mg at each dialysis session for 5 days 1
  • Consider prophylaxis for exposed patients 1

Infection Control Measures

• Place febrile patient in isolation or at least 6 feet from other patients 1
• Ensure proper hand hygiene by all staff 1
• Clean environmental surfaces with appropriate disinfectants 1
• Consider having patient wear a surgical mask to prevent droplet transmission 1

Continued Monitoring

• Monitor vital signs frequently during remainder of dialysis session 1
• Assess for orthostatic hypotension before discharging patient from dialysis unit 1
• Consider isothermic dialysis (maintaining predialysis body temperature) to improve hemodynamic stability 1
• Evaluate need for hospitalization based on severity of illness and response to initial interventions 3, 2

Pitfalls and Caveats

• Do not assume fever is always due to infection; consider non-infectious causes such as:

  • Adrenal insufficiency, particularly in patients recently withdrawn from steroids 6
  • Reaction to dialyzer membrane or dialysate 1
  • Medication reactions 1

• Avoid premature discontinuation of antibiotics if cultures are negative but clinical suspicion for infection remains high 3, 2

• Remember that dialysis patients may have atypical presentations of infection due to uremia-associated immunosuppression 6

• Consider rare infections in appropriate epidemiological contexts (e.g., brucellosis in patients consuming unpasteurized dairy products) 4