What precautions should be taken for a patient with Chronic Dialysis Failure (CDF) and possible sepsis?

Precautions for Patients with Chronic Dialysis Failure and Possible Sepsis

For patients with chronic dialysis failure (CDF) and possible sepsis, implement contact precautions, administer appropriate antibiotics after blood cultures, and use continuous renal replacement therapy for hemodynamically unstable patients while monitoring for complications specific to dialysis patients.

Infection Control Measures

• Implement contact (enteric) precautions until diarrhea resolves (formed stool for at least 48 hours) 1
• Place patient in a private room with en suite hand washing and toilet facilities when possible; if unavailable, cohort patients with confirmed infections 1
• Use hand hygiene with soap and water rather than alcohol-based sanitizers, as the latter may not effectively remove spores 1
• Ensure proper cleaning and disinfection of the environment and patient equipment 1

Antibiotic Management

• Obtain blood cultures from both the dialysis catheter and peripheral vein before starting antibiotics 2
• Start empiric antibiotics promptly after obtaining cultures, with coverage for both gram-positive and gram-negative organisms 1
• Consider vancomycin or cefazolin for gram-positive coverage, particularly for dialysis access-related infections 3
• For patients with CDF, adjust antibiotic dosing based on residual kidney function 1
• Avoid nephrotoxic antibiotics such as aminoglycosides and tetracyclines 1
• Schedule antibiotic administration after hemodialysis sessions to prevent drug removal during dialysis 4

Vascular Access Management

• Assess dialysis access site for signs of infection, as it represents the most common source of sepsis in hemodialysis patients 5
• Consider that arteriovenous fistulas have lower infection rates compared to catheters and grafts 5
• For catheter-related sepsis, antibiotics may be administered while the catheter remains in place, though removal may be necessary in refractory cases 2

Hemodynamic Management

• Use norepinephrine as the first-choice vasopressor in septic shock, with an initial target mean arterial pressure (MAP) of 65 mmHg 6
• Administer vasopressors through central venous access with continuous arterial blood pressure monitoring 6
• For refractory hypotension, consider adding vasopressin (0.03 units/minute) to norepinephrine 6

Renal Replacement Therapy

• Either continuous or intermittent renal replacement therapy can be used for patients with sepsis and acute kidney injury 1
• Use continuous therapies to facilitate management of fluid balance in hemodynamically unstable septic patients 1
• Avoid initiating renal replacement therapy solely for increased creatinine or oliguria without other definitive indications 1

Additional Considerations

• Schedule non-urgent procedures for the first day after hemodialysis when toxins are eliminated and intravascular volume is optimal 1
• Monitor blood glucose levels every 1-2 hours until stable, then every 4 hours, targeting levels ≤180 mg/dL 1
• Provide venous thromboembolism prophylaxis with low-molecular-weight heparin, adjusting for renal function, or use mechanical prophylaxis if anticoagulation is contraindicated 1
• Implement stress ulcer prophylaxis with either proton pump inhibitors or histamine-2 receptor antagonists if risk factors for GI bleeding are present 1
• Consider early enteral nutrition rather than parenteral nutrition when feasible 1

Monitoring Parameters

• Monitor for signs of catheter-related infections, which account for approximately 70% of sepsis episodes in hemodialysis patients 7
• Assess for electrolyte abnormalities, acid-base disturbances, and fluid overload, which are common in dialysis patients with sepsis 8
• Use arterial blood rather than capillary blood for glucose monitoring when arterial catheters are available 1
• Monitor prothrombin time in patients receiving anticoagulants, as ceftriaxone and other antibiotics may alter coagulation parameters 4