What are the KDOQI (Kidney Disease Outcomes Quality Initiative) guidelines for managing tunneled catheter infections?

KDOQI Guidelines for Managing Tunneled Catheter Infections

Tunneled catheter infections should be managed based on the type of infection, with exit site infections treated with topical antibiotics and appropriate local care, while catheter-related bacteremia requires parenteral antibiotics and catheter removal if the patient remains symptomatic for more than 36 hours or is clinically unstable. 1

Classification and Management of Tunneled Catheter Infections

Exit Site Infections

• Exit site infections are characterized by redness, crusting, and exudate at the exit site without systemic symptoms and negative blood cultures 1
• Management approach:
  • Apply topical antibiotics and ensure proper local exit site care; do not remove the catheter 1
  • If tunnel drainage is present, treat with parenteral antibiotics (anti-staphylococcal, anti-streptococcal therapy pending exit site cultures) in addition to appropriate local measures 1
  • Definitive therapy should be based on culture results 1
  • Do not remove the catheter unless the infection fails to respond to therapy 1
  • If the infection fails to respond to therapy, remove the catheter and replace it using a different tunnel and exit site 1

Catheter-Related Bacteremia

• Characterized by positive blood cultures with or without systemic signs or symptoms of illness 1
• Management approach:
  • Initiate parenteral antibiotics appropriate for suspected organisms (usually Staphylococcus and Streptococcus) 1
  • Adjust definitive therapy based on the organism(s) isolated 1
  • Remove the catheter if:
    • Patient remains symptomatic for more than 36 hours 1
    • Patient is clinically unstable 1
    • Tunnel tract involvement is present 1
  • In stable asymptomatic patients without exit site or tunnel tract involvement, consider changing the catheter over a guidewire plus a minimum of 3 weeks of systemic antibiotic therapy 1
  • Monitor effectiveness with periodic blood cultures during and immediately after treatment 1
  • Do not place new permanent access until blood cultures, performed after cessation of antibiotic treatment, have been negative for at least 48 hours 1

Antibiotic Selection and Duration

• Initial empiric therapy should cover both Gram-positive (Staphylococcus and Streptococcus) and Gram-negative organisms 1
• For uncomplicated infections when salvaging the catheter, antibiotic lock therapy should be used for 2 weeks along with standard systemic therapy 1
• For catheter-related bacteremia, a minimum of 3 weeks of systemic antibiotic therapy is recommended 1
• For methicillin-susceptible S. aureus bloodstream infections, antistaphylococcal penicillinase-resistant penicillin (nafcillin or oxacillin) is recommended over vancomycin 1

Catheter Salvage vs. Removal Decision Algorithm

1. Remove catheter immediately if:

   • Patient is clinically unstable 1
   • Tunnel tract infection or port abscess is present 1
   • Patient remains symptomatic after 36 hours of appropriate antibiotic therapy 1
   • Complicated infection with septic thrombosis, endocarditis, or metastatic seeding 1

2. Consider catheter salvage with guidewire exchange if:

   • Patient is clinically stable 1
   • No exit site or tunnel tract involvement 1
   • Infection is uncomplicated 1
   • Patient responds to initial antibiotic therapy 1

3. For salvage attempts:

   • Change catheter over guidewire after obtaining bactericidal antibiotic levels 1
   • Implement antibiotic lock therapy in addition to systemic antibiotics 1
   • Monitor with serial blood cultures 1

Common Pitfalls and Caveats

• Catheter-related bacteremia is a life-threatening condition requiring initial hospitalization and parenteral antibiotic therapy 1
• Systemic antibiotics alone salvage less than 25% of catheters in catheter-mediated bacteremia; most infections recur once antibiotics are discontinued 1
• Preliminary studies show that catheter guidewire exchange in stable patients without tunnel involvement can salvage most catheters without apparent ill effects 1, 2
• S. aureus and Candida infections are associated with higher complication rates and may warrant more aggressive management with catheter removal 1
• Guidewire exchange has shown superior cure rates compared to systemic antibiotics alone, particularly for S. aureus infections 2
• Preserving venous access sites is important in hemodialysis patients, making guidewire exchange a valuable option when appropriate 3