What is the treatment for hemodialysis (HD) related sepsis?

Treatment of Hemodialysis-Related Sepsis

Hemodialysis-related sepsis requires immediate broad-spectrum antibiotics within 1 hour, prompt source control of the infected vascular access, aggressive fluid resuscitation (at least 30 mL/kg crystalloids within 3-6 hours despite ESRD status), and norepinephrine as first-line vasopressor when MAP remains <65 mmHg despite adequate fluid resuscitation. 1, 2, 3

Immediate Antimicrobial Therapy

• Obtain blood cultures from both the dialysis catheter and peripheral vein before initiating antibiotics 3, 4
• Administer broad-spectrum empiric antibiotics within 1 hour covering both gram-positive organisms (particularly Staphylococcus species, which cause 70% of vascular access-related bacteremia) and gram-negative bacilli (25% of cases) 1, 5
• Recommended empiric regimen: Piperacillin-tazobactam 4.5g IV every 6-8 hours OR a carbapenem 1
• Adjust antibiotic dosing based on residual kidney function and avoid nephrotoxic agents like aminoglycosides 3
• For catheter-related infections specifically, bacterial cultures typically reveal Staphylococcus sp. (41%), Pseudomonas sp. (29%), Enterobacter sp. (24%), or Streptococcus sp. (6%) 4

Source Control and Vascular Access Management

• For catheter-related sepsis, use "locked-in" antibiotic retention therapy in addition to systemic antibiotics - this involves retaining antibiotics in both inflow and outflow catheter lumens for 24 hours, replaced daily, for 13-24 days depending on clinical response 4
• This approach cures sepsis in 100% of cases compared to 71% with systemic antibiotics alone, and preserves catheter function in 90% of patients 4
• Routine catheter removal is not necessary if locked-in therapy plus systemic antibiotics are used 4
• However, if clinical deterioration occurs despite appropriate therapy, remove or ligate the vascular access 5

Fluid Resuscitation

A critical pitfall is under-resuscitating HD patients due to fear of volume overload - this must be avoided. 6, 7

• Administer at least 30 mL/kg of crystalloid fluid within the first 3-6 hours targeting MAP ≥65-70 mmHg 1, 2
• Use crystalloid solutions as first-line therapy 1, 2
• Aggressive fluid resuscitation (≥20-30 mL/kg) is safe in ESRD patients and does not increase rates of volume overload, urgent dialysis, or intubation 6, 7
• Continue fluid challenges as long as hemodynamic improvement occurs based on dynamic assessment 2
• Studies show only 23% of ESRD patients receive guideline-concordant fluid resuscitation compared to 60% of non-ESRD patients, representing significant under-treatment 6

Vasopressor and Hemodynamic Support

• Initiate norepinephrine as first-choice vasopressor when MAP <65 mmHg despite adequate fluid resuscitation 8, 1, 2, 3
• Target MAP ≥65 mmHg 8, 2
• Vasopressin (0.01-0.04 units/min) or terlipressin can be added as rescue therapy in refractory shock 8
• Do NOT routinely use inotropes 8, 2
• Administer dobutamine only when low cardiac output is accompanied by ScvO2 <70% despite adequate fluid resuscitation and MAP optimization 8, 2
• The combination of dobutamine plus norepinephrine is first-line when inotropic support is indicated 8, 2

Renal Replacement Therapy Management

• Use continuous renal replacement therapy (CRRT) rather than intermittent hemodialysis in hemodynamically unstable septic patients to facilitate fluid balance management 8, 1, 2, 3
• CRRT and intermittent HD are equivalent in stable patients 8, 2
• Continue scheduled dialysis without interruption during sepsis treatment 4
• No additional supplementary dosing of antibiotics is required following dialysis, as ceftriaxone (a common choice) is not removed by hemodialysis 9

Metabolic and Glucose Management

• Implement protocolized glucose control, initiating insulin when two consecutive blood glucose levels exceed 180 mg/dL 8, 1, 2, 3
• Target upper blood glucose ≤180 mg/dL (NOT ≤110 mg/dL, which increases hypoglycemia risk) 8, 1, 2
• Monitor blood glucose every 1-2 hours until stable, then every 4 hours 8, 1, 2, 3
• Use arterial blood rather than capillary blood for glucose monitoring when arterial catheters are available 3

Adjunctive Supportive Care

• Provide VTE prophylaxis with dalteparin (preferred LMWH with low renal metabolism) OR unfractionated heparin given renal impairment 8, 1, 2, 3
• Dalteparin is specifically recommended when creatinine clearance <30 mL/min 8, 1
• Administer proton pump inhibitor (preferred over H2 blocker) for stress ulcer prophylaxis given septic shock as a bleeding risk factor 8, 1, 2, 3
• Initiate early enteral nutrition within 48 hours if tolerated 1
• Implement contact precautions and rigorous hand hygiene with soap and water 3

Monitoring Parameters

• Continuously monitor MAP, urine output (target ≥0.5 mL/kg/h), lactate levels, and ScvO2 (target ≥70%) 8, 1, 2
• Monitor SpO2 ≥95% 8
• Target hemoglobin 7-9 g/dL 2

Prognostic Considerations

Mortality in HD-related sepsis is substantial and access-dependent: 10, 5

• Overall mortality from catheter-related sepsis is approximately 18% 5
• Sepsis increases mortality risk three-fold compared to non-septic HD patients 10
• Catheter use is associated with 1.8-fold higher sepsis risk compared to arteriovenous fistula 10
• Among patients who develop sepsis, catheter use nearly doubles 1-year mortality compared to fistula (HR 1.94) 10
• Sepsis-associated acute renal failure carries 70% mortality 1