What to do if a patient on hemodialysis (HD) has persistent fever and chills despite treatment with paracetamol (acetaminophen) and hydrocortisone?

Management of Persistent Fever and Chills During Hemodialysis Despite Initial Treatment

Stop the dialysis session immediately, obtain at least two sets of blood cultures from the fistula/graft or peripheral site (or from bloodlines if no peripheral access), and start empirical broad-spectrum antibiotics with vancomycin PLUS gram-negative coverage (third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination) without delay. 1, 2

Immediate Actions

The fact that paracetamol and hydrocortisone have already been given but symptoms persist strongly suggests an infectious etiology rather than a simple infusion reaction or dialyzer-related pyrogenic response. 1, 2

Critical steps to take now:

• Terminate the dialysis session immediately - continuing dialysis during active infection increases risk of hemodynamic instability 1, 2

• Obtain blood cultures before antibiotics - draw at least two sets from the fistula, graft, or peripheral site; if peripheral access is unavailable, draw from the bloodlines connected to the dialysis circuit 1, 2

• For catheter patients specifically: obtain one set from the catheter AND one from a peripheral site if feasible 2

• Start empirical antibiotics immediately after cultures are drawn - vancomycin PLUS gram-negative coverage (options include third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination based on your local antibiogram) 1, 2

Why Antibiotics Are Essential Now

Hemodialysis patients presenting with chills during dialysis have a 60% rate of infection and 33.5% rate of bacteremia, even when no obvious source is identified. 3 The persistence of fever and chills despite symptomatic treatment (paracetamol and hydrocortisone) makes catheter-related bloodstream infection (CRBSI) or access-site infection highly likely, and delays in antibiotic treatment increase mortality risk. 2

Diagnostic Evaluation While Awaiting Culture Results

Examine the vascular access site carefully:

• Inspect for erythema, warmth, purulent drainage, or tenderness at the fistula/graft site 1, 2
• For catheter patients, examine the exit site and tunnel for signs of infection 2
• Look for signs of metastatic infection including new heart murmurs (endocarditis), focal bone pain (osteomyelitis), or limb swelling (suppurative thrombophlebitis) 2

Investigate the dialysis equipment:

• Test dialysis water and dialysate for endotoxin and bacterial contamination 1, 2
• Review machine disinfection protocols - inadequate disinfection can cause pyrogenic reactions that mimic infection 1

Catheter Management Algorithm (If Patient Has a Catheter)

If cultures grow S. aureus, Pseudomonas species, or Candida species:

• Remove the infected catheter immediately 4, 1
• Insert a temporary (nontunneled) catheter at a different anatomical site 4
• A long-term catheter can be placed once blood cultures are negative 4

If cultures grow other pathogens (coagulase-negative staphylococci, other gram-negative bacilli):

• Continue empirical antibiotics without immediate catheter removal 4
• Remove the catheter if symptoms persist beyond 2-3 days OR if metastatic infection develops 4, 2
• If symptoms resolve within 2-3 days and no metastatic infection is present, the catheter can be exchanged over a guidewire for a new long-term catheter 4
• Alternatively, retain the catheter and add antibiotic lock therapy as adjunctive treatment for 10-14 days 4

Antibiotic De-escalation Based on Culture Results

If methicillin-susceptible S. aureus is identified:

• Switch from vancomycin to cefazolin 20 mg/kg (actual body weight), rounded to nearest 500-mg increment, given after dialysis 4, 1, 2

If vancomycin-resistant enterococci:

• Use daptomycin 6 mg/kg after each dialysis session OR oral linezolid 600 mg every 12 hours 4, 2

If cultures remain negative at 48-72 hours AND symptoms have resolved:

• Discontinue antibiotics if no other infection source is identified 1

Antibiotic Duration

• 10-14 days for uncomplicated infection with symptom resolution and negative repeat cultures 4, 1, 2

• 4-6 weeks for persistent bacteremia/fungemia >72 hours after catheter removal, endocarditis, or suppurative thrombophlebitis 4, 1, 2

• 6-8 weeks for osteomyelitis 4

Common Pitfalls to Avoid

• Do not wait for culture results to start antibiotics - delays worsen outcomes in hemodialysis patients with suspected CRBSI 2

• Do not assume this is just a pyrogenic reaction - while dialyzer reuse and water contamination can cause fever/chills, the 60% infection rate in this population mandates treating as infection until proven otherwise 3, 5

• Do not rely on procalcitonin - it has poor sensitivity (77%) and specificity (59%) for bacterial infection in hemodialysis patients and cannot usefully identify those requiring antibiotics 6

• Do not draw blood cultures only from a catheter - if possible, obtain at least one peripheral set for comparison 2