Can a patient with an infected arteriovenous fistula (AVF) undergoing treatment with intravenous (IV) antibiotics still undergo dialysis through the infected AVF?

Can a Patient with an Infected AVF Continue Dialysis Through That Access?

Yes, a patient with an infected arteriovenous fistula (AVF) can continue dialysis through the infected access while receiving IV antibiotics, but cannulation must avoid the infected site itself. 1

Treatment Protocol for Infected AVF

Primary Management Strategy

• Infected AVFs are rare and should be treated as subacute bacterial endocarditis with 6 weeks of IV antibiotic therapy. 1
• Initial empiric antibiotic coverage must include both Gram-negative and Gram-positive organisms, including Enterococcus, until culture results guide definitive therapy. 1
• The infected AVF can remain in use for dialysis during antibiotic treatment, unlike infected grafts which often require surgical intervention. 1

Critical Cannulation Restrictions

• Cannulation must cease at the specific infected site—needles should be placed in unaffected portions of the fistula away from any area showing signs of infection. 2
• Avoid cannulating through or near sites with erythema, warmth, tenderness, drainage, or compromised skin integrity. 3, 2
• The "Look-Listen-Feel" approach should be performed before each dialysis session to identify safe cannulation zones. 2

When AVF Takedown Is Required

• Fistula takedown (surgical removal) is mandatory only in cases of septic emboli. 1
• Immediate AVF closure is also required for monomelic ischemic neuropathy or severe symptomatic ischemia with tissue necrosis. 2
• If the patient remains symptomatic with fever/bacteremia for more than 36 hours despite appropriate antibiotics, or if the patient is clinically unstable, surgical intervention should be considered. 1

Key Distinction: AVF vs. AVG Infections

AVF (Native Fistula) Infections

• Can typically be salvaged with antibiotics alone (6-week course). 1
• Surgical repair is effective in 82% of cases when needed, preserving the native access. 4
• Dialysis can continue through unaffected portions during treatment. 1

AVG (Synthetic Graft) Infections

• Local infection requires antibiotics PLUS incision/resection of the infected graft portion. 1
• Extensive infection requires antibiotics AND total graft resection. 1
• Newly placed grafts (within 1 month) require complete removal regardless of infection extent. 1

Alternative Access Considerations

• If the infected AVF cannot be safely cannulated due to extensive involvement, establish temporary alternative access (tunneled catheter, not PICC line) rather than abandoning the fistula. 1, 5
• Avoid PICC lines in dialysis patients as they are associated with 2.8-fold increased odds of AVF failure (OR 2.8,95% CI 1.5-5.5). 5
• If parenteral antibiotics require central access, use a tunneled central venous catheter rather than a PICC to preserve peripheral veins. 5

Monitoring During Treatment

• Assess the access at every dialysis session for changes in thrill, bruit, or new signs of infection spread. 2
• Monitor for systemic signs: persistent fever, chills, or bacteremia beyond 36 hours warrant reassessment of the treatment plan. 1
• Blood cultures should be repeated periodically during and immediately after antibiotic therapy. 1
• Resume full use of the AVF only when infection has completely resolved, swelling has substantially subsided, and the entire access course is easily palpable. 3

Common Pitfalls to Avoid

• Do not delay evaluation or treatment—even minor signs of AVF infection require immediate initiation of the 6-week antibiotic protocol. 1, 2
• Do not attempt to cannulate through infected tissue, as this exacerbates the infection and risks access failure. 3, 2
• Do not confuse AVF management with AVG management—infected grafts almost always require surgical intervention, while infected fistulas can usually be salvaged medically. 1, 4
• Failing to recognize early signs of septic emboli (new neurologic deficits, peripheral embolic phenomena) delays necessary surgical takedown. 1