What is the management approach for a hemodialysis patient with a catheter who experiences chills during dialysis?

Management of Chills During Hemodialysis in a Catheter Patient

Immediately initiate empirical antibiotic therapy with vancomycin PLUS gram-negative coverage (third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination) after obtaining blood cultures, as this represents catheter-related bloodstream infection (CRBSI) until proven otherwise. 1

Immediate Actions

• Obtain at least two sets of blood cultures before starting antibiotics 1, 2, 3

  • Draw from peripheral veins not intended for future fistula creation (e.g., hand veins) 1
  • If peripheral access is unavailable, draw from the bloodlines connected to the dialysis circuit during hemodialysis 1, 2
  • Draw one set from the catheter AND one from a peripheral site if feasible 3

• Start empirical antibiotics immediately after cultures are drawn 1, 2, 3

  • Vancomycin: 20 mg/kg (actual body weight) loading dose during the last hour of dialysis 4
  • PLUS gram-negative coverage based on local antibiogram: third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination 1
  • Avoid aminoglycosides due to substantial risk of irreversible ototoxicity in dialysis patients 1, 4

Clinical Assessment for Complications

Examine the patient for signs of metastatic infection that would require prolonged therapy and immediate catheter removal: 1, 3

• Assess for endocarditis, suppurative thrombophlebitis, or osteomyelitis 1, 4
• Inspect catheter exit site for erythema, warmth, purulent drainage, or tunnel infection 2, 3
• Look for signs of septic shock or hemodynamic instability 1

Catheter Management Algorithm

For S. aureus, Pseudomonas species, or Candida species (once identified):

• Always remove the infected catheter immediately 1, 3
• Insert a temporary catheter at a different anatomical site 1, 3

For other pathogens (coagulase-negative staphylococci, other gram-negative bacilli):

• Continue empirical antibiotics without immediate catheter removal 1
• Remove the catheter if symptoms (fever, chills, hemodynamic instability) persist beyond 2-3 days OR if metastatic infection develops 1
• If symptoms resolve within 2-3 days and no metastatic infection is present, you have two options: 1
  • Exchange the catheter over a guidewire for a new long-term hemodialysis catheter 1
  • Retain the catheter and add antibiotic lock therapy (vancomycin ≥5 mg/mL with heparin) after each dialysis session for 10-14 days 1, 4

Antibiotic De-escalation

• Switch from vancomycin to cefazolin 20 mg/kg (actual body weight, rounded to nearest 500-mg increment) after dialysis if methicillin-susceptible S. aureus is identified 1
• For vancomycin-resistant enterococci, use daptomycin 6 mg/kg after each dialysis session OR oral linezolid 600 mg every 12 hours 1, 4

Treatment Duration

• 10-14 days for uncomplicated infection (symptoms resolve within 2-3 days, no metastatic infection) 1, 4
• 4-6 weeks if persistent bacteremia/fungemia >72 hours after catheter removal, endocarditis, or suppurative thrombophlebitis 1, 4
• 6-8 weeks for osteomyelitis 1, 4

Follow-up Monitoring

• Obtain surveillance blood cultures 1 week after completing antibiotics if the catheter was retained 1, 4
• If surveillance cultures are positive, remove the catheter and place a new one only after obtaining negative blood cultures 1, 4

Key Clinical Context

Research shows that hemodialysis patients with chills have a 60% rate of infection and 33.5% rate of bacteremia, with catheter access being the strongest risk factor (OR 6.2) 5. The most common pathogens are coagulase-negative staphylococci and S. aureus 1. Most patients can be managed in the outpatient setting; hospitalization is only indicated for severe sepsis or metastatic infection 1, 3, 4.

Common pitfall: Delaying antibiotic therapy while waiting for culture results increases mortality risk in CRBSI 3. The high infection rate in catheter patients with chills justifies immediate empirical treatment 5.