In a patient on hemodialysis who develops bacteremia, is a tunneled hemodialysis catheter the preferred vascular access?

Tunneled HD Catheters Are NOT Preferred for Hemodialysis Patients with Bacteremia

Tunneled hemodialysis catheters should be avoided in favor of arteriovenous fistulas (AVF) or arteriovenous grafts (AVG), as catheters carry a 7-fold higher risk of bacteremia compared to AVF and are associated with significantly increased mortality and morbidity. 1, 2

Infection Risk Hierarchy: Why Catheters Are the Worst Choice

The evidence clearly establishes a hierarchy of infection risk:

• Arteriovenous fistulas (AVF): 0.2 bacteremia episodes per 100 patient-months—the lowest risk option 1, 2
• Arteriovenous grafts (AVG): 0.5 bacteremia episodes per 100 patient-months 1
• Tunneled (cuffed) catheters: 5.0 bacteremia episodes per 100 patient-months 1
• Non-tunneled catheters: 8.5 bacteremia episodes per 100 patient-months 1

The relative risk of bacteremia with catheters is 7 times higher than with AVF. 1, 2 This translates directly to worse patient outcomes: catheter use is associated with a 51% increase in mortality and 130% increase in severe infection compared to AVF or AVG. 3, 4

Management Algorithm for HD Patients with Bacteremia

Step 1: Identify the Source

• Obtain paired blood cultures: one from the catheter lumen and one peripheral sample 2
• Examine the catheter exit site and tunnel tract for erythema, purulence, warmth, or tenderness 1
• Perform transesophageal echocardiography (TEE) to exclude endocarditis in patients without contraindications 1

Step 2: Immediate Catheter Management Based on Clinical Presentation

Remove the catheter immediately if: 1

• Tunnel tract infection or exit-site infection is present
• Septic thrombosis is suspected
• Patient has uncontrolled sepsis, hemodynamic instability, or persistent fever >48 hours despite antibiotics
• Endocarditis is confirmed
• Infection involves S. aureus, Pseudomonas species (other than P. aeruginosa), Burkholderia cepacia, Stenotrophomonas, Candida species, mycobacteria, Bacillus, or Corynebacterium species

Guidewire exchange may be considered ONLY if: 1, 5, 6

• Patient is hemodynamically stable and defervesces within 48 hours of antibiotics
• No evidence of tunnel tract infection
• Limited venous access options exist
• Infection is uncomplicated (no endocarditis, no septic thrombosis)
• Combined with 21 days of systemic antibiotics

However, guidewire exchange has an 18-45% failure rate even in selected patients, with success rates of only 36.7% with antibiotics alone versus 81.4% when combined with catheter exchange. 5, 6 This is a salvage strategy, not standard care.

Step 3: Antibiotic Therapy Duration

• Uncomplicated bacteremia with catheter removal: 10-14 days for gram-negative organisms; 14 days for coagulase-negative staphylococci with negative TEE 1
• S. aureus bacteremia: 14 days if catheter removed and TEE negative; 4-6 weeks if endocarditis present 1
• Candida species: Remove catheter and treat for 14 days after last positive blood culture 1
• Complicated infections (septic thrombosis, endocarditis, osteomyelitis): 4-8 weeks 1

Step 4: Transition to Permanent Access

The definitive solution is catheter removal and placement of AVF or AVG. 2, 4, 7, 8

• First choice: Radial-cephalic (wrist) AVF 2, 4
• Second choice: Brachial-cephalic (elbow) AVF 2, 4
• Third choice: AVG if AVF not feasible 2, 4
• Last resort only: Tunneled catheter for patients with multiple failed AV accesses, severe arterial occlusive disease, uncorrectable central venous stenosis, or limited life expectancy 1, 2

Critical Pitfalls to Avoid

• Never use non-tunneled catheters for >1 week or in non-hospitalized patients 3, 4
• Never use femoral catheters for >5 days or in ambulatory patients 1, 3, 4
• Avoid subclavian vein catheterization due to high risk of central venous stenosis that precludes future ipsilateral arm access 1, 4
• Do not perform routine scheduled catheter exchanges—this does not reduce infection rates 1, 4
• Do not attempt guidewire exchange in the presence of bacteremia with non-tunneled catheters—the skin tract is the infection source 1
• Do not use vancomycin for β-lactam-susceptible S. aureus—it has higher failure rates and slower bacteremia clearance than oxacillin or nafcillin 1

The Bottom Line

Tunneled hemodialysis catheters are the access of last resort, not a preferred option. When a hemodialysis patient develops bacteremia, the priority is catheter removal (not retention), appropriate antimicrobial therapy, and urgent planning for permanent AVF or AVG placement to prevent recurrent life-threatening infections. 1, 2, 7, 8