Michael Sean Boger, MD, infectious diseases fellow, Vanderbilt University School of Medicine, Nashville, Tennessee, who conducted the research while doing his residency at Wake Forest University School of Medicine, Winston-Salem, North Carolina, presented the research at a poster session on October 13^th.

"We see a lot of patients on our ward who have catheter-related infections related to their dialysis," Dr. Boger explained. "One of the questions that commonly comes up is how soon we can replace their catheter. The longer they stay in hospital, the more interruption they have of their outpatient [dialysis] schedule, so it would be preferable to perform early replacement."

But the optimal timing of replacement is open to debate. Dr. Boger noted that a study published in 2002 found many nephrologists waited until blood cultures were negative for anywhere from 48 to 72 hours before replacing a catheter in cases of CRI.

The study initially recruited 91 hemodialysis patients who were treated at Wake Forest Baptist Medical Center. Patients were excluded from the study if they had metastatic infection, sepsis syndrome, endocarditis, positive blood cultures thought to be contaminated, infectious etiology other than or in addition to the hemodialysis catheter, fever that persisted beyond 72 hours, or cultures that continued to be positive beyond 72 hours despite removing the infected catheter.

Twelve subjects were randomized to immediate double-lumen dialysis catheter replacement as soon as feasible by an interventional radiologist at another site and 14 to delayed double-lumen tunnelled dialysis catheter replacement after 48 hours of negative blood cultures. The two groups were comparable on factors such as age, sex, and race.

Both treatment groups received 2 weeks of intravenous antibiotics based on culture and sensitivity data. Three sets of blood cultures were obtained daily for the first 48 hours or longer with persistent fever or persistent positive blood cultures. In terms of follow up, blood culture were taken at 1 week, 1 month, and 3 months after completion of antibiotics.

Mean time to catheter replacement was 1.35 days in patients who were to have catheters replaced as soon as was feasible, and the mean time was 7.2 days in the control group that received delayed replacement. The difference was statistically significant, with a P value of less than .001.

In terms of cure, 6 of 7 patients who underwent immediate replacement were cured while all 12 who got delayed replacement were cured. Five of the 12 in the experimental group died due to factors other than catheter infection -- 2 due to cardiac arrest, 1 due to infection with a different organism, and 2 due to respiratory arrest.

One patient experienced relapse just before the 3-month follow-up mark.

Patients in the immediate replacement group were in worse health than those who received delayed replacement.

"If we were able to perform more early replacement of catheters, it would save on health care dollars," said Dr. Boger, noting a larger study will be conducted in the future to confirm the findings.

The study was independently supported.


[Presentation title: Randomized Trial of Early Versus Delayed Catheter Replacement in Hemodialysis Patients with Catheter-Related Infection. Poster 429]

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