Nephrology Book

Organ Failure

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Bloodstream Infections in Hemodialysis

Aka: Bloodstream Infections in Hemodialysis, Fever in End Stage Renal Disease, Febrile Dialysis Patient, Bacteremia in ESRD, Sepsis in Hemodialysis Patient
  1. See Also
    1. Sepsis
    2. Hemodialysis
    3. Dialysis Emergencies
    4. Hypotension in the Dialysis Patient
    5. End Stage Renal Disease
    6. Dialysis Disequilibrium Syndrome
  2. Epidemiology
    1. Incidence: 37,000 bloodstream infections in ESRD patients with Central Line in 2008 (CDC)
  3. Causes: Infection Sources
    1. See Dialysis-Related Spontaneous Bacterial Peritonitis
    2. Hemodialysis access sites (including old sites)
      1. Increased risk with tunneled catheters more than grafts or fistulas
      2. Consider if Intermittent Fever, malaise, relative Hypotension or Leukocytosis
      3. Observe closely for local erythema, tenderness, swelling or drainage at fistula site
        1. Presentation may be subtle
    3. Epidural Abscess
    4. Endocarditis (especially the aortic valve)
    5. Septic Pulmonary Embolus
    6. Osteomyelitis
    7. Septic Arthritis (e.g. wrist, knee, Shoulder)
    8. Urinary Tract Infection (especially Polycystic Kidney Disease patients)
    9. Pneumonia (or empyema)
    10. Extremity Cellulitis
    11. Perirectal Abscess
    12. Dental abscess
  4. Imaging
    1. Chest XRay
    2. Echocardiogram
      1. Consider to evaluate for valvular vegetations (Bacterial Endocarditis)
    3. Shunt Ultrasound
      1. Consider to evaluate for abscess at shunt site
  5. Labs
    1. Complete Blood Count
    2. Blood Cultures
      1. Consider culture from percutaneous Dialysis catheter (consult with hematology first before accessing catheter)
    3. Lactic Acid
    4. Urine Culture (if ESRD patient still produces urine)
    5. Other cultures
      1. Drainage expressed from fistula site
      2. Peritoneal dialysate fluid (also obtain cell count and Gram Stain)
  6. Management: Empiric antibiotics for Sepsis
    1. Coverage for skin flora (Gram Positive Bacteria including MRSA) as well as Gram Negative Bacteria
    2. Preferred regimen
      1. Vancomycin AND
      2. Gentamicin 2-5 mg/kg (or other Aminoglycoside)
    3. Alternative regimens
      1. Piperacillin/Tazobactam (Zosyn)
      2. Ticarcillin-clavulanate
      3. Imipenem or Meropenem
      4. Ceftazidime
  7. Prognosis
    1. Mortality in Dialysis patient with bloodstream infection: 25%
  8. References
    1. Campana (2014) Crit Dec Emerg Med 28(4): 2-8
    2. Glauser (2013) Crit Dec Emerg Med 27(10): 2-12
    3. Mallemat, Swaminathan and Egan in Herbert (2014) EM:Rap 14(10): 5

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