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Author Interview: Dr. Jacob A Akoh
Vascular Access Infections: Epidemiology, Diagnosis, and Management
Akoh JA.
Curr Infect Dis Rep. 2011 Apr 26.
What are the main findings of the study?
Infections account for approximately 15-36% of all deaths in dialysis patients (the second leading cause after cardiovascular events) and 20% of hospital admissions. There is a demonstrable hierarchy of infection risk from temporary catheter, tunnelled cuffed catheter, arteriovenous grafts to arteriovenous fistula in decreasing order.
Compared with dialysis using arteriovenous fistulas, long-term dialysis with tunnelled cuffed catheters is associated with: two to threefold increased risk of death; a five to 10-fold increased risk of serious infection; increased hospitalisation; a decreased likelihood of adequate dialysis; and an increased number of vascular access procedures
Metastatic infective complications are common with central venous catheters.
Catheter-sparing diagnostic methods, such as differential quantitative blood cultures and differential time to positivity have emerged as reliable techniques for diagnosing catheter related infection.
Were any of the findings unexpected?
Yes. The prevalence of use of central venous catheters in spite of the widespread adoption of the "Fistula First Initiative", for example, eighty two percent of patients started dialysis with a central venous catheter in the US in 2006.
What should clinicians and patients take away from this study?
The need for a comprehensive vascular access management strategy including existing clinical practice guidelines concerning the prevention, diagnosis, and treatment of bacterial infections in patients requiring long term vascular access.
Management includes removal of the access in appropriate cases.
The best way to treat vascular access infection is prevention bearing in mind, “Fistula First” and “Lines Last”, with the appropriate use of arteriovenous grafts and newer devices sandwiched in between.
What recommendations do you have for nephrology health care providers as a result of your study?
Avoidance of central venous catheters is the best way to decrease the incidence of vascular access infections. When used, adherence to evidence-based catheter insertion and maintenance practices can positively influence bacteraemia rates. Effective prevention strategies including cutaneous antisepsis, maximum sterile barrier, antimicrobial catheters, and antimicrobial catheter lock solution can be used
Jacob A Akoh
Abstract
Vascular Access Infections: Epidemiology, Diagnosis, and Management
Akoh JA.
Curr Infect Dis Rep. 2011 Apr 26.
Gastroenterology, Surgery & Renal Services Directorate, Plymouth Hospitals NHS Trust, Derriford Hospital, Plymouth, PL6 8DH, UK
Infection is the most challenging and life-threatening complication of vascular access and causes significant morbidity, loss of access, and mortality. The aims of this review are to determine the magnitude of the infection problem, identify possible factors, and provide an update on the management of vascular access infections.
Infections account for approximately 15% to 36% of all deaths in dialysis patients (the second leading cause after cardiovascular events) and for about 20% of admissions. Several studies demonstrate a hierarchy of infection risk from temporary catheter, tunnelled cuffed catheter, arteriovenous grafts, to arteriovenous fistula in decreasing order.
Suspicion of infection must be followed by appropriate blood cultures, including possible simultaneous sampling from a peripheral vein and the access. The best way to treat vascular access infection is prevention, bearing in mind the idea "fistula first" and "lines last", with the appropriate use of arteriovenous grafts and newer devices sandwiched in between.
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