Original Article

JIOM Nepal, Volume 41, Number 2, August 2019, page 11-16

Hemodialysis Catheter-Related Infection in a Teaching Hospital of

Central Nepal
1
Arun Sedhain, 2Abja Sapkota, 3Narayan B Mahotra
1
Department of Medicine (Nephrology Unit), Chitwan Medical College, Bharatpur, Chitwan, Nepal, 2Department of
Nursing, Nepal Medical College, Jorpati, Kathmandu, Nepal, 3Department of Clinical Physiology, Maharajgunj Medical
Campus, Institute of Medicine, Maharajgunj, Kathmandu, Nepal

Corresponding author:
Arun Sedhain, MD, DM
Department of Medicine (Nephrology Unit), Chitwan Medical College, Bharatpur, Chitwan, Nepal
Email: [email protected]

Submitted : Jan 5, 2019

Accepted : Jul 20, 2019

ABSTRACT
Introduction
Infection of the central venous catheter (CVC) is a major complication seen among patients undergoing
hemodialysis. Identifying CVC related infection (CRI) and its risk factors and causative organisms is important for
better implementation of preventive strategies.
Methods
A prospective study was conducted at Chitwan Medical College for a duration of 2 years from January 2017
to December 2018 among the patients undergoing hemodialysis via CVC. The data collected were related to
patients’ demographics, site of catheter insertion, and duration, microbiological data including cultures from
catheter sites, blood, and catheters’ tips and antibiotic sensitivity. Catheter related infection was divided into
catheter related local infection (CRLI) and catheter related blood stream infection (CRBSI). Data was analyzed
using IBM SPSS Statistics version 21.0.
Results
A total of 41 cases of CVC related infection (CRI) were documented with an incidence rate of 6.94 episodes
per 1000 catheter days at risk. Out of the total CRI, 39.02% were CRLI and 60.98% were CRBSI. Fever with chills
and rigor were the most common clinical presentation. Risk factors for the development of CRI were duration
of catheter in situ, repeated change of CVC and the use of CVC for indications other than hemodialysis (HD).
Staphylococci and Klebsiella were the most common organisms isolated in culture.
Conclusion
The rate of CRI among Nepalese patients undergoing hemodialysis is high. Prolonged duration of CVC usage,
recent change of catheter and the use of the HD catheter for the purpose of institution of intravenous medication
have been found as the risk factors for CRI.
Keywords: Catheter related infection, central venous catheter, hemodialysis

INTRODUCTION Infection is an important cause of hospitalization

V
and the second most common cause of death
ascular access for hemodialysis is attained by
arteriovenous fistula (AVF), arteriovenous (AV) among patients undergoing hemodialysis.2,3 For
graft or central venous catheter (CVC). Central clinical convenience, CVC related infection (CRI) has
venous catheter (CVC) is used approximately in 80% been divided into CVC related local infection (CRLI)
of patients at the time of initiation of hemodialysis and CVC related bloodstream infection (CRBSI).
(HD).1 Although CVCs were originally introduced for Hemodialysis catheter-related blood stream infection
short-term dialysis, they may be used as a permanent (CRBSI) remains a significant cause of morbidity and
access especially for the patients with limited access mortality among patients undergoing hemodialysis.4
options. Dual lumen non-cuffed catheters are used The mean incidence of uncuffed temporary catheters
for temporary access whereas dual lumen tunneled is around 5/1000 catheter days.5 In comparison to
catheters are the preferred form of access for the arteriovenous (AV) access, the relative risks of
intermediate use. catheter related bacteremia and infection-related

11
Sedhain et al.

death among patients undergoing hemodialysis developed a CRBSI, the patient days at risk (catheter
has been estimated to be about 10 times and two days) were defined as the number of days from
to three-fold higher respectively.6,7 The cumulative catheter insertion to the date paired blood cultures
likelihood of catheter-related bacteremia has been were sent. CVC related local infection (CRLI) was
documented to be 35 percent within three months.8 diagnosed if a semi quantitative culture of an
intravascular catheter segment (>15 colony-forming
Dialysis catheter-related bacteremia can develop
units) was found to be positive and the diagnosis of
either due to migration from the skin along the outside
CRBSI was based on the clinical presentation of fever,
of the catheter into the bloodstream or due to direct
chills and/or hypotension and any of the following
inoculation from a biofilm containing pathogenic
two criteria13:
micro-organisms.4 Multiple factors contribute
to the development of dialysis catheter related • Same organism recovered from percutaneous
bacteremia.9,10 The major organisms responsible blood culture and from semi-quantitative roll-plate
for such infections are gram-positive organisms, culture (>15 CFU) of the catheter tip.
most important of which are coagulase-negative • Same organism recovered from a percutaneous
staphylococcal and Staphylococcus aureus.11,12 and a catheter lumen blood culture, with growth
There is paucity of information on the CRI on detected 2 hours earlier (i.e. 2 hours less
Nepalese context. So, this study was done with an incubation period) in the blood collected through
aim to determine the clinical profile and the microbial catheter than the blood collected percutaneously.
etiology of CRBSI among patients with end stage Data were entered and analyzed by using IBM SPSS
renal disease (ESRD) undergoing hemodialysis in a Statistics software version 21.0 (IBM, Armonk, NY).
tertiary care hospital in central part of Nepal. Continuous response variables were presented as
mean ± SD. Chi square test and Fisher exact test were
METHODS used for qualitative variables. Logistic regression
analysis was done to compare the variables between
This prospective study was conducted in the the patients with and without CRI. p ≤ 0.05 was
Nephrology unit, Department of Medicine at Chitwan considered as statistically significant.
Medical College for a duration of two years from
January 2017 to December 2018. Ethical approval was
obtained from the Institutional Review Committee Table 1. Characteristics of
of Chitwan Medical College (CMC-IRC) before the study population and CVC catheter
initiation of study and written informed consent from Number
the participants was taken. Parameters
(Percentage)
All patients who were initiated on hemodialysis
Age (years)
(HD) using double lumen hemodialysis catheter for
<18 12 (2%)
more than 48 hours were eligible for inclusion in the
18-40 138 (23.2%)
study. Patients with CVC insertion for non-dialysis 41-65 297 (50%)
indications and HD patients who presented with any >65 147 (24.7%)
other source of infection were excluded from the
study. Participants were followed up for one month Sex
after insertion of catheter for any evidence of CRI. Male 420 (70.7%)
Catheter related bacteremia was suspected when a Female 274 (29.3%)
patient experienced fever, chills, purulent discharge Indication for hemodialysis
from catheter site, erythema or tenderness over exit AKI 210 (35.3%)
site, in the absence of any other focus of infection. CKD 384 (64.6%)
Blood samples were collected from the hemodialysis
catheter hubs and from the peripheral veins using CVC location
aseptic precaution, which were sent immediately Right internal jugular vein 463 (77.9%)
to the laboratory for culture and sensitivity testing. Femoral vein 118 (19.8%)
Hemodialysis catheter was removed immediately Left internal jugular vein 13 (2.2%)
when clinically indicated, such as CVC infection, non- Duration of catheterization
functional CVC, fulfilment of its indication and the <30 days 257 (43.2%)
death of the patient.Under aseptic precautions, the >30 days 337 (56.7%)
tip was cut into approximately 5 cm segment using
sterile scissors and transported to the laboratory Reason for CVC catheter removal
No more indicated 511 (86%)
immediately for culture and sensitivity test. After
CVC infection 41 (6.9%)
sending the blood and tip samples for the cultures
Death of the patient 25 (4.2%)
the patients were immediately started on empiric
Not functioning 17 (2.8%)
intravenous antibiotic therapy. For patients who

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 Hemodialysis Catheter-Related Infection

Table 2. Clinical features of total CRI, 39.02% were CRLI and 60.98% were
HD catheter-related infection CRBSI. Most common clinical feature was fever
with chills and rigor (100%) followed by nausea and
Clinical features Number (%)
vomiting (25.8%), Hypotension (63.4%) and catheter
Fever during dialysis 41 (100%) dysfunction (41.4%). Erythema at infection site and
Chills 31 (75.6%) purulent discharge were seen in 12.1% and 7.3% of
Rigors 31 (75.6%) patients respectively. (Table 2)
Nausea, vomiting 27 (65.8%)
Biochemical parameters were compared between
Hypotension 26 (63.4%)
the patients with and without CRI, which is shown
Fever before dialysis 18 (43.9%)
on table 3. Among patients with CRI, serum level of
Catheter dysfunction 17 (41.4%)
albumin was lower andthe levels of ferritin and uric
Malaise 17 (41.4%)
acid were significantly higher.
Breathlessness 13 (31.7%)
Altered sensorium 7 (17.0%) Various possible risk factors were analyzed between
Fever after hemodialysis 5 (12.1%) the patients with and without CRI. A total of 64.5%
Erythema at exit site 5 (12.1%) of patients with CKD and 11.9% of AKI developed
Purulent discharge 3 (7.3%) CRI. Table 4 shows the different risk factors for the
development of CRI.
Most commonly isolated microorganisms in CRI
RESULTS were coagulase negative staphylococci (26.8%),
Staph aureus (24.4%) and Klebsiella pneumoniae
A total of 594 central venous catheters (CVC) were (21.9%). Table 5 shows the details of the isolated
inserted for the purpose of hemodialysis during the microorganisms with classification into CRLI and
study period. Out of the total patients included in CRBSI.
the study, 70.7 % were males. The mean age of the
patients was 53.10±17.75 years (Range: 16-85 years).
DISCUSSION
The indication for the insertion of CVC for hemodialysis
Even though central venous catheter-related infection
was acute kidney injury (AKI) in 35.36% and chronic (CRI) remains a leading cause of morbidity and
kidney disease (CKD) in 64.64%of patients. HD mortality among patients undergoing hemodialysis,14
catheter was kept in situ for a mean period of 9±4 initiation of hemodialysis by uncuffed non-tunneled
days in patients with AKI and 46±23 days in patients central venous catheter is a common practice
with CKD. Most commonly used site for CVC especially in south Asian countries.15
insertion was right internal jugular vein (77.94%),
The incidence rate of CRI in our study was 6.94
followed by femoral vein (19.86%) and left internal
episodes per 1000 patient days at risk, which is
jugular vein (2.2%). Subclavian vein was used in none
higher than the findings from studies from North
of the patients. Details of the baseline parameters is
America, Europe and Africa (ranging between 1.67
shown on table 1.
and 5.6/1000 catheter days)16-18 but slightly lower
A total of 41 cases of CVC related infection (CRI) than that reported from India (7.4 episodes per 1000
were documented with an incidence rate of 6.94 catheter days).19 One of the reasons for variation in
episodes per 1000 patient days at risk. Out of the the findings could be the use of different criteria for

Table 3. Laboratory parameters of patients with and without CVC related infection
Catheter related infection
Biochemical parameters p-value
Positive (n=41) Negative (n=553)
WBC count (000/mm3) 14.6±6.3 7.6±3.2 0.35
Hemoglobin (gm/dl) 8.9±2.3 9.45±1.9 0.14
Platelets (000/mm3) 134.5±10.6 186±11.3 0.96
Albumin (gm/dl) 3.0±0.15 3.4±0.67 0.04
Iron (µmmol/L) 24.47±11.8 15.2±9.4 0.09
Ferritin (ng/mL) 809±432 506±205 0.03
TSAT (%) 19.4±6.4 21.34±7.6 0.08
Uric Acid (mg/dL) 8.9±3.4 6.9±2.6 0.045
Calcium (mg/dL) 9.56±2.3 9.45±1.9 1.12
Phosphorus (mg/dL) 6.45±1.7 5.9±1.6 1.10
PTH 280±121 261±103 0.93
TSAT: transferrin saturation, PTH: parathyroid hormone

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Sedhain et al.

Table 4. Risk factors for CVC related infection (CRI)

Catheter related infection
Factors HR 95% CI p-value
Positive (n=41) Negative (n=553)
Age >65 years 21.9% 19.3% 1.34 0.94-1.65 0.90
Male 73.1% 70.3% 1.17 0.89-1.54 0.95
Diabetes 17.0% 9.5% 1.06 1.01-1.23 0.08
Femoral CVC 9.5% 6.4% 1.92 1.56-2.05 0.12
Duration >30 days 78.0% 32.1% 0.94 0.84-1.51 0.04
Recent surgery 9.7% 6.3% 1.19 0.78-1.57 0.21
Recent change of CVC 29.2% 12.5% 0.87 0.63-1.08 0.03
Use of CVC for medication 34.1% 5.6% 0.89 0.52-1.09 0.03

CRI. In this study, IDSA criteria13 was used, whereas difficulty of performing an arteriovenous fistula (AVF)
majority of other studies had used Center for Disease which is a common problem encountered in our set
Control (CDC) criteria.20 up primarily due to reluctancy of the patients and also
Most common clinical features encountered in this due to the unavailability of the competent vascular
study were fever during dialysis, chills and rigor; surgeons. To avoid this complication, preparation
nausea and vomiting and hypotension, which are in of AV fistula well in advance in ESRD patients is
accordance with other few studies.21-23 Significant suggested. Repeated manipulation and changing
laboratory parameters among patients with CRI were of dialysis catheter; and the usage of dialysis CVC
lower albumin, higher levels of serum ferritin and for the purposes other than dialysis like institution
higher levels of uric acid. Hypoalbuminemia could of intravenous medication and blood transfusion
be an indirect marker of poor nutritional status of the needs to be strictly discouraged to avoid further
patients undergoing HD and these patients are prone development of CRI.
for the development of any infection in the body Although CRI rate was higher with femoral catheters,
including CRI. Lower level of albumin can also be seen location of CVC was not an independent risk factor
in systemic infection and inflammation. However, in for CRI in our study, which is in accordance to few
this study it was difficult to ascertain the cause and studies26-28 but in contrary to the reports by Lemaire et
effect relationship of serum albumin with CRI. One al.29 Coagulase negative staphylococci, Staph. aureus
of the factors hindering the accurate interpretation of and Klebsiella pneumoniae were the most common
the levels of these biochemical parameters could be organisms responsible for CRI. Staph. aureus as the
the timing of the testing in CKD patients undergoing
commonest organism causing CRI has been found in
hemodialysis with infection.
many reports.26,27
The significant risk factors for the development
The reasons for the removal of CVC catheters were
of catheter related infection in this study were the
the completion of the indication of the catheter,
persistence of CVC catheter for a longer duration
development of CVC infection, death of the
(>30 days), recent change of CVC with the use of
patient and non-functional catheter, which were in
guidewire and the use of hemodialysis catheter
accordance to the standard guidelines.30
for institution of intravenous medication and blood
transfusion. Diabetes and prolonged duration of CVC Despite exploring the HD catheter related infections
usage have been described as major risk factors in Nepalese context, our study has some limitations.
related to infection in hemodialysis patients.24-26 One First of all, this was an observational study done in a
of the reasons for the prolonged duration of CVC single center. There was also no control on the length
usage especially in the patients with CKD was due to of time the catheters were in place as the lack of

Table 5. Pathogenic organisms causing CVC related infection

Microorganism Overall (n=41) CRLI (n=16) CRBSI (n=25)
Coagulase negative Staphylococci 11 (26.8%) 6 (37.5%) 5 (20%)
Staphylococcus aureus 10 (24.4%) 1 (6.25%) 9 (36%)
Klebsiella pneumoniae 9 (21.9%) 5 (31.2%) 4 (16%)
Proteus species 4 (9.7%) 2 (12.5%) 2 (8%)
Escherichia coli 3 (7.3%) 1 (6.2%) 2 (8%)
Pseudomonas 3 (7.3%) 1 (6.2%) 2 (8%)
Candida species 1 (2.4%) 0 1 (4%)

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 Hemodialysis Catheter-Related Infection

alternate vascular access influenced the decision to Snydman DR, Jaber BL. Iron storage indices: novel
salvage the catheter. Larger multi centric prospective predictors of bacteremia in hemodialysis patients
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2004;38(8):1090-4.
various aspects pertaining to catheter salvageability.
11. Jacobsson G, Dashti S, Wahlberg T, Andersson R.
The epidemiology of and risk factors for invasive
CONCLUSION Staphylococcus aureus infections in western Sweden.
Scand J Infect Dis 2007; 39:6.
The rate of CRI in Nepalese CKD patients undergoing
hemodialysis is high. Prolonged duration of CVC 12. Marr KA, Sexton DJ, Conlon PJ, Corey GR, Schwab SJ,
Kirkland KB. Catheter-related bacteremia and outcome
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of attempted catheter salvage in patients undergoing
the HD catheter for the purpose of institution of hemodialysis. Ann Intern Med. 1997;127(4):275-80.
intravenous medication have been found as the risk
13. Mermel LA, Allon M, Bouza E, et al. Clinical practice
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ACKNOWLEDGEMENT by the Infectious Diseases Society of America
[published correction appears in Clin Infect Dis. 2010
We acknowledge the nursing staff of Hemodialysis Apr 1;50(7):1079. Dosage error in article text] [published
Unit at Chitwan Medical College for their help in data correction appears in Clin Infect Dis. 2010 Feb
1;50(3):457]. Clin Infect Dis. 2009;49(1):1-45.
collection. We also would like to thank Dr. Bikash
Pandey and Mr. Pramuib Ghimire for the compilation 14. Jaber BL. Bacterial infections in hemodialysis patients:
pathogenesis and prevention. Kidney Int. 2005;67:2508-
of data. We also would like to express our sincere
19.
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