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