II. Epidemiology

  1. Incidence: 37,000 bloodstream infections in ESRD patients with Central Line in 2008 (CDC)

III. 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

IV. 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

V. 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)

VI. 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

VII. Prognosis

  1. Mortality in Dialysis patient with bloodstream infection: 25%

VIII. 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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