Meta-analysis: Antibiotics for Prophylaxis against Hemodialysis Catheter–Related Infections

15 April 2008 | Volume 148 Issue 8 | Pages 596-605

Background: Catheter-related infections cause morbidity and mortality in patients undergoing hemodialysis.

Purpose: To examine whether topical or intraluminal antibiotics reduce catheter-related bloodstream infection compared with no antibiotic therapy in adults undergoing hemodialysis.

Data Sources: Electronic databases, trial registries, bibliographies, and conference proceedings up to October 2007, with no language restrictions.

Study Selection: Two reviewers independently selected randomized, controlled trials using topical or intraluminal antibiotics for prophylaxis of infection in adults with catheters who are undergoing hemodialysis.

Data Extraction: Two independent reviewers assessed studies for inclusion, quality, and extracted data.

Data Synthesis: Fixed-effects models were used to estimate pooled rate ratios for outcomes. Topical antibiotics reduced the rate of bacteremia (rate ratio, 0.22 [95% CI, 0.12 to 0.40]; 0.10 vs. 0.45 case of bacteremia per 100 catheter-days), exit-site infection (rate ratio, 0.17 [CI, 0.08 to 0.38]; 0.06 vs. 0.41 case of infection per 100 catheter-days), need for catheter removal, and hospitalization for infection. Intraluminal antibiotics reduced the rate of bacteremia (rate ratio, 0.32 [CI, 0.22 to 0.47]; 0.12 vs. 0.32 case of bacteremia per 100 catheter-days) and need for catheter removal. Intraluminal antibiotics did not significantly reduce the rate of exit-site infection, and no hospitalization data were available for these agents.

Limitations: The evidence base included only 16 trials, and most had less than 6 months of follow-up. Only one third of studies were blinded. Publication bias was evident.

Conclusion: Both topical and intraluminal antibiotics reduced the rate of bacteremia as well as the need for catheter removal secondary to complications. Whether these strategies will lead to antimicrobial resistance and loss of efficacy over longer periods remains unclear.

Editors' Notes Context Catheter-related infections are a major cause of illness among hemodialysis patients. Contribution This systematic review found 16 randomized trials that evaluated antibiotic prophylaxis for adults receiving long-term hemodialysis with a central venous catheter. The trials assessed the potential benefits of applying antibiotics topically to the catheter exit site or instilling them intraluminally into the catheter. Compared with no antibiotic therapy, prophylaxis with either topical or intraluminal antibiotics reduced bloodstream infections and the need for catheter removals. Caution Most trials were short in duration and were not blinded. Implication Topical or intraluminal antibiotic prophylaxis may reduce catheter-related bloodstream infections in hemodialysis patients. —The Editors

 

Author and Article Information

From the University of Calgary, Calgary, and University of Alberta and Institute of Health Economics, Edmonton, Alberta, Canada.

Acknowledgment: The authors thank Drs. C.K. Jacobs, T.F. Saad, M.G.H. Betjes, C.E. Lok, and A.K. Saxena for providing additional study information.

Grant Support: By the Alberta Kidney Disease Network. Dr. James was supported by a KRESCENT award from the Kidney Foundation of Canada and an Alberta Heritage Foundation for Medical Research Award. Drs. Tonelli and Hemmelgarn were supported by Population Health Investigator Awards from the Alberta Heritage Foundation for Medical Research. Drs. Tonelli, Manns, and Hemmelgarn were supported by New Investigator Awards from the Canadian Institutes for Health Research.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Brenda R. Hemmelgarn, PhD, MD, Division of Nephrology, Foothills Medical Centre, 1403 29th Street Northwest, Calgary, T2N 2T9 Alberta, Canada; e-mail, Brenda.Hemmelgarn{at}CalgaryHealthRegion.ca.

Current Author Addresses: Drs. James, Conley, Manns, MacRae, and Hemmelgarn: University of Calgary, Foothills Medical Centre, 1403 29th Street Northwest, Calgary, T2N 2T9 Alberta, Canada.

Dr. Tonelli: University of Alberta, 7-129 Clinical Sciences Building, Edmonton, T6G 2G3 Alberta, Canada.