Infections in the dialysis patient

Fever, chills, and rigors are the typical presenting symptoms of the hemodialysis patient who has graft-related bacteremia. Chills and rigors typically precede fever. These phenomena often occur during the hemodialysis treatment or shortly thereafter. Physical evidence of graft infection is often absent. Indeed, bacteria may have been introduced into the bloodstream by the dialysis needles during graft cannulation. The febrile hemodialysis patient with a synthetic graft should be presumed to have graft-related bacteremia unless the history, physical examination, or initial investigations provide convincing evidence to the contrary. Blood cultures should be obtained. Empirical antibiotic therapy consists of loading doses of vancomycin (20 mg/kg) and either gentamicin (2 mg/kg) or tobramycin (2 mg/kg). Because methicillin-resistant S. aureus (MRSA) and coagulase-negative staphylococci are common pathogens, a -lactam antibiotic is not an appropriate empirical agent. Continued antibiotic therapy should be guided by the blood culture isolate findings. If enterococci or -lactam-resistant staphylococci are isolated, continued vancomycin therapy is appropriate. If staphylococci that are susceptible to -lactam antibiotics are isolated, a -lactam should be substituted for vancomycin unless the patient has a -lactam allergy. If gram-negative bacilli are isolated, the aminoglycoside antibiotic may be continued. If there is no evidence of metastatic infection, the author’s practice is to administer a 3-week course of antibiotic therapy. Dosage regimens are described late. Blood cultures should be obtained after completion of antibiotic therapy to confirm that bacteremia has been eradicated. It must be emphasized that extensive graft infection may be present even when the physical examination ?ndings are unremarkable. If bacteremia or fever is persistent or recurrent in spite of appropriate antibiotic therapy, surgical exploration is mandatory.

Duke Scholars

Author Michael Scott Berkoben Medicine, Nephrology