Antibiotic line locks for central venous catheters in adult patients on haemodialysis

Transcription

1 Trust Clinical Guidelines Derby Hospitals NHS Foundation Trust Antibiotic line locks for central venous catheters in adult patients on haemodialysis Introduction Reference No: Microbial colonisation of a haemodialysis catheter can trigger catheter related bloodstream infections (CRBSI) and may spread from catheter to the bloodstream. It is relatively common and can increase both hospital cost and length of patient stay. It is also a significant cause of morbidity and mortality among haemodialysis patients. Effective treatment of CRBSI requires catheter removal or exchange, however, in some patients, catheter salvage may be attempted. The decision to salvage the catheter depends on the clinical condition of a patient, continued need for the central venous catheter, pathogen involved and response to treatment. This guideline will not cover the decision to remove or salvage a central line catheter. The prophylactic use of antibiotic line lock has been shown to decrease the incidence of CRBSI in multiple reports. Antibiotic line locks are used in patients who have had a previous incidence of line sepsis. This strategy has no obvious consequences to exposure to antibiotics or vascular access function. It also proved to have a further beneficial implication on treatment cost due to reduced epoetin requirements. Aim and Purpose The aim of this guideline is to ensure that antibiotic line locks are used safely and appropriately to prevent catheter related bloodstream infections in haemodialysis patients. Scope All adult haemodialysis patients in the renal unit and ward 407 Antibiotic line lock Antibiotic line lock is the instillation of highly concentrated antibiotic solution into an intravascular catheter lumen to prevent catheter related bloodstream infections. Concentrations must be 100- to 1000-fold greater to kill the bacteria within a biofilm. The antibiotic solution is left in the catheter lumen for a period of time before aspiration. Higher concentrations are Trust Policy on the Development and Management of Clinical Practice Guidelines Page 1 of 5

2 directly delivered to the colonised line for a longer period of time and sterilisation of the line is enhanced. The length of dwelling time varies from four to six hours to three days, depending on the stability of the line lock or catheter access. There is a potential for the antibiotic to leak out into the systemic circulation but the total amount given in the line lock is only a small fraction of its therapeutic dose. Hence, this leakage can be considered to be not clinically important in adult patients. Antibiotic locks are received by haemodialysis patients following dialysis. This is used by patients with temporary dialysis access site (permacaths) and they remain in situ until the next dialysis session when they are replaced. Choice of antibiotic Gentamicin line lock is the first line option for haemodialysis patients in prevention of CRBSI within the Trust. However, taurolidine and citrate can also be used. Gentamicin Preparation of the line lock The constituents of the lock are, in order: Gentamicin 5mg (0.5ml of gentamicin 20mg/2ml injection) Heparin 5,000units (1ml of heparin 5000units/ml injection) Sodium chloride 0.9% 0.5ml (to total of 2ml for lock ) Line locks are prepared by a dialysis nurse. Administration of Gentamicin line lock 1. Line lumen contents must be aspirated before injecting the new line lock (not needed if this is the first time). This must be done before the line is used. Seek senior medical advice if it is not possible to aspirate the line. 2. Withdraw the gentamicin, heparin and sodium chloride 0.9% using appropriate syringe, in the order shown above. 3. With the use of a bioconnecter to connect the syringe to the line, instil the lock slowly into the line in a quantity sufficient to fill the lumen completely. 4. The lock is left inside the line until the next dialysis session. Alternatively, this can be left and removed every week. 5. At the start of the next dialysis session, remove quantity instilled previously using a syringe. Ensure that quantity removed corresponds to the quantity instilled to avoid the possibility of the catheter solution leaking into the bloodstream. Trust Policy on the Development and Management of Clinical Practice Guidelines Page 2 of 5

3 Monitoring Gentamicin levels are not checked. Monitor patients for any systemic adverse effects. Taurolock Taurolock is used for patients who had an adverse reaction and are intolerant to gentamicin or heparin. Taurolock contains taurolidine and citrate 4%. Taurolidine is a broad spectrum antibiotic and antiendotoxin that covers against gram-positive and gram-negative, anaerobes and fungi. Citrate is used as an anticoagulant but can also help improve antimicrobial activity. The FDA advises against use of citrate concentrations exceeding 4% as high concentration was shown to impair cardiac function. Majority of evidence for taurolidine and citrate line locks is in the prevention of CRBSI. Preparation of the line lock Taurolock vials (5mls) are supplied by pharmacy. Line locks are prepared by a dialysis nurse. Administration of Taurolock 1. Line lumen contents must be aspirated before injecting the new line lock. This must be done before the line is used. Seek senior medical advice if it is not possible to aspirate the line. 2. With the use of a bioconnecter to connect the syringe to the line, flush the line with 10ml of saline (Sodium Chloride 0.9%) at the end of each dialysis session. 3. Withdraw Taurolock from container using appropriate syringe. 4. Instill Taurolock slowly into the line in a quantity sufficient to fill the lumen completely (see Table 1 below). 5. Taurolock is left inside the line until the next dialysis session. Alternatively, this can be left and removed every week. 6. At the start of the next dialysis session, remove quantity instilled previously using a syringe. Ensure that quantity removed corresponds to the quantity instilled to avoid the possibility of the catheter solution leaking into the bloodstream. Monitoring Whilst instilling Taurolock solution, monitor for any signs of discomfort and tingling or burning. There is a potential for the antibiotic to leak out into the systemic circulation but the total amount given in the line lock is only a small fraction of its total dose. Hence, this leakage can be considered to be not clinically important in adult patients. Trust Policy on the Development and Management of Clinical Practice Guidelines Page 3 of 5

4 The Renal Unit uses the KIMAL 14F x 28cm Split Cath III which has divided lumens with volumes of 1.7ml (red end) and 1.8ml (blue end). This is mainly used in the unit for most haemodialysis patients with permacaths. Please ensure the correct volume is instilled into the line. The lumen volume is usually marked on the line itself. Ensure this is checked if the permacath stated above is not used. References McIntyre C, Hulme L, Taal M, Fluck R. Locking of tunnelled haemodialysis catheters with gentamicin and heparin. Kidney International. Vol 66 (2004), Berrington A, Gould K. Use of antibiotic locks to treat colonised central venous catheters. Journal of Antimicrobial Chemotherapy 2001; 48: VandenBussche H. Antibiotic lock therapy for treatment of catheter-related bloodstream infections. UpToDate The Renal Association. Haemodialysis Guidelines. Available at: Taurolock. Antimicrobial Catheter Lock System to Provide Patency and Infection Control. Available at: Taurolidine. Micromedex. February 2013 Lacey J. Antibiotic line lock locks for central venous catheters in adults. Draft update. May 2012 National electronic library for medicines. Medicines Q+As. Which antibiotics should be used to treat colonized central venous catheters and how should they be administered? August 2011 Trust Policy on the Development and Management of Clinical Practice Guidelines Page 4 of 5

5 Documentation Controls Development of Guidelines: Titles of staff or Group involved in development Consultation With: For Trust Guidelines must include the Directorate Clinical Governance group or equivalent Approved By; Title only Local Guidelines must be signed off by the Service Director All Trust Guidelines will be signed off by the Chair of the Clinical Guidelines Group Name and Position: Person signing off guidelines Approval Date: Review Date: 2 years Key Contact: Sue Shaw (Renal Pharmacist) Trust Policy on the Development and Management of Clinical Practice Guidelines Page 5 of 5