Infectious complications of the hemodialysis access

Infectious complications of the hemodialysis access. Infectious complicatio ns of the vascular access are a major source of morbidity and mortality amo ng hemodialysis (HD) patients. Numerous reports implicate the vascular acce ss in up to 48 to 73 % of all bacteremias in HD patients. The incidence of vascular access-related infection is highest when central venous dialysis c atheters are employed. Native arteriovenous fistulas carry the lowest risk of infection. Unfortunately, prosthetic arteriovenous grafts, which represe nt the most common type of HD access in the United States, have been repeat edly shown to be a risk factor for bacteremic and nonbacteremic infections. Silent infection in old nonfunctional clotted prosthetic arteriovenous gra fts has recently been recognized as a frequent cause of bacteremia and morb idity among HD patients. High proportions of infections related to the vasc ular access are caused by staphylococcal organisms. which carry high rates of mortality, recurrence, and metastatic complications. Management of vascu lar access-related infection has two aspects: The first relates to the choi ce. duration, and mode of administration of antibiotic therapy. Empiric ant ibiotic therapy, guided hy demographic data and severity of illness, should be employed when the causative organisms are unknown. Prolonged administra tion of specific parenteral antibiotics is crucial in decreasing complicati ons of infection, especially in cases of staphylococcal bacteremia. The sec ond aspect relates to management of the vascular access. Efforts directed t oward bacteriological cure should be concurrent with efforts to preserve na tive venous access sites whenever possible. Efforts to prevent vascular acc ess-related infection should focus on increasing placement of arteriovenous fistulas and minimizing insertion of central venous dialysis catheters. Ca reful inspection and monitoring of the vascular access is of paramount impo rtance in early detection of vascular access site-related infections. Sever al new approaches aimed at preventing catheter and prosthetic graft-related infection are being explored.