The incidence and costs of bacteremia due to lack of gentamicin lock solutions for dialysis catheters

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Arterio‐venous fistulae are the gold standard for vascular access in hemodialysis. However, tunneled cuffed dialysis catheters (TDCs) continue to have an important role in incident dialysis management and are used to provide long‐term vascular access for some patients. In New Zealand, 23% of prevalent hemodialysis patients used a TDC as vascular access at the end of 2013.1 Catheter‐related blood stream infection (CRBSI) is a potentially life‐threatening complication for all patients with a TDC.
It is thus vital to prevent CRBSI. Antibiotic lock solution (ALS) use has been shown to be associated with a lower incidence of CRBSI.2 The most frequently used antibiotic is gentamicin which at the concentrations achieved in ALS is effective against both staphylococcus and Gram‐negative bacteria.1 However, there has been no cost analysis with the use of ALS in prevention of CRBSI.
In Auckland City Hospital, prior to 2012, gentamicin and heparin locks (gentamicin 5 mg/lumen in heparin 1000 IU/mL) were the routine standard for any patients with a TDC to prevent CRBSI. In addition to using ALS, standard precautions include sterile technique when accessing the catheter hub and the use of topical antibiotic patches where appropriate.
In 2012, the supplier withdrew gentamicin locks from the market in New Zealand. Various alternative solutions were discussed with suppliers and the hospital pharmacy department, which included locally mixed gentamicin‐heparin solutions. However, for a number of reasons, this did not proceed. As a consequence, all TDCs were locked with heparin solution (1000 IU/mL) only from 14 December 2012 until 31 December 2013. On 31 December 2013, gentamicin‐citrate solution (gentamicin 1.6 mg/mL in citrate 4%) was introduced as ALS for all hemodialysis patients with TDC. All catheter locks were administered after each access of dialysis catheters.
This unfortunate experience provided an opportunity to compare the impact of 3 different locking solutions, one without any added antibiotic. An audit was carried out to review the consequences of the changes in catheter lock solutions, in particular the rate of CRBSI and the financial impact to the hospital. The hypothesis was that the incidence of CRBSI would increase during the period without ALS, followed by a decline when ALS was reintroduced. The use of ALS is hypothesized to lead to reduced financial impact due to the lower rate of CRBSI.
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