Diagnosis, prevention and treatment of haemodialysis catheter-related bloodstream infections (CRBSI): a position statement of European Renal Best Practice (ERBP)

Abstract

In the July 2009 issue of the journal Clinical InfectiousDiseases, the Infectious Diseases Society of America (IDSA) published an update of their ‘Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection’ [1]. The largest part of the IDSA text relates to non-dialysis catheters, and it is not always clear how far these general recommendations can be extrapolated to the haemodialysis condition. A specific section of the IDSA guidelines is, however, devoted to haemodialysis catheters. In the present position statement by European Renal Best Practice (ERBP), we intend to focus on the items in these guidelines which are relevant for nephrologists and to amend them to haemodialysis conditions and/or for the European situation with regards to tunnelled catheters. ERBP is the new guidance body of the European Renal Association-European Dialysis and Transplantation Association (ERA-EDTA), replacing European Best Practice Guidelines (EBPG) since 2008. We will discuss only those IDSA guidelines worth reflection or amendment. The corresponding IDSA guidelines will be mentioned between parentheses (). Guidelines which we did not consider for discussion, although they still might be relevant, are summarized in Table 1. IDSA guidelines of relevance to nephrology which are not discussed in the present position statement Examples given in this table and text are not exhaustive. We refer the reader to the original text [1] for the full list of examples. For details on how this should be done, please read in the text under ‘Antibiotic and antimycotic treatment’. IDSA guidelines of relevance to nephrology which are not discussed in the present position statement Examples given in this table and text are not exhaustive. We refer the reader to the original text [1] for the full list of examples. For details on how this should be done, please read in the text under ‘Antibiotic and antimycotic treatment’. The present text has been issued in accordance with the new philosophy of ERBP to offer guidance by means of position statements commenting on documents issued by other guideline bodies or on recent relevant studies, next to ad hoc recommendations when not enough evidence is available [2,3]. Real guidelines are to be issued only in case of sufficient evidence. ERBP recently published two position statements along these principles [4,5]. Of note, earlier EBPG recommendations have been issued on vascular access and infectious disease in haemodialysis patients [6,7]. The current document further elaborates and updates these documents. The IDSA guidelines are well written with a clear distinction between several subheadings, covering a general and a specific part. The same guidelines are frequently repeated, and the same items are also often covered both in the general and specific guidelines, albeit that the recommendations are not always exactly the same. The grading system is not the same as the one currently propagated by Grading of Recommendations, Assessment, Development and Evaluation (GRADE) and applied by ERBP and Kidney Disease: Improving Global Outcomes (KDIGO) [3,8,9.]: it is a nine-tiered system with three levels of evidence and three levels of strength vs two levels of evidence and four levels of strength for the three bodies mentioned above. Although the majority of IDSA guidelines are based on only one or two non-randomized trials often generated by one single research group, most of them are graded as level A.II, with only seven of 123 recommendations (5.7%) having the highest level (A.I). Although A.II gives the impression of being based on robust evidence, ‘dramatic results even from uncontrolled experiments’ suffice to attribute this level. The result is that, without clear notification to the readership, poorly-evidenced statements or ‘parachute type’ guidelines (i.e. guidelines which seem obvious but have not been or cannot be evidenced, like the recommendation of using a parachute when jumping out of a flying plane) are classified as well evidenced. However, the real evidence level of these IDSA guidelines is not high, which unfortunately is also true for most nephrological recommendations [2]. For the sake of clarity, the present position statement contains recommendations which are not based on a systematic literature review and are not supported by an evidence review team. The reader should consider them rather as practical expert advice than as real ‘guidelines’ which are supposed to be supported by strong evidence. IDSA only covered diagnosis and treatment, not prevention. In this ERBP monography, we will start with general aspects and prevention (‘General: tunnelled vs non-tunnelled catheters’ and ‘Prevention of infection’ sections—two aspects not covered by the IDSA), only then followed by comments and amendments of the IDSA guidelines per se in ‘Overall aspects’ and ‘Unique aspects’ sections. Permanent tunnelled central vein catheters are generally consid