Dialysis-related infections

Introduction

Dialysis-related infections are infections that develop in people undergoing hemodialysis or peritoneal dialysis. These infections, ranging from mild access-site redness to serious bloodstream infections, can significantly impact health, daily life, and long-term outcomes. Patients might experience fever, chills, or pain around the catheter or fistula site. With up to 30% of dialysis sessions complicated by some form of infection, it’s a prevalent concern. In this article we’ll look at symptoms, underlying causes, possible treatments, and what the future outlook might be.

Definition and Classification

Dialysis-related infections refer to bacterial, fungal, or rarely viral invasions associated with the dialysis process. They can be classified by:

• Mode of dialysis: hemodialysis vs peritoneal dialysis
• Localization: vascular access site, peritoneal cavity, or systemic bloodstream infection
• Onset: early (within 2 weeks of access placement) vs late
• Severity: localized access-site inflammation, tunnel infections, catheter-related bloodstream infections (CRBSI)

Most often, hemodialysis patients develop access-site infections at arteriovenous fistulas or grafts, while peritoneal dialysis users face peritonitis via the catheter track. Clinically relevant subtypes include exit-site infections, tunnel infections, and peritonitis, each demanding distinct management.

Causes and Risk Factors

Understanding why dialysis-related infections occur involves looking at both patient factors and procedural elements. The main causes include:

• Bacterial contamination: Staphylococcus aureus, coagulase-negative staphylococci, Pseudomonas aeruginosa are common culprits. Contaminated dialysate or improper hand hygiene by staff or patients can introduce pathogens.
• Catheter use: Indwelling catheters, particularly tunneled central venous catheters, pose a high risk because biofilms develop on their surfaces.
• Skin flora migration: Skin bacteria can track along the needle puncture or catheter exit site.
• Immunosuppression: Chronic kidney disease itself impairs immune defenses—dialysis patients have reduced neutrophil function and altered cytokine responses.
• Peritoneal fluid contamination: In peritoneal dialysis, touch contamination during bag exchanges is a key risk.

Other risk factors, some modifiable and others not, include:

• Non-modifiable: advanced age, diabetes mellitus, prolonged dialysis vintage (time on dialysis), vascular disease
• Modifiable: poor catheter care practices, inconsistent exit-site dressing changes, breaches in aseptic technique during exchanges or cannulation
• Environmental: facility cleanliness, dialyzer reprocessing protocols
• Genetic predispositions: though mostly unclear, some HLA types may influence susceptibility to peritonitis in PD patients

Even with the best protocols, not all infection causes are fully understood—biofilm resilience and host-pathogen interactions still hold mysteries. Real-world example: “Mrs. J.”, a 68-year-old diabetic on hemodialysis, developed a catheter-related bloodstream infection after a power outage delayed dialysis schedules, compromising sterile technique in a rushed session.

Pathophysiology (Mechanisms of Disease)

Dialysis-related infections start when bacteria or fungi breach the body’s outer defenses. For hemodialysis, repeated needle punctures or an indwelling catheter allow microorganisms to enter. In peritoneal dialysis, contamination during fluid exchanges can seed the peritoneum. Once inside, microbes adhere to tissues or catheter surfaces, forming a biofilm—a slimy matrix that shields them from antibiotics and immune cells.

Key mechanisms:

• Biofilm formation: Microorganisms attach to the artificial surfaces of catheters or grafts, secreting extracellular polymeric substances. This matrix makes them up to 1,000 times more resistant to antibiotics.
• Immune evasion: Within biofilms, pathogens avoid opsonization and phagocytosis. Uremia in CKD patients further diminishes neutrophil chemotaxis and phagocytic activity.
• Inflammatory cascade: Bacterial toxins and cell wall components activate complement and pro-inflammatory cytokines (IL-6, TNF-α), leading to systemic symptoms like fever and hypotension in severe cases.
• Tissue damage: Chronic local inflammation at the access site can cause fibrosis or tunnel tract breakdown, worsening infection risk and complicating future access creation.

Over time, untreated or recurrent infections can spread hematogenously, seeding distant sites such as heart valves (endocarditis) or bones (osteomyelitis). While antibiotics are mainstay treatments, the recalcitrant nature of biofilm-bound bacteria often requires catheter removal or surgical intervention.

Symptoms and Clinical Presentation

Symptoms vary by infection type but often include a blend of local and systemic signs:

• Access site infections: Redness, swelling, warmth, tenderness at needle puncture points, graft sites, or catheter exit sites. Purulent drainage may be present.
• Tunnel infections: Painful, erythematous tract along the subcutaneous catheter path.
• Catheter-related bloodstream infection (CRBSI): Fever, chills, hypotension, rigors, malaise without another focus of infection.
• Peritonitis in PD: Cloudy dialysate fluid, abdominal pain, fever, diarrhea or vomiting sometimes accompanies.

Early manifestations tend to be subtle: a small area of erythema or slight temp spike post-dialysis. Progressive cases evolve over 24–48 hours into high-grade fever, rigors, tachycardia, and potential hypotension. Some patients feel merely fatigued or develop muscle aches before overt signs appear.

Warning signs requiring urgent care include:

• Spiking fever (>38.5°C) with chills during or after dialysis
• Rapidly expanding redness around the access site
• Purulent or foul-smelling discharge
• Abdominal rigidity or rebound tenderness in PD patients
• Altered mental status or signs of sepsis

Real-life note: “Mr. A.” noticed his PD fluid was cloudy one morning but shrugged it off. By evening he had severe pain and fever, prompting emergency admission for peritonitis. That delay almost led to catheter removal.

Diagnosis and Medical Evaluation

Diagnosing dialysis-related infections is a stepwise process combining clinical signs, lab tests, and imaging:

1. Clinical assessment: Evaluate access site for erythema, swelling, discharge. Ask about systemic symptoms like fever or chills.
2. Blood cultures: At least two sets drawn from catheter ports and one peripheral stick, before antibiotics if possible, to pinpoint the causative organism and guide therapy.
3. Dialysate or exudate cultures: For PD peritonitis, culture the effluent. For tunnel or exit-site infections, swab any drainage.
4. Laboratory tests: CBC shows leukocytosis; CRP and procalcitonin may be elevated in systemic infection.
5. Imaging: Ultrasound of the access site can detect abscess or fluid collections. Echocardiography if endocarditis is suspected. CT scan rarely used but helpful for deep-seated infections.
6. Differential diagnosis: Cellulitis unrelated to dialysis, allergic reactions to antiseptics, non-infectious inflammation (steal syndrome).

Typical diagnostic pathway starts in the dialysis unit with staff noticing signs, followed by referral to a nephrologist or infectious disease specialist. In PD, cloudy effluent often triggers immediate lab assessment. If cultures return positive, antibiotic regimens are tailored. Persistent or recurrent infections may require catheter removal and temporary switch to an alternate access.

Which Doctor Should You See for Dialysis-related infections?

If you suspect a dialysis-related infection, the first professional to consult is usually your nephrologist, since they oversee dialysis care. A dialysis nurse or vascular access coordinator often spots warning signs early. For severe or persistent infections, an infectious disease specialist is called in to recommend targeted antibiotic regimens.

When to seek urgent care:

• High fever with chills during or immediately after a session
• Rapidly spreading access-site redness
• Signs of sepsis (low blood pressure, confusion)

Telemedicine can help schedule prompt virtual assessments, discuss lab results, and triage your case—but it doesn’t replace in-person catheter evaluation, drainage, or emergency treatment when serious symptoms emerge. Think of online care as a complementary tool for second opinions, clarifying discharge instructions or discussing new symptoms when you can’t get to the clinic right away.

Treatment Options and Management

Managing dialysis-related infections involves antimicrobial therapy, access care, and sometimes surgery:

• Antibiotics: Empiric broad-spectrum coverage with agents like vancomycin plus a gram-negative agent (e.g., ceftazidime) in hemodialysis CRBSI. PD peritonitis often starts with intraperitoneal cefazolin plus ceftazidime.
• Catheter management: Minor exit-site infections might respond to topical mupirocin. Tunnel infections or CRBSI often require catheter removal and placement of a new access at a different site.
• Supportive measures: Antipyretics, fluid management, nutritional support for wound healing.
• Adjunct therapies: Ethanol or antibiotic locks to sterilize catheter lumens, particularly if salvage is attempted.
• Lifestyle measures: Strict hand hygiene, regular exit-site cleaning, chlorhexidine dressings.

First-line treatments are generally effective within 48–72 hours. If symptoms persist or cultures grow resistant organisms (e.g., MRSA, Pseudomonas), therapy escalates to advanced antibiotics like daptomycin or linezolid, often under infectious disease guidance.

Prognosis and Possible Complications

With prompt, appropriate treatment, many dialysis-related infections resolve without long-term harm. However, complications can arise:

• Recurrence: Up to 20% of patients face repeat infections within 6 months if access care lapses.
• Access loss: Persistent or severe infections may require permanent removal of catheters or grafts, necessitating new surgery and delaying dialysis.
• Sepsis and septic shock: Uncontrolled CRBSI can progress to life-threatening systemic infection.
• Endocarditis: Bacteremia may seed heart valves, especially in patients with preexisting valvular disease.
• Peritoneal sclerosis: Recurrent PD peritonitis can cause fibrotic thickening, reducing dialytic efficiency.

Factors that worsen prognosis include delayed diagnosis, inappropriate antibiotic choice, advanced age, diabetes, and poor nutritional status. Conversely, strict infection-control protocols and early intervention dramatically improve outcomes.

Prevention and Risk Reduction

Preventing dialysis-related infections centers on aseptic technique, patient education, and facility protocols:

• Strict hand hygiene: Both staff and patients must wash hands or use alcohol-based rubs before any contact with access sites or PD bags.
• Chlorhexidine skin antisepsis: Preferred over povidone-iodine for exit-site cleaning in hemodialysis and PD.
• Protective barriers: Use of masks and gloves when accessing or changing dressings.
• Regular exit-site care: Daily cleansing and weekly dressing changes, with topical antibiotic ointment as indicated.
• Catheter care training: Standardized patient education programs reduce peritonitis rates by up to 50% in PD users.
• Facility monitoring: Surveillance of infection rates, feedback to staff, and periodic audits of sterile technique.
• Dialyzer reprocessing: Single-use or proper sterilization protocols to avoid cross-contamination.

Early detection strategies include routine exit-site cultures in high-risk patients and periodic screening blood cultures in long-term catheter users. While not all infections are preventable—biofilm and immunosuppression still pose challenges—consistent adherence to these measures substantially lowers risk.

Myths and Realities

Misconceptions about dialysis-related infections can lead to anxiety or dangerous shortcuts. Let’s debunk some common myths:

• Myth: “Saltwater rinses or herbal soaks will disinfect my catheter.”
  Reality: Unproven home remedies can introduce new contaminants. Only medical-grade antiseptics should touch the access site.
• Myth: “If I feel fine, I don’t need to report cloudy PD fluid.”
  Reality: Cloudy effluent is often the earliest sign of peritonitis; reporting it promptly avoids complications.
• Myth: “I can skip dressing changes if I wear gloves.”
  Reality: Gloves protect the caregiver but sterile dressings remain essential to block environmental pathogens.
• Myth: “Antibiotic locks every week prevent all bloodstream infections.”
  Reality: While helpful in high-risk cases, antibiotic locks don’t replace good hand hygiene or exit-site care, and overuse can drive resistance.
• Myth: “Once you’ve had a CRBSI, you’ll always get it back.”
  Reality: Proper catheter removal, antibiotic therapy, and new access placement can fully clear the infection.

It’s easy to get misled by online forums or outdated leaflets. Always cross-check with current guidelines from kidney associations and infectious disease societies for evidence-based info.

Conclusion

Dialysis-related infections remain a significant challenge for people on hemodialysis and peritoneal dialysis, impacting quality of life, health outcomes, and healthcare costs. They arise from a mix of procedural factors, host immunity, and microbial virulence, with biofilm formation at the heart of persistence. Early recognition—watching for fever, access-site redness, and cloudy effluent—and prompt, appropriate treatment can prevent complications like sepsis or access loss. Preventive measures, strict asepsis, and patient education are cornerstone strategies. If you’re on dialysis, stay vigilant, ask questions, and partner closely with your nephrology team to minimize infection risks and keep your dialysis journey as safe as possible.

Frequently Asked Questions (FAQ)

• 1. What is a dialysis-related infection? An infection occurring at or around the hemodialysis vascular access or peritoneal catheter, often caused by bacteria or fungi.
• 2. How common are these infections? They affect up to 10–40% of dialysis patients annually, varying by center protocols and patient factors.
• 3. What are early signs of access-site infection? Redness, tenderness, mild swelling, or slight warmth around the fistula, graft, or catheter exit site.
• 4. Can I continue dialysis if I have an infection? Minor exit-site infections may allow continued dialysis; severe CRBSI often requires temporary catheter removal and alternate access.
• 5. How is dialysis-related infection diagnosed? By clinical exam, blood and effluent cultures, lab markers (CBC, CRP), and sometimes ultrasound or echocardiography.
• 6. What’s the role of telemedicine here? Telehealth can help review symptoms, discuss lab results, and guide early management—though in-person evaluation remains vital.
• 7. Which doctor treats these infections? Your nephrologist is the primary provider, often collaborating with infectious disease specialists for complex cases.
• 8. How long is antibiotic treatment? Typically 10–14 days for exit-site infections, 14–21 days for CRBSI, and 14–28 days for PD peritonitis, depending on organism and response.
• 9. Can infections cause long-term damage? Yes—untreated cases can lead to catheter loss, sepsis, endocarditis, or peritoneal sclerosis.
• 10. What preventive measures matter most? Hand hygiene, chlorhexidine cleansing, sterile dressing changes, and patient training for PD bag exchanges.
• 11. Are antibiotic locks safe? They’re useful in high-risk patients but should be balanced against potential resistance and guided by protocols.
• 12. When should I seek emergency care? High fever (>38.5°C), chills, hypotension, spreading redness, or altered mental status after dialysis.
• 13. Can I get vaccinated to prevent these infections? No specific vaccine exists; however, flu and pneumococcal vaccines help reduce overall infection burden in CKD patients.
• 14. How does diabetes affect infection risk? Poorly controlled blood sugar impairs immune response, raising the chance of access-site and bloodstream infections.
• 15. Does switching to PD eliminate infection risk? It changes the risk profile—PD patients get peritonitis via the catheter track but avoid bloodstream infections tied to vascular access.

Note: This article is for informational purposes and does not replace professional medical advice. Always consult your healthcare team for personal guidance.