Moore Carol L, Besarab Anatole, Ajluni Marie, Soi Vivek, Peterson Edward L, Johnson Laura E, Zervos Marcus J, Adams Elizabeth, Yee Jerry
Divisions of Nephrology and Hypertension, Department of Pharmacy Services, and
Stanford University, Palo Alto, California; and.
Clin J Am Soc Nephrol. 2014 Jul;9(7):1232-9. doi: 10.2215/CJN.11291113. Epub 2014 Jun 26.
Infection is the second leading cause of death in hemodialysis patients. Catheter-related bloodstream infection and infection-related mortality have not improved in this population over the past two decades. This study evaluated the impact of a prophylactic antibiotic lock solution on the incidence of catheter-related bloodstream infection and mortality.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This prospective, multicenter, observational cohort study compared the effectiveness of two catheter locking solutions (gentamicin/citrate versus heparin) in 555 hemodialysis patients dialyzing with a tunneled cuffed catheter between 2008 and 2011. The groups were not mutually exclusive. Rates of catheter-related bloodstream infection and mortality hazards were compared between groups.
The study population (n=555 and 1350 catheters) had a median age of 62 years (interquartile range=41-83 years), with 50% men and 71% black. There were 427 patients evaluable in the heparin period (84,326 days) and 322 patients evaluable in the antibiotic lock period (71,192 days). Catheter-related bloodstream infection in the antibiotic lock period (0.45/1000 catheter days) was 73% lower than the heparin period (1.68/1000 catheter days; P=0.001). Antibiotic lock use was associated with a decreased risk of catheter-related bloodstream infection compared with heparin (risk ratio, 0.23; 95% confidence interval, 0.13 to 0.38 after multivariate adjustment). Cox proportional hazards modeling found that antibiotic lock was associated with a reduction in mortality (hazard ratio, 0.36; 95% confidence interval, 0.22 to 0.58 in unadjusted analyses; hazard ratio, 0.32; 95% confidence interval, 0.14 to 0.75 after multivariate adjustment). The rate of gentamicin-resistant organisms decreased (0.40/1000 person-years to 0.22/1000 person-years) in the antibiotic lock period (P=0.01).
The results of this study show that the use of a prophylactic, gentamicin/citrate lock was associated with a substantial reduction in catheter-related bloodstream infection and is the first to report a survival advantage of antibiotic lock in a population at high risk of infection-related morbidity and mortality.
感染是血液透析患者的第二大死因。在过去二十年中，该人群中与导管相关的血流感染及感染相关死亡率并未得到改善。本研究评估了预防性抗生素封管溶液对导管相关血流感染发生率及死亡率的影响。
设计、地点、参与者及测量指标：这项前瞻性、多中心、观察性队列研究比较了2008年至2011年间555例使用隧道式带 cuff 导管进行血液透析的患者中两种导管封管溶液（庆大霉素/柠檬酸盐与肝素）的有效性。各分组并非相互排斥。比较了两组之间导管相关血流感染率及死亡风险。
研究人群（n = 555，导管1350根）的中位年龄为62岁（四分位间距 = 41 - 83岁），男性占50%，黑人占71%。肝素封管期有427例患者可评估（84326天），抗生素封管期有322例患者可评估（71192天）。抗生素封管期的导管相关血流感染率（0.45/1000导管日）比肝素封管期（1.68/1000导管日）低73%（P = 0.001）。与肝素相比，使用抗生素封管与导管相关血流感染风险降低相关（风险比，0.23；多变量调整后95%置信区间，0.13至0.38）。Cox 比例风险模型发现，抗生素封管与死亡率降低相关（未调整分析中风险比，0.36；95%置信区间，0.22至0.58；多变量调整后风险比，0.32；95%置信区间，0.14至0.75）。抗生素封管期耐庆大霉素微生物的发生率下降（从0.40/1000人年降至0.22/1000人年）（P = 0.01）。
本研究结果表明，使用预防性庆大霉素/柠檬酸盐封管与导管相关血流感染的大幅降低相关，并且首次报告了抗生素封管在感染相关发病和死亡高风险人群中的生存优势。
