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Nephrology With Joel Topf, MD

Nephrology

Dr. Topf is an assistant clinical professor of medicine at Oakland University William Beaumont School of Medicine, a visual abstract editor for the Clinical Journal of the American Society of Nephrology, creator and host of the Freely Filtered and Channel Your Enthusiasm podcasts, creator of the Precious Bodily Fluids blog, and co-creator of NephMadness and NephJC.

Antibiotic Catheter Locks: Taurolidine-Heparin Lock Could Reduce CRBSI by 70%

Dear readers,

I was reorganizing the NephJC website and reviewing the list of articles we are considering, but I will probably never cover. I came across this gem, the LOCK IT-100 trial. This trial showed that a taurolidine-heparin antibiotic lock could reduce catheter-related bloodstream infections (CRBSI) by 70%, which is simply an effect size that is unheard of in dialysis. 

This drew me down the rabbit hole of antibiotic locks. While we have been pounding the table demanding patients get AV fistulas, tunneled central catheters have become safer and safer. In 2009, the U.S. Centers for Disease Control and Prevention sponsored a collaborative study implementing a bundle of care interventions that reduced CRBSI by 54%. The intervention was durable for 4 years after implementation. 

There are many different recipes for antibiotic locks. Gentamicin and citrate were popular in some dialysis units, but the LOCK IT-100 attempted to make taurolidine-heparin an FDA-approved product. They were successful with Defencath getting FDA approval this past November.

Research fired me up, and I was ready to fight to get antibiotic locks into my units. However, I then learned that, without my knowledge, this had already been implemented. In May 2019, Davita made chlorhexidine-impregnated catheter caps part of standard catheter care in all their units. The caps are more than just a cap; they include a rod that runs about a centimeter down the barrel of the catheter and leaches chlorhexidine—no mixing antibiotics, no additional nurse time needed—just put these caps on and watch your CRBSI rate plummet. You can follow the evidence with the links below. 

I also included one final link to AI-generated figures for a scientific manuscript. Just don’t. 

Kind regards,

Joel Topf, MD

Articles
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    Cluster-Randomized Trial of Devices to Prevent Catheter-Related Bloodstream Infection - 3 month(s) ago

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      kidney_boy

      This is a trial of a chlorhexidine impregnated cap for the ends of the permacath. The cap, ClearGuard HD, incorporates a rod that extends down the lumen of the catheter and elutes chlorhexidine. It is an antibiotic lock in a device. And it works about as well as any antibiotic lock (Incidence rate ratio of 0.37 P=0.001, favoring the chlorhexidine cap).

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    Catheter-Associated Bloodstream Infections among Patients on Hemodialysis Progress before and during the COVID-19 Pandemic - 3 month(s) ago

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      kidney_boy

      The investigators hypothesized that mask and contact precautions implemented by dialysis units during the early months of the COVID pandemic would result in lower catheter-related blood stream infections (CRBSI). They did find a lower rate of CRBSI during the pandemic, but it turns out this decrease in infections was part of a larger trend that began before the pandemic. The authors traced the improvement in CRBSI back to May of 2019 when Davita began using ClearGuard HD permcath caps in all of their tunneled catheter patients.

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    AI is now doing scientific illustrations and it is not going well - 3 month(s) ago

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      kidney_boy

      This manuscript used AI to create the figures and they were totally incomprehensible. [Do yourself a favor and look at figure 1, and when you look at figure 2, count the JAKs] Despite this it cleared peer review and was published. It did not clear the keen eyes of Redit and Twitter, where it was widely ridiculed. The journal has posted "expression of concern." Another win for post-publication peer review.