NDT Advance Access published online on April 18, 2008
Nephrology Dialysis Transplantation, doi:10.1093/ndt/gfn193
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New recommendations in the treatment of Gram-positive bacteraemia in dialysis patients
Correspondence and offprint requests to: E-mail: Michel.Jadoul{at}uclouvain.beSir,
Professor Ponticelli timely reviewed a wealth of important, new information on the prevention and treatment of Gram-positive bacteraemia in dialysis patients. Surprisingly, despite the title of his paper [1], he does not discuss a point of major clinical relevance, i.e. the optimal empirical antibiotic regimen in haemodialysis patients with suspected bacteraemia. It should be based on local epidemiology (country, unit) and characteristics of the individual patient (history of MRSA carriage, recent hospitalization in a high MRSA risk setting such as an ICU). The incidence of MRSA bacteraemia in our chronic haemodialysis patients was very low in 2007 (0.063 per 1000 patient-days) and the previous 5 years (L. Labriola, unpublished data), and such episodes were only observed in patients with a history of recent ICU stay. Therefore, whenever bacteraemia is suspected, we still use cefazolin alone at the end of each HD session as a first-line empirical therapeutic option. This simple, inexpensive regimen has proved both safe and effective against methicillin-sensitive Staphylococcus aureus (MSSA) in dialyzed patients, in our hands and that of others [2]. Only a history of recent hospitalization, particularly in the ICU, or recent infection by another agent than MSSA, triggers the empirical choice of vancomycin, alone or with a third-generation cephalosporin or aminoglycoside. We acknowledge that the local epidemiology of S. aureus strains may differ greatly from country to country [3] or unit to unit but emphasize that our approach has the major advantage not to favour the indiscriminate use of last-resort anti-MRSA antibiotics, be it vancomycin or the newer, more expensive drugs reviewed by Ponticelli.
Professor Ponticelli further cited a single study of an antibiotic-lock solution as an effective method to reduce catheter-related bacteraemia (CRB) [1]. As showed by our recent meta-analysis of eight randomized controlled trials, the use of antimicrobial lock solutions (ALS) reduced the incidence of CRB by about a factor 3 [4]. However, the incidence of CRB with an ALS was similar to rates in units not using ALS but with a low CRB incidence. Moreover, two included studies with a low baseline incidence of CRB did not show a significant reduction of CRB by the ALS [4]. On the other hand, some trials revealed a dramatic reduction of CRB simply after reinforcing hygienic precautions in catheter care (discussed in [4]). In our unit, the incidence of CRB in 2007 was 0.23 per 1000 catheter-days, without using ALS.
Finally, the author did not mention thrombocytopenia as a side effect of vancomycin [1]. Recently, Von Drygalski et al. reported thrombocytopenia due to vancomycin-dependent antiplatelet antibodies in 34 patients. [5]. Thus thrombocytopenia should be considered as a potential side effect of vancomycin, like cutaneous reactions, neutropenia and hepatotoxicity.
Conflict of interest statement. None declared.
Department of Nephrology, Cliniques Universitaires St. Luc, Université, Catholique de Louvain, Belgium
References
- Ponticelli C. New recommendations in the treatment of Gram-positive bacteraemia in dialysis patients. Nephrol Dial Transplant (2008) 23:27–32.
[Free Full Text] - Fogel MA, Nussbaum PP, Feintzeig ID, et al. Cefazolin in chronic haemodialysis patients: a safe, effective alternative to vancomycin. Am J Kidney Dis (1998) 32:401–409.[Web of Science][Medline]
- Centers for Disease Control and Prevention (CDC). Invasive methicillin-resistant Staphylococcus aureus infections among dialysis patients—United States 2005. MMWR Morb Mortal Wkly Rep (2007) 56:197–199.[Medline]
- Labriola L, Crott R, Jadoul M. Preventing haemodialysis catheter-related bacteraemia with an antimicrobial lock solution: a meta-analysis of prospective randomized trials. Nephrol Dial Transplant (2007) 23:1666–1672.[CrossRef][Medline]
- Von Drygalski A, Curtis BR, Bougie DW, et al. Vancomycin-induced immune thrombocytopenia. N Engl J Med (2007) 356:904–910.
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