Management of hemodialysis access infections.

Management of hemodialysis (HD) access infection is one of the most challenging and most common problems faced by surgeons, interventional radiologists, and nephrologists. The goal to eradicate infection is often at odds with the need to maintain access. Patients on HD are immunocompromised and typically have significant comorbid conditions placing them at high risk for the occurrence of access infection. Infection is most common with central-vein catheter access, followed by prosthetic arteriovenous grafts (AVG) and is rare with autogenous fistulas. The diagnosis is usually evident on physical exam, but it is not uncommon for these patients to present with atypical symptoms and lack of clinical findings. Although Staphylococcal species are the most common organism to cause infection, early empiric antimicrobial therapy should also include coverage for Gram-negative organisms. Management of central-vein catheter infection includes removal and delayed replacement or, in patients with mild clinical symptoms, catheter exchange over a guide wire. Our management of AVG infection includes total graft excision when patients present with sepsis or the entire graft is bathed in pus, subtotal graft excision when all of the graft is removed except a small oversewn cuff of prosthetic material on an underlying patent artery, and partial graft excision when only a limited infected portion of the graft is removed and a new graft is rerouted in adjacent sterile tissue to maintain patency of the original graft. This strategy has proven to be highly successful in the management of these complicated cases.