Creation/Revision Date: December 03, 2009
December 3, 2009
Thomas R. Frieden, MD, MPH, Director
Centers for Disease Control
Department of Health and Human Services
1600 Clifton Road, NE
Atlanta, GA 30333
Subject: Draft Guidelines for the Prevention of Intravascular Catheter-Related Infections
Dear Dr. Frieden:
The Renal Physicians Association (RPA) is the professional organization of nephrologists whose goals are to ensure optimal care under the highest standards of medical practice for patients with renal disease and related disorders. RPA acts as the national representative for physicians engaged in the study and management of patients with renal disease. We are writing to provide comments on the CDC’s Draft Guidelines for the Prevention of Intravascular Catheter-Related Infections.
Unique Nature of Dialysis Catheters
RPA commends the CDC for the development of the revised draft guideline, and while many of the recommendations captured in the document do apply to dialysis catheters, there are also clear differences between catheters used in treating dialysis patients and in nephrology practice, and those used in the other disciplines addressed in the guideline. Dialysis catheters come in two varieties, temporary and permanent catheters. The temporary catheters used in dialysis care more closely resemble the general catheters addressed in the document. Conversely, permanent catheters are typically placed in dialysis patients for an extended period of time, with a significant number greater than 90 days and many being the patient’s only vascular access for years. As such, RPA believes catheter use in dialysis patients is unlike that of any other patient population or discipline.
Another difference between dialysis catheters and the catheters generally referred to in the document is that dialysis catheters have a long subcutaneous tunnel, and in addition, most have a cuff in the tunnel near the exit site. While there are peripherally inserted central catheters (PICCs) that are similar to this, it is our impression is that they are not routine, and the guideline does not specifically refer to them. RPA urges the CDC to more clearly emphasize the differences between catheters typically used to treat dialysis patients and those used in treating other patient sub-populations.
• Catheters with Anticoagulants and Antibiotics—Manufacturers are beginning to impregnate catheters both with anticoagulants and antibiotics. However, long-term studies on use of dialysis catheters with these modifications are not available. As such, we would urge the CDC to consider the absence of evidence on this point as it proceeds with this and future policy development in this area.
• Bundling—RPA urges caution regarding development of a bundle that would combine strategies or elements of catheter use in performance measurement. We believe that implementation of a bundle in this area that accomplishes the CDC’s policy goals without creating the potential for adversely affecting care provided to dialysis patients would be very difficult. For example, it would be reasonable to include in such a bundle the infections that occur within the first 72 hours after placement, as they can easily be related to technique and insertion. However to penalize the interventional facility , in this circumstance for problems which occur in the dialysis unit or with patient hygiene is neither fair nor reasonable. We would once again note that this is a significant difference in catheter use in dialysis patients and in non-dialysis patient populations.
• Antibiotic Use in Catheters—RPA believes that use of antibiotics such as bacitracin, neomycin, or polymyxin B at the catheter exit may be different for dialysis catheters. While there is literature that has found protective benefit from use of these drugs, other dialysis care providers have raised the issue of increased risk of Candida infections. We would urge the CDC to consider this issue as refinement of the draft guideline proceeds.
As always, we welcome the opportunity to work collaboratively with CDC in its efforts to improve the quality of care provided to the nation’s ESRD patients, and we stand ready as a resource to CDC in its future endeavors. Any questions or comments regarding this correspondence should be directed to RPA’s Director of Public Policy, Rob Blaser, at 301-468-3515, or by email at email@example.com.
Edward R. Jones, M.D.