Dialysis-access infection

Synopsis

Recognise infection of a dialysis fistula or graft before sepsis, haemorrhage or access loss, obtain blood and direct deep microbiology, and combine renal-appropriate antibiotics with source control when prosthetic material or deep tissue is involved.

In sepsis, obtain at least two sets of peripheral blood cultures if this does not delay treatment, start renal-adjusted intravenous antibiotics promptly, and resuscitate while arranging dialysis-safe ongoing care.
Purulence, sinus formation, deep collection or exposed prosthetic graft requires urgent vascular source-control planning; retained infected material carries persistent infection, disruption and bleeding risk.
Sentinel or active bleeding from an infected access is a surgical emergency: apply direct control, activate major-haemorrhage support and do not blindly clamp or probe the anastomosis.

Key red flags

Hypotension, confusion, rigors, rising lactate or rapidly progressive erythema indicates systemic infection requiring immediate resuscitation, cultures and intravenous antibiotics.

Sentinel bleeding, an exposed anastomosis, pseudoaneurysm, skin necrosis or a pulsatile infected mass risks sudden exsanguination and requires emergency vascular control.

Persistent Staphylococcus aureus bacteraemia, a new murmur, embolic signs, back pain or focal joint pain raises concern for endocarditis or metastatic infection.

Purulence, fluctuance, deep tenderness or graft exposure indicates deep infection in which antibiotics alone rarely eradicate prosthetic biofilm.

A painful inflamed access with absent thrill may be infected and thrombosed; do not proceed to routine declotting until infection has been assessed.

Bacteraemic sepsis

Rigors during or after dialysis, fever, hypotension, confusion, tachypnoea or rising lactate can occur even when local access signs are subtle.

Impending rupture

Sentinel bleeding, rapidly thinning or necrotic skin, pulsatile mass, infected pseudoaneurysm or visible anastomosis requires immediate haemorrhage control and vascular surgery.

Investigation priorities

Blood cultures before antibioticsFirst step

Obtain at least two peripheral sets in systemic illness, ideally before therapy when this causes no harmful delay, and repeat to document clearance in significant bacteraemia.

Direct deep sampling — preferred microbiologyPreferred

Send multiple tissue, perigraft-fluid or explanted-material specimens during drainage or surgery, before antibiotics where safe, rather than relying on surface swabs.

Management branches

Emergency pathwaySepsis or threatened access rupture

Use for shock, altered mental state, rapidly progressive infection, purulence over an anastomosis, exposed graft, pseudoaneurysm or sentinel bleeding.

Resuscitate, control external bleeding with direct pressure, obtain blood cultures if this causes no delay, begin renal-adjusted broad intravenous cover and involve vascular surgery, renal and infection teams immediately.
Do not cannulate or declot the infected segment; create a parallel plan for essential dialysis through the safest alternative site while preserving future veins where possible.

Stable pathwayLocalised infection without systemic features

Use for focal erythema or discharge with stable observations, preserved thrill and no abscess, graft exposure, bleeding or bacteraemia.

Key medicines

Flucloxacillin intravenous — susceptible MSSA1 g IV every 8–12 hours in severe renal failure with creatinine clearance under 10 mL/min; the product is not significantly removed by haemodialysis, so no supplemental dialysis dose is required. Duration follows bloodstream clearance and source control: complete graft removal may allow 2 weeks IV then 2–4 weeks oral therapy; endocarditis, metastatic infection, replacement or retained material requires a longer specialist course.Contraindicated with any history of hypersensitivity to penicillins or other beta-lactam agents, and with previous flucloxacillin-associated jaundice or hepatic dysfunction. Monitor liver and kidney function during prolonged treatment, sodium load, neutropenia and high-dose hypokalaemia. Severe renal impairment, sepsis, malnutrition and concomitant paracetamol increase high-anion-gap metabolic acidosis risk. In pregnancy use when benefit outweighs risk; limited human data have not established teratogenicity.

Vancomycin intravenous — MRSA or serious beta-lactam allergy coverFor adults receiving intermittent haemodialysis, give 15 mg/kg IV as the RRT starting dose and redose according to a pre-dialysis serum level, dialysis membrane and residual kidney function; a critically ill patient may need an unreduced 25–30 mg/kg loading dose. Infuse each dose over at least 60 minutes or at no faster than 10 mg/min, whichever gives the longer administration time. Continue only until cultures permit narrowing, then set total duration by source control, bacteraemia clearance and metastatic infection.There is no safe fixed dialysis interval: high-flux haemodialysis increases clearance, so obtain levels before dialysis and usually replace after the session according to the result. Monitor ototoxicity, infusion reactions, blood counts and concurrent nephrotoxic or ototoxic drugs. In pregnancy use only if clearly needed and monitor levels carefully; increased doses may be required.

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