Introduction: Infections of hemodialysis (HD) catheter tips by Gram-negative bacteria, especially Enterobacter species, can be life-threatening. They begin with local colonization and may progress to bacteremia, carrying high early mortality. Studies show a 3-month mortality of ~25.3% for Gram-negative bacteremia in HD patients, versus 16% for Gram-positive. If untreated, these infections may lead to sepsis, endocarditis, and require catheter removal. Prompt diagnosis and treatment are essential. Description: A 46-year-old man with autosomal dominant polycystic kidney disease and end-stage renal disease on HD presented with episodic fevers up to 104°F and flu-like symptoms for a month, occurring during dialysis sessions. His history included Enterococcus faecalis bacteremia and right subclavian DVT on Eliquis. He had previously visited the emergency department with similar symptoms but was discharged without signs of infection. On readmission, he had a 103.1°F fever, persistent myalgia, no leukocytosis, and a clean catheter site. An extensive workup—including chest X-ray, CT abdomen/pelvis, viral panel, urinalysis, transthoracic echocardiogram, and blood cultures—was negative. Fever resolved after acetaminophen. Infectious disease recommended culturing the HD catheter tip, which grew fewer than 15,000 colonies of Enterobacter cloacae. After catheter removal, symptoms resolved, follow-up cultures were negative, and a new catheter was placed. He completed 3 days of Zosyn and Vancomycin but received no further antibiotics. A repeat upper extremity ultrasound showed no persistent DVT. He was discharged symptom-free, with no recurrence. Discussion: This patient had recurrent fevers despite a prior emergency visit. At his recent visit, catheter tip infection with E. cloacae was diagnosed. A history of bacteremia and DVT increased his catheter-related infection (CRI) risk. While Gram-positive organisms cause 55.7–66% of CRIs, Gram-negatives like Enterobacter account for ~26.7%. These infections can lead to severe complications. KDOQI guidelines recommend 10–14 days of antibiotics for CRI, even without bacteremia. E. cloacae infections in tunneled HD catheter tips are rare without concurrent bacteremia, and untreated Gram-negative catheter infections can cause significant morbidity and mortality.
Gill et al. (Sun,) studied this question.