Evaluation and Management of Fever in a Dialysis Patient with AV Fistula

Initial Diagnostic Approach

The Infectious Diseases Society of America recommends obtaining two sets of blood cultures (at least 20ml total volume): one from the AV fistula and one from a peripheral vein to allow calculation of differential time to positivity 3, 4
For multilumen access, the Society for Critical Care Medicine suggests sampling from all lumens as colonization can occur in a single lumen 4
The American College of Physicians advises collecting cultures before initiating antimicrobial therapy to maximize diagnostic yield 5
Assess for severity of illness (presence of hypotension, organ dysfunction) to guide management decisions, as recommended by the Infectious Diseases Society of America 1
Examine the AV fistula site for signs of infection including erythema, tenderness, purulence, or drainage, according to the Clinical Infectious Diseases guidelines 2, 6

For Mild to Moderate Illness (no hypotension or organ failure), the Infectious Diseases Society of America recommends considering empiric antimicrobial therapy while awaiting culture results 5
If fever persists with no other source identified, the American College of Physicians suggests considering removal and culture of the vascular access 5, 1
For Severe Illness (hypotension, signs of organ failure), the Infectious Diseases Society of America advises removing the vascular access, culturing the tip, and inserting a new access at a different site 5, 2
Initiate broad-spectrum antimicrobial therapy immediately, as recommended by the Society for Critical Care Medicine 5

S. aureus and coagulase-negative staphylococci are the most common pathogens in vascular access infections, according to the Annals of Oncology 4
S. aureus colonization of vascular access has 25% risk of developing bacteremia if not treated promptly, as reported by the Infectious Diseases Society of America 1
Consider nasal culture for S. aureus and treatment of carriers with mupirocin ointment (2%), as recommended by the Clinical Infectious Diseases guidelines 5, 8

Unnecessary removal of vascular access should be avoided as most catheters from patients with suspected infection are sterile (71% in one series), according to the Infectious Diseases Society of America 5, 1
Thrombolytic agents (e.g., urokinase) should not be used as adjunctive therapy for vascular access infections, as advised by the American College of Physicians 1, 7