Diagnostic Gaps and Management Hurdles: Central Venous Catheter-related Infections in an End-stage Renal Disease Patient in Nigeria

Abstract

Vascular access-related infections are a significant cause of morbidity and mortality among patients on maintenance hemodialysis (MHD). In developing countries like Nigeria, the reliance on central venous catheters (CVCs) as a primary vascular access point increases the risk of catheter-related bloodstream infections (CRBSI). This report highlights the clinical management of CRBSI and the systemic constraints faced in resource-limited settings. The index case was a 49-year-old woman with end-stage renal disease (ESRD) secondary to diabetes mellitus, currently on MHD via a CVC, presented with a high-grade fever during a dialysis session. Clinical examination and positive blood cultures drawn from the dialysis tubing confirmed a CRBSI. No other focal source of infection was identified. Microbiological analysis identified the pathogen (consistent with common isolates like Staphylococcus aureus). The patient was managed with a combination of topical and parenteral antibiotics tailored to the microbiogram. Following initial stabilization and antibiotic therapy, a catheter exchange was performed to eliminate the source of the infection.The patient showed clinical improvement with the resolution of fever and clearance of the bloodstream infection. However, the management process was complicated by significant local constraints, including the inability to monitor serum trough levels for antibiotic dosing, the high cost of specialized medications, and the limited availability of drugs effective against methicillin-resistant S. aureus (MRSA). Catheter-related bloodstream infection remains a formidable complication for hemodialysis patients in Nigeria. While definitive treatment involving targeted antibiotics and catheter exchange is effective, there is an urgent need for improved access to affordable MRSA-active antibiotics and laboratory facilities for therapeutic drug monitoring to optimize patient outcomes.

INTRODUCTION

Effective hemodialysis is fundamentally dependent on reliable vascular access.[1] While the arteriovenous fistula (AVF) remains the international “gold standard” due to its longevity and lower infection rates, achieving permanent access remains one of the most significant hurdles in the management of end-stage renal disease (ESRD) in Sub-Saharan Africa.

In Nigeria, the utilization of permanent vascular access is critically low. While clinical guidelines suggest that the majority of maintenance hemodialysis (MHD) patients should utilize an AVF, local studies reveal a starkly different reality.[2,3,4]

Consequently, over 90% of patients in Nigerian dialysis centers rely on catheter-based vascular access. These primarily include femoral catheters, tunneled and nontunneled internal jugular catheters (IJC). Recent data underscores this trend; at the University College Hospital, Ibadan, 7.2% of patients utilize nontunneled IJCs, while a 6-year review at the University of Benin Teaching Hospital reported a significantly higher rate of 28.5%.[5,6]

The overwhelming reliance on central venous catheters (CVCs) exposes a vulnerable patient population to severe complications, most notably Catheter-related bloodstream infections (CRBSI). These infections are a primary driver of morbidity, hospital readmission, and mortality among hemodialysis patients.[7]

In resource-limited settings, the challenge is two-fold. The first is high prevalence. This arises from high turnover and prolonged use of temporary catheters due to the prohibitive cost of AVF surgery. Then, the issue of management barriers arising from a lack of facilities for therapeutic drug monitoring (TDM) – specifically serum trough levels – and the scarcity of potent antibiotics for resistant strains like methicillin-resistant Staphylococcus aureus (MRSA).[7,8] This case report discusses the clinical course of a 59-year-old patient with CRBSI, highlighting the diagnostic process and the systemic constraints that complicate the management of such infections in the Nigerian healthcare system.

CASE PRESENTATION

Patient information

The patient is a 49-year-old woman, known diabetic of 8 years, and has been managed for ESRD secondary to diabetic nephropathy on MHD.

Clinical findings

The patient presented to the dialysis unit with a 6-day history of high-grade, continuous fever (38.8°C) accompanied by rigors and generalized weakness. Notably, the fever exacerbated approximately 1 h into each dialysis session.

Vascular access history

Non-tunneled right-sided IJC in situ for 3 months. The reason for the CVC is the primary failure of a previous AVF. Figure 1 showed failed radio-cephalic fistula and a central vascular catheter for MHD inserted in the index patient. The CVS was maintained by regular exit-site cleaning and routine use of antibiotic locks postdialysis.

Figure 1.

(a) Both forearms of the patient with radiocephalic fistula failure. (b) Uncuffed internal jugular vascular access

Physical examination

The patient was acutely ill-looking, febrile (38.8°C), and tachypneic (28 cycles/min). The cardiovascular system showed tachycardia (pulse rate - 112 bpm), blood pressure = 140/80 mmHg. The apex beat was displaced to the 6^th left intercoastal space (LICS), lateral to the mid-clavicular line. Heart sounds were normal, first, and second heart sounds.

Local site

The IJC exit site showed hyperemia, mild swelling, tenderness, and purulent discharge.

Systems review

No signs of meningeal irritation, clear lung fields, and no evidence of focal infections (no dysuria, cough, or abdominal pain).

Diagnostic assessment

Following admission, an extensive workup was conducted to identify the pathogen and assess for systemic seeding:

Peripheral blood film

Revealed significant leukocytosis with toxic granulations and a left shift, consistent with a severe bacterial infection [Table 1]. Red cell morphology showed a normochromic, normocytic pattern with occasional microcytes, typical of anemia of chronic disease/ESRD.

Table 1.

Results of investigations

Variable	Result	Reference range
WBC (cells/µL)	16×103	4–11×103
Granulocyte (%)	86.5	45–55
Monocyte (%)	3	1–5
Lymphocytes (%)	38	10–40
Hemoglobin (g/dL)	11	10.5–13.5
Platelets (cells/µL)	212	150–400
ESR (mm 1 h)	98	0–15

WBC=White blood cells, ESR=Erythrocyte sedimentation rate

Microbiology

• Catheter exit-site swab: Gram stain showed Gram-positive cocci in clusters. Culture yielded S. aureus

• Blood culture (from dialysis tubing): Confirmed S. aureus with weak beta-hemolysis. The isolate was sensitive to vancomycin, rifampicin, and trimethoprim (TMP)-sulfamethoxazole, but resistant to methicillin, confirming MRSA

• Imaging: An echocardiogram was performed to rule out infective endocarditis. Findings included concentric left ventricular hypertrophy with a preserved ejection fraction (57%), but notably, no valvular vegetations or pericardial effusions were detected.

Diagnosis

A clinical diagnosis of Sepsis secondary to CRBSI was made. The diagnosis was supported by:

• Temporal relationship: Fever spikes during dialysis

• Local signs: Purulent discharge and inflammation at the catheter exit site

• Microbiological evidence: Positive blood cultures (drawn from the blood tubing at the peak of fever), which identified the causative pathogen, in the absence of any other identifiable source of infection.

Therapeutic interventions

The patient was initially started on empiric intravenous (IV) ceftriaxone (1 g every 12 h) and IV metronidazole (500 mg every 8 h). On confirmation of MRSA, the regimen was pivoted to definitive therapy with intravenous vancomycin initiated with a loading dose of 1 g (15–20 mg/kg), followed by a maintenance dose of 900 mg adjusted for her renal status. To prevent “Red Man Syndrome,” each dose was administered via infusion pump at a rate of 10 mg/min over 1 h.

Topical therapy

The catheter exit site was dressed twice daily with mupirocin cream.

Source control

On the 3^rd day of vancomycin therapy, clinical stability allowed for catheter salvage and eventually a scheduled exchange.

Follow-up and outcomes

The patient showed rapid clinical and biochemical improvement within 4 days.

Clinical

Resolution of fever, chills, and rigors during dialysis sessions.

Inflammatory markers

The erythrocyte sedimentation rate (ESR) dropped from 98 mm/h to 35 mm/h, and the total white cell count (WBC) normalized from 16 × 10³/mm³ to 5 × 10³/mm³.

The patient was discharged after 1 week of inpatient care to continue IV vancomycin as an outpatient (twice daily for 1 week, then transitioned to postdialysis administration for 2 weeks).

Long-term outcome

A repeat blood culture and exit-site swab 1 week after completing the antibiotic course showed no growth. Two weeks posttreatment, the noncuffed IJC was successfully exchanged for a tunneled catheter. The patient has remained clinically stable with a healed exit site and no recurrence of sepsis.

DISCUSSION

This case illustrates the classic presentation and successful management of a CRBSI in an MHD patient. However, it also highlights the precarious nature of managing such infections in a resource-limited setting where the “gold standard” of care often meets the “reality of the clinic.”

The primary driver of infection in this patient was the prolonged use of a nontunneled IJC.[8] As noted in local literature from Ibadan and Benin City, over 90% of Nigerian dialysis patients rely on these temporary measures.[5,6] The failure of this patient’s primary AVF forced a transition to a CVC, which inherently carries a higher risk of biofilm formation and subsequent bacteremia.

The isolation of MRSA in this case is consistent with global trends in dialysis units but presents a unique set of hurdles in Nigeria.[9] While vancomycin remains the workhorse for MRSA, newer alternatives like Linezolid or Daptomycin are often prohibitively expensive or entirely unavailable in local pharmacies.[10,11,12] The sensitivity to TMP-Sulfamethoxazole and rifampicin in this patient is a positive finding, as these can sometimes serve as adjuncts or oral step-down options. However, they are rarely used as monotherapy for CRBSI.

A critical highlight of this case is the lack of TDM. In ideal settings, vancomycin dosing is guided by serum trough levels to ensure the concentration stays between 15 and 20 µg/mL.[13,14,15] This is vital to prevent ototoxicity and nephrotoxicity: High troughs can damage remaining vestigial renal function or hearing.[16,17] Low troughs promote the development of vancomycin-intermediate S. aureus.[18] In this instance, the clinicians had to rely on calculated renal adjustments and clinical observation rather than biochemical confirmation. The success of the treatment – evidenced by the drop in ESR and WBC – demonstrates that clinical vigilance can mitigate the absence of TDM, though it remains a significant risk factor for treatment failure or toxicity.

While current guidelines often recommend immediate catheter removal for S. aureus CRBSI, the scarcity of vascular access options and the financial burden of repeated insertions often lead clinicians in Nigeria to attempt catheter salvage.[19,20] In this case, the combination of parenteral vancomycin and topical Mupirocin allowed for stabilization before the eventual transition to a tunneled catheter, which provides a better long-term infection barrier than nontunneled IJCs.

CONCLUSION

The management of CRBSI in Nigerian hemodialysis patients represents a delicate balancing act between clinical necessity and resource availability. As this case demonstrates, the heavy reliance on nontunneled catheters – often necessitated by the high failure rate or late initiation of AVFs – creates a persistent reservoir for high-risk pathogens like MRSA. While the gold standard of care dictates immediate catheter removal and stringent TDM, the Nigerian reality frequently mandates a salvage-first approach. This case underscores several critical takeaways for practicing clinicians in similar environments: Clinical Vigilance as a Proxy, Strategic Antibiotic Stewardship, and vascular access crisis (an urgent need to improve the uptake of tunneled catheters and early AVF creation to reduce the duration of exposure to high-risk temporary access sites). Ultimately, the successful resolution of this infection serves as a testament to the efficacy of aggressive parenteral therapy and clinical oversight. However, it also serves as a call to action for the expansion of diagnostic infrastructure – specifically TDM and advanced vascular access services – to bridge the gap between Nigerian nephrology practice and global benchmarks.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.