Comprehensive management of hemodialysis catheter-related bloodstream infections: a narrative review

Tunneled central venous catheters (CVC) are essential vascular access for many maintenance hemodialysis(HD) patients, yet catheter-related bloodstream infections (CRBSI) remain a persistent complication driven by biofilm formation and multidrug-resistant organisms, creating a clinical dilemma between source control (catheter removal) and vascular access preservation. This narrative review synthesizes current evidence across HD-CRBSI epidemiology, pathogenesis, prevention, treatment, and future directions, and provides an evidence-based, decision-oriented management framework. Key contributions include: systematic distinction between extraluminal (skin → cuff → bloodstream) and intraluminal (hub contamination) routes of infection; an HD-specific pathogen profile establishing Gram-positive predominance (approximately 64% of cases, with coagulase-negative staphylococci accounting for approximately 32%); a structured clinical classification differentiating uncomplicated versus complicated CRBSI and exit-site, tunnel, and systemic infections; explicit criteria for catheter salvage (hemodynamically stable patients with uncomplicated CRBSI caused by low-virulence pathogens, mandatory clinical and microbiological reassessment at 48-72 hours, and documented clearance of bacteremia) versus mandatory catheter removal (Staphylococcus aureus, Pseudomonas aeruginosa, Candida spp., tunnel infection, septic shock, or persistent bacteremia >72 hours); systematic integration of antimicrobial lock therapy into the salvage pathway, supported by HD-specific evidence including the LOCK-IT-100 trial; prioritization of standard-of-care prevention practices (mandatory catheter hub disinfection, standardized aseptic connection/disconnection protocols, staff training with care bundles) over experimental strategies; and identification of key research priorities including standardized CRBSI surveillance methodologies, prospective validation of AI-assisted diagnostic tools, and rigorous evaluation of next-generation preventive technologies.