347Acta Med Indones - Indones J Intern Med • Vol 54 • Number 3 • July 2022

EDITORIAL

The Vascular Access Related Infections: Have We Anticipated  
Them Adequately?

Erni Juwita Nelwan*
Division of Tropical and Infectious Diseases, Department of Internal Medicine, Faculty of Medicine Universitas 
Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

*Corresponding Author:
Erni Juwita Nelwan, MD., PhD. Division of Tropical and Infectious Diseases, Department of Internal Medicine, 
Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital. Jl. Salemba Raya 6, Jakarta 10430, 
Indonesia. Email: erni.juwita@ui.ac.id. 

T h e  n u m b e r  o f  p a t i e n t s  i n  n e e d  o f 
haemodialysis (HD) is increasing from time to 
time. In 2018, the Indonesian Renal Registry 
documented more than 130,000 active patients 
from 651 registered HD centres. Twenty percent 
are diabetic patients with end-stage renal disease 
(ESDR) equal to 8,633 patients.1 Diabetes Mellitus 
accounts for 2% of all diabetes cases in the age 
of 15 year-old and above.2 Hence, the increasing 
need for HD is inevitable and is parallel with the 
need for vascular access procedures.

One of the major problems that occurs 
with vascular access is the risk of infection. 
Among HD patients, mortality and morbidity 
are predominantly associated with infection; 
about one-fifth as a cause of hospital admissions, 
one-fourth of the infection-related admissions 
are due to infection of vascular access. In 
addition, patients on HD are hospitalized 
more frequently compared to other illnesses. 
Therefore, information on the magnitude of the 
problems needs to be well understood.3 Susilo 
et.al,4 reported around 40% of patients with 
temporary vascular access had an infection. Data 
is limited and might be also underestimated.

The definition of vascular access-related 
infection needs to be carefully classified. The 
infection site can be classified as: (1) exit site 
infection, inflammation confined around the skin 
area at the catheter exit site and not involving the 
cuff if the catheter is tunneled; (2) the infection of 
the tunnel, inflammation along the subcutaneous 

tunnel whereby exudate can be drained to the 
exit site; and (3) bloodstream infection, with 
positive blood culture.5 An agreed upon and 
unified definition is mandatory for clinical use 
and research. Challenges for clinicians even start 
from determining the incidence due to different 
views on the reporting of such instances, whether 
the occurrence of infection should be reported 
as per dialysis session or rate per-patient-day 
or per-catheter-day. This heterogeneity makes 
the general picture of the problem  needs to be 
carefully analyzed.6,7

U n f o r t u n a t e l y,  t h e  a v a i l a b l e  s t u d i e s 
examining risk factors for vascular access-
associated infection are scarce and mostly 
collected with substandard methodology.3 
Susilo et al.4 found that female gender, anemia, 
duration of catheter use, and diabetes mellitus 
are risk factors for temporary vascular access 
related infection. However, the vascular access 
type is also an important factor contributing to 
bloodstream infection.4,6

It is to be highlighted that the study of 
Susilo et al.4 may represent the population of 
a  referral hospital for HD, yet as a reader it is 
worth noting that heterogeneity among centres 
and populations should be acknowledged. 
Information is needed on the clinical impact 
of transient vascular access-related infections 
such as mortality, which has not been described 
in this report. A comprehensive in-depth review 
and further research of these studies are crucial 



Erni Juwita Nelwan                                                                                       Acta Med Indones-Indones J Intern Med

348

for a greater level of understanding for the cause 
of infection and therefore inform effective early 
detection and prevention strategies to reduce 
morbidity and mortality among haemodialysis 
patients, especially at-risk patients.

RefeRences
1. Indonesian Renal Registry. (2018). 11 th Report 

of Indonesian Renal Registry 2018. http://www.
indonesianrenalregistry.org/

2. Badan Penelitian dan Pengembangan Kesehatan. 
Laporan Nasional Riskesdas 2018-Badan Penelitian dan 
Pengembangan Kesehatan. Jakarta: Lembaga Penerbit 
Badan Penelitian dan Pengembangan Kesehatan; 2019.

3. Menegueti MG, Betoni NC, Bellissimo-Rodrigues F, 
Romão EA. Central venous catheter-related infections 
in patients receiving short-term hemodialysis therapy: 
Incidence, associated factors, and microbiological 
aspects. Revista Da Sociedade Brasileira de 
Medicina Tropical. 2017;50(6):783–7. https://doi.
org/10.1590/0037-8682-0438-2017

4. Susilo A, Suryana KD, Nugroho P, Muhadi, Alodia 
B, Nainggolan L. Risk factors for temporary vascular 
access infection in patients with end-stage renal disease 
undergoing hemodialysis in Cipto Mangunkusumo 
Hospital. Acta Med Indones - Indones J Intern Med. 
2022;54(3):356-64.

5. Lok CE, Huber TS, Lee T, et al. KDOQI Clinical 
practice guideline for vascular access: 2019 update. 
American Journal of Kidney Diseases. 2020;75(4): 
S1–S164.

6. Basri NS, Patrianef P. Infection of double lumen 
catheter as hemodialysis access. The New Ropanasuri 
Journal of Surgery. 2017;2(1):25–8. https://doi.
org/10.7454/nrjs.v2i1.18

7. Miller LM, Clark E, Dipchand C, et al. Hemodialysis 
tunneled catheter-related infections. Canadian Journal 
of Kidney Health and Disease. 2016;3(1). https://doi.
org/10.1177/2054358116669129