Cost-effectiveness of three strategies of managing tunnelled, cuffed haemodialysis catheters in clinically mild or asymptomatic bacteraemias

Background. Immediate tunnelled, cuffed catheter (TCC) removal is the current standard of care when bacteraemia is associated with severe clinical symptoms. When minimal or no symptoms are present, the optimal strategy of TCC management is controversial. The following three strategies have been proposed: TCC 'salvage' (antibiotic administration without TCC removal), TCC exchange over a guidewire with antibiotics or immediate TCC removal with delayed reinsertion and antibiotics. Methods. We developed a decision-analytic model to assess the cost-effectiveness of each strategy for episodes of TCC-associated bacteraemia presenting with minimal symptoms, in a hypothetical cohort of haemodialysis patients followed for a 3 month period. Data regarding the probability of treatment failure due to recurrent infection for each strategy, secondary infectious complications and patient mortality were obtained from existing clinical trials and from the 1998 United States Renal Data System database. Costs were substituted with the current 2000 New York hospital charges. Results. Tunnelled, cuffed catheter exchange over a guidewire was associated with a reduction in net charges of $5241 and $750 when compared with TCC salvage and immediate TCC removal, respectively. The expected 3 month patient survival for TCC guidewire exchange and immediate TCC removal were similar (93%), whereas survival for TCC salvage was worse (89%). Tunnelled, cuffed catheter guidewire exchange remained the most cost-effective strategy when the probability of treatment failure with recurrent bacteraemia in 3 months was <25% for this strategy. Conclusions. Tunnelled, cuffed catheter guldewire exchange is the most cost-effective strategy of catheter management when mild or no symptoms are present.