**5. Effects of other drugs used on dialysis**

Several other drugs that are frequently used on dialysis have known interactions with microbes. Heparin is used frequently to block dialysis catheters when not in use to preserve their patency. Unfortunately, heparin has been found to promote growth of bacterial biofilm in dialysis catheters (Shanks et al., 2005). Citrate has been used as an alternative to heparin to block catheters and was found to have inhibitory effects on biofilms at elevated concentration. Reminiscent of the "Goldilocks effect" observed with aspirin, citrate stimulates biofilm formation at sub inhibitory concentrations, an effect which might have clinical relevance at catheter tips (Shanks et al., 2006). EDTA also has an inhibitory effect on biofilm. The mechanism for both EDTA and citrate is thought to be through chelation of divalent ions essential to the extracellular matrix structure of biofilm (Percival et al., 2005).

Diltiazem, Amlodipine and the angiotension converting enzyme inhibitor Zofenopril have modest in vitro antimicrobial activity against S.aureus. Most of these effects are bacteriostatic and occur at higher drug concentrations in vitro than the therapeutic concentrations that are usually achieved during therapy in vivo. It has to be noted however, that drug concentration can vary considerably throughout different organs and body compartments. In the case of Amiloride it has been determined that urine concentrations achieved in patients are not sufficient to replicate the antibacterial effects that are observed in vivo (Cederlund et al., 1993). The relevance of these observations probably concerns more microbial purity testing of drugs during the fabrication process rather than clinical effects.

Emla cream, a mixture of lidocaine, prilocaine and preservatives, which is used for topical anesthesia at the site of dialysis fistula puncture, has no effect on microbial growth (Kruszewska et al., 2010). Other drugs relevant to ESRD that have been tested and were found to be devoid of antimicrobial effects are the loop diuretics furosemide and bumetanide.

The antihistaminic drug diphenhydramine has been reported to be synergistic with the penicillins (Kristiansen, 1992) and amiloride reportedly enhances uptake of tobramycin in pseudomonas aeruginosa (Cederlund et al., 1993).

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