Infection control: Special Challenges in Renal Services

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Infection control Special Challenges in Renal
Services

• Richard Fluck, Consultant Renal Physician, Derby

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Morbidity and mortality
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Infection aetiology
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Vascular access prevalent patients UK 2005
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Renal Registry Vascular access survey incident
cohort
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Venous catheters and morbidityUK Vascular access
survey 2005
Year 2004 1547 Staph. Aureus infections (462
(29) related to MRSA) in haemodialysis
population One third of bed days in HD population
related to catheter related problems Cost of a
single episode of bacteraemia 6209
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Infection pathways and access
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Positive blood cultures 1999-2004 HD patients
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System review

• Primary prevention reduce reliance on catheters
• Insertion
• Care
• Dressing type
• Frequency
• Training
• Connection technique
• Treatment
• Antibiotic proformas
• Lead nurse
• Weekly infection reviews

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Antibiotic locking Study Characteristics

• 8 trials identified
• total of 624 patients
• 819 catheters, 448 tunnelled, 371 non tunnelled
• At least partially blinded
• Single or multicentre
• Fairly matched demographics
• Several solutions tested vs. heparin
• Antibiotic commonly Gentamicin
• Antimicrobial
• Combination/ mixed

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Survival to first CRI
P0.02
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Rates of CRI expressed as number/ 1000 catheter
days
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Results

• All catheters-
• A CRI event was 7.72 times less likely with ALS
• (95 CI 5.11-10.33)
• Tunnelled lines specifically-
• showed a greater benefit with ALS
• 8.5 times less likely to develop CRI
• (95 CI 3.54-13.46)

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Conclusions of meta-analysis

• ALS significantly reduce the rate of CRI
• ALS are more effective with tunnelled catheters
  compared to non-tunnelled.
• Use of ALS not associated with
• adverse events
• Increased morbidity or mortality (over study
  period)
• Further assessment required to identify the
  optimal ALS and long term effects

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Tunnelled CRI infections
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Positive blood cultures 2005 2006 HD patients
2005 6 of 17 had tunnelled access at time of
blood culture 2006 6 of 17 had tunnelled access
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Patients per episode
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Results

• 2004 CRI 3.7 infections per 1000 catheter days
  (mean tunneled catheter usage 47 per month).
• 2005 CRI 0.12 infections per 1000 catheter day
  (mean tunnelled catheter usage 44 per month).
• Culture negative episodes with a strong clinical
  index of suspicion for CRI did not change between
  2004 and 2005.

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High Impact Intervention No2cRenal dialysis
catheter care bundle
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Summary

• Infection is a significant issue in dialysis
  units
• Morbidity
• Mortality
• It is not inevitable
• It requires a multidisciplinary, multifaceted
  approach
• Zero tolerance
• Monitoring and review
• Clear policies
• Be proactive not reactive or complacent
• www.dh.gov.uk/reducingmrsa