Bloodstream Infections in Hemodialysis Patients

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Bloodstream Infections in Hemodialysis
PatientsEmerging Trends and Preventive Measures

• Source Patel PR, Kallen AJ, Arduino MJ.
  Epidemiology, surveillance, and prevention of
• bloodstream infections in hemodialysis patients.
  Am J Kidney Dis. 201056566577.

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• Infections, particularly bloodstream infections
  (BSI) are a major cause of significant morbidity
  and mortality in patients undergoing
  hemodialysis.
• National data from the US Renal Data System
  (USRDS) indicate that hospitalizations caused by
  BSI in hemodialysis patients have increased by
  34 from 1993 to 2006.

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Emerging Trends

• BSI can be life-threatening and associated with
  complications such as endocarditis and
  osteomyelitis in patients undergoing
  hemodialysis.
• Thus, increase in morbidity due to BSI has led to
  longer duration of hospital stay and cost.
  Various studies of BSI in hemodialysis patients
  have indicated most common organism as
  Staphylococci and other gram-positive cocci
  (Table 1).
• Emerging infection program by centers for disease
  control and prevention (CDC) conducted a
  population-based surveillance, which shows that
  dialysis patients are 100 times more likely to
  acquire methicillin-resistant S. aureus infection
  than individuals in the general population.
• Even, the organism isolated in patients with BSI
  depends on type of vascular access.
• The major risk factor associated with BSI in
  hemodialysis patients is the type of vascular
  access.
• Findings in a multi-centre study and National
  Healthcare Safety Network (NHSN) study data
  indicate increased risk of developing BSI with
  CVC than other vascular access types (Table 2).
• Other risk factors associated with BSI in
  hemodialysis patients include previous history of
  BSI, poor patient hygiene, contiguous skin
  infection, iron overload, low albumin levels, and
  history of nasal colonization with S. aureus.

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Preventive Interventions

• Several measures and actions along with evidence
  of their use have been suggested to prevent BSI
  in hemodialysis patients, which are discussed
  here based on CDCs and National Kidney
  Foundation Kidney Disease Outcomes Quality
  Initiative (KDOQI) recommendations.

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Catheter Use

• Reducing and avoiding the use of CVC for vascular
  access is recommended.
• Prompt removal of an intravascular catheter that
  is no longer needed is indicated.
• Decreased catheter use has been emphasized based
  on the national data collected over the past 15
  years indicating a increase of BSI risk in
  catheter patients.
• Fistula first as the preferred action should
  target the decrease in CVC use for both short and
  long terms (gt90 days) thereby, reducing the BSI
  risk in patients.

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Surveillance

• Active surveillance involving collection of data,
  its review, and feedback is an essential part of
  recommended BSI prevention program.
• The NHSN includes a dialysis event module that is
  available in US hemodialysis centers for BSI
  surveillance and patient care.
• This module is a free internet-based system using
  standardized validated measures that can share
  data with other entities such as end-stage renal
  disease (ESRD) network, health department, other
  dialysis centers etc.
• Some of the other features include multiple
  analytical options such as analysis of facility
  data, generation of surveillance reports and
  track rates of dialysis events.

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Surveillance

• Outcome and process measures for surveillance of
  dialysis facilities include
• The BSI rates stratified by vascular access
  types, pathogens, and antimicrobial
  susceptibility
• Antimicrobial starts and intravenous courses,
  which
• can be individualized to specific antimicrobials
• Hospital admissions and duration of
  hospitalization
• Local vascular access site infections
• Pyrogenic reactions based on clinical features
  and
• blood culture results
• Hand hygiene adherence to dialysis environment
• Number and duration of CVC use
• Adherence to CVC insertion practices

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Catheter Care

• CDC and KDOQI recommend educating healthcare
  personnel on catheter care and aseptic technique.
• Hand hygiene should be performed and sterile
  gloves to be used before accessing the catheter.
• The KDOQI recommends wearing surgical mask during
  catheter connect, disconnect, and dressing change
  procedures.
• Use of chlorhexidine is preferentially
  recommended for skin antisepsis foe catheter
  insertion and exit-site care.
• Recommended alternative skin antiseptics are 70
  alcohol and povidone-iodine.
• Catheter-site dressings should be changed when
  they become loose, wet, or soiled.
• Chlorhexidineimpregnated dressings are currently
  not recommended for routine use by both CDC and
  KDOQI.
• Cleansing catheter hubs and blood tubing
  connectors with chlorhexidine is recommended by
  KDOQI.
• Caution should be observed when using
  alcohol-based antiseptics as it may damage
  polyurethane catheters on prolonged contact.

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Antimicrobial Ointments

• Application of topical povidone-iodine ointment
  to the catheter exit site is recommended.
• Use of mupirocin ointment for topical application
  is recommended by KDOQI, but not by CDC as there
  is a risk of developing resistance.
• Topical ointments should be used with caution as
  some ointments containing polyethylene glycol may
  not be compatible with certain polyurethane
  catheters.

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Antimicrobial Catheter Lock Solutions

• Currently, both CDC and KDOQI do not recommend
  the prophylactic use of antimicrobial lock
  solutions.

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Antimicrobial-impregnated catheters

• KDOQI does not recommend and CDC recommends
  against the use of catheters impregnated with
  antimicrobials such as silver sulfadiazine,
  rifampicin, or minocycline.

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Employing Best Practices

• Implementation of group interventions such as
  amending hand-hygiene use of full barrier
  precaution during catheter insertion, dressing,
  and exit insertion site skin antisepsis with
  chlorhexidine optimal catheter site selection
  and removal of catheter when not needed, can
  dramatically reduce catheter related BSI in
  dialysis patients.

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• Multiple evidence-based approaches are required
  to reduce the serious risk of morbidity and
  mortality from BSI in hemodialysis patients, with
  the use of CVC and other vascular access types.
• Patient safety and quality improvement should be
  a prior consideration along with concentrated
  efforts on patient education and training health
  personnel.
• A diverse action plan aimed at improving
  adherence and practice of currently recommended
  evidence-based approach can dramatically decrease
  BSIs and other infections in hemodialysis
  facilities.

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Comprehensive Basketin Anemia Management