Bloodstream Infection Prevention in ESRD: Forging a Pathway for Success

Abstract

Related Article, p. 259 Related Article, p. 259 There should be little doubt regarding the importance of infections in the hemodialysis patient population. For years, the US Renal Data System has reported increasing hospitalization rates for all infectious diagnoses and for bacteremia/sepsis in patients treated with hemodialysis.1US Renal Data System. USRDS2013 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2013Google Scholar In 2011, the Centers for Disease Control and Prevention (CDC) reported that although the burden of central line–associated bloodstream infections (BSIs) in hospitalized patients had declined nationally, the estimated burden of central line–associated BSIs in people treated with outpatient hemodialysis was substantial, possibly reaching 37,000 in 2008.2CDCVital signs: central line–associated blood stream infections—United States, 2001, 2008, and 2009.MMWR Morb Mortal Wkly Rep. 2011; 60: 243-248PubMed Google Scholar Soon after, the US Department of Health and Human Services released their National Action Plan to Prevent Healthcare-Associated Infections (HAIs) for End Stage Renal Disease (ESRD) Facilities.3Department of Health and Human Services. National action plan to prevent healthcare-associated infections: roadmap to elimination: end stage renal disease facilities. http://www.hhs.gov/ash/initiatives/hai/esrd.html. Accessed September 24, 2013.Google Scholar The Action Plan, which was developed by the Federal Steering Committee for the Prevention of HAIs in ESRD Facilities with dialysis community stakeholder input, highlighted BSIs as a top priority for national prevention efforts. Despite this prioritization, reports of large-scale BSI prevention efforts in US dialysis centers remain scarce. Some prevention efforts may have been hindered by unanswered questions regarding what fraction of these infections is preventable, whether evidence exists to support interventions, and concerns about the feasibility of such interventions in outpatient dialysis centers in which the resources dedicated to tracking or reducing infections may be limited. In this issue of AJKD, Rosenblum et al4Rosenblum A. Wang W. Ball L.K. et al.Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative.Am J Kidney Dis. 2014; 63: 259-267Scopus (36) Google Scholar describe results of a compelling study that implemented 2 central line–associated BSI prevention interventions—scrubbing catheter hubs prior to their access and using chlorhexidine with alcohol for catheter exit-site care, both of which are well supported by evidence—in more than 200 of their company's dialysis centers. Not only did the authors demonstrate a 41% reduction in BSIs in catheter patients after 1 year, but they achieved a 22% reduction in this measure compared to the control group after only 3 months of the intervention. In the past several years, incremental steps toward broader success in preventing BSIs have occurred. In 2009, the CDC Dialysis BSI Prevention Collaborative was launched.5Centers for Disease Control and Prevention. Dialysis BSI Prevention Collaborative. http://www.cdc.gov/dialysis/collaborative/index.html. Accessed September 25, 2013.Google Scholar CDC experts and dialysis partners reviewed guidelines from the CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC) and found evidence to support interventions that could be packaged for collective implementation in outpatient dialysis centers (Box 1). In 2010, a group of dialysis centers began implementing the interventions as part of the CDC Collaborative. That same year, a published report showed that implementing several recommended interventions in a single facility could reduce central line–associated BSIs.6Bakke C.K. Clinical and cost effectiveness of guidelines to prevent intravascular catheter-related infections in patients on hemodialysis.Nephrol Nurs J. 2010; 37: 601-615PubMed Google Scholar Earlier this year, results from 17 CDC Collaborative facilities were published that showed a 32% reduction in overall BSIs and 54% reduction in vascular access–related BSIs.7Patel P.R. Yi S.H. Booth S. et al.Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report.Am J Kidney Dis. 2013; 62: 322-330Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar The studies documenting these prevention efforts were limited in that they were observational studies and most of the facilities involved were hospital-based outpatient dialysis centers that might not represent typical freestanding dialysis facilities.6Bakke C.K. Clinical and cost effectiveness of guidelines to prevent intravascular catheter-related infections in patients on hemodialysis.Nephrol Nurs J. 2010; 37: 601-615PubMed Google Scholar, 7Patel P.R. Yi S.H. Booth S. et al.Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report.Am J Kidney Dis. 2013; 62: 322-330Abstract Full Text Full Text PDF PubMed Scopus (82) Google ScholarBox 1CDC Approach to BSI Prevention in Dialysis Facilities1. Surveillance and feedback using NHSN: Conduct monthly surveillance for BSIs and other dialysis events using CDC's NHSN. Calculate facility rates and compare to rates in other NHSN facilities. Actively share results with front-line clinical staff.2. Hand hygiene observations: Perform observations of hand hygiene opportunities monthly and share results with clinical staff.3. Catheter/vascular access care observations: Perform observations of vascular access care and catheter accessing quarterly. Assess staff adherence to aseptic technique when connecting and disconnecting catheters and during dressing changes. Share results with clinical staff.4. Staff education and competency: Train staff on infection control topics, including access care and aseptic technique. Perform competency evaluation for skills such as catheter care and accessing every 6-12 months and upon hire.5. Patient education/engagement: Provide standardized education to all patients on infection prevention topics, including vascular access care, hand hygiene, risks related to catheter use, recognizing signs of infection, and instructions for access management when away from the dialysis unit.6. Catheter reduction: Incorporate efforts (eg, through patient education or vascular access coordinator) to reduce catheters by identifying and addressing barriers to permanent vascular access placement and catheter removal.7. Chlorhexidine for skin antisepsis: Use an alcohol-based chlorhexidine (>0.5%) solution as the first-line skin antiseptic agent for central line insertion and during dressing changes.a8. Catheter hub disinfection: Scrub catheter hubs with an appropriate antiseptic after cap is removed and before accessing. Perform every time catheter is accessed or disconnected.b9. Antimicrobial ointment: Apply antibiotic ointment or povidone-iodine ointment to catheter exit sites during dressing change.cAbbreviations: BSI, bloodstream infection; CDC, Centers for Disease Control and Prevention; NHSN, National Healthcare Safety Network.Reproduced from the CDC.16Centers for Disease Control and Prevention. CDC approach to BSI prevention in dialysis facilities. http://www.cdc.gov/dialysis/PDFs/Dialysis-Core-Interventions-5_10_13.pdf. Accessed November 5, 2013.Google ScholaraPovidone-iodine (preferably with alcohol) or 70% alcohol are alternatives for patients with chlorhexidine intolerance.bIf closed needleless connector device is used, disinfect connector device per manufacturer's instructions.cSee information on selecting an antimicrobial ointment for hemodialysis catheter exit sites (http://www.cdc.gov/dialysis/prevention-tools/core-interventions.html#sites). Use of chlorhexidine-impregnated sponge dressing might be an alternative. 1. Surveillance and feedback using NHSN: Conduct monthly surveillance for BSIs and other dialysis events using CDC's NHSN. Calculate facility rates and compare to rates in other NHSN facilities. Actively share results with front-line clinical staff. 2. Hand hygiene observations: Perform observations of hand hygiene opportunities monthly and share results with clinical staff. 3. Catheter/vascular access care observations: Perform observations of vascular access care and catheter accessing quarterly. Assess staff adherence to aseptic technique when connecting and disconnecting catheters and during dressing changes. Share results with clinical staff. 4. Staff education and competency: Train staff on infection control topics, including access care and aseptic technique. Perform competency evaluation for skills such as catheter care and accessing every 6-12 months and upon hire. 5. Patient education/engagement: Provide standardized education to all patients on infection prevention topics, including vascular access care, hand hygiene, risks related to catheter use, recognizing signs of infection, and instructions for access management when away from the dialysis unit. 6. Catheter reduction: Incorporate efforts (eg, through patient education or vascular access coordinator) to reduce catheters by identifying and addressing barriers to permanent vascular access placement and catheter removal. 7. Chlorhexidine for skin antisepsis: Use an alcohol-based chlorhexidine (>0.5%) solution as the first-line skin antiseptic agent for central line insertion and during dressing changes.a 8. Catheter hub disinfection: Scrub catheter hubs with an appropriate antiseptic after cap is removed and before accessing. Perform every time catheter is accessed or disconnected.b 9. Antimicrobial ointment: Apply antibiotic ointment or povidone-iodine ointment to catheter exit sites during dressing change.c Abbreviations: BSI, bloodstream infection; CDC, Centers for Disease Control and Prevention; NHSN, National Healthcare Safety Network. Reproduced from the CDC.16Centers for Disease Control and Prevention. CDC approach to BSI prevention in dialysis facilities. http://www.cdc.gov/dialysis/PDFs/Dialysis-Core-Interventions-5_10_13.pdf. Accessed November 5, 2013.Google Scholar aPovidone-iodine (preferably with alcohol) or 70% alcohol are alternatives for patients with chlorhexidine intolerance. bIf closed needleless connector device is used, disinfect connector device per manufacturer's instructions. cSee information on selecting an antimicrobial ointment for hemodialysis catheter exit sites (http://www.cdc.gov/dialysis/prevention-tools/core-interventions.html#sites). Use of chlorhexidine-impregnated sponge dressing might be an alternative. In this regard, the study by Rosenblum et al4Rosenblum A. Wang W. Ball L.K. et al.Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative.Am J Kidney Dis. 2014; 63: 259-267Scopus (36) Google Scholar is a major contribution in the field of dialysis patient safety. The authors conducted a cluster randomized effectiveness trial in which 211 hemodialysis facilities implemented the intervention (ie, initiated routine use of 2% chlorhexidine with alcohol for catheter exit-site care and scrubbed the catheter hubs with alcohol upon connection and disconnection). These facilities were matched to an equal number of facilities that continued their usual catheter care practices (most often, exit-site care was conducted with povidone-iodine or sodium hypochlorite solution and there was no standard protocol for scrubbing catheter hubs once disconnected from the blood tubing or catheter end caps; instead, catheter caps were soaked in antiseptic solution prior to dialysis initiation). The primary outcome was BSI, defined as any positive blood culture result, in patients with a catheter. During the 3 months after intervention implementation, the BSI rate was significantly lower in catheter patients in the intervention group compared to the usual-care group, and this difference also was observed at 1 year of extended follow-up. The work by Rosenblum et al4Rosenblum A. Wang W. Ball L.K. et al.Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative.Am J Kidney Dis. 2014; 63: 259-267Scopus (36) Google Scholar confirms that BSIs in maintenance hemodialysis patients can be prevented by adhering to recommended practices, and this was demonstrated in a large number of corporate-owned dialysis centers. Whereas previous studies were observational and lacked a comparison group, this is the first study to evaluate the effectiveness of a set of recommended BSI prevention procedures in dialysis centers using a randomized clinical trial design. Similar to results from the CDC Dialysis BSI Prevention Collaborative, Rosenblum et al4Rosenblum A. Wang W. Ball L.K. et al.Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative.Am J Kidney Dis. 2014; 63: 259-267Scopus (36) Google Scholar demonstrated that a decrease in BSI rates occurred relatively rapidly after implementation of these interventions, and lower BSI rates were sustained for the full year of extended observation.4Rosenblum A. Wang W. Ball L.K. et al.Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative.Am J Kidney Dis. 2014; 63: 259-267Scopus (36) Google Scholar, 7Patel P.R. Yi S.H. Booth S. et al.Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report.Am J Kidney Dis. 2013; 62: 322-330Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar Additionally, the authors showed that changes in BSI rates appeared to be accompanied by reductions in intravenous antibiotic use and hospitalizations due to sepsis. These findings, together with their cost estimates for hospital days related to sepsis and resulting number of missed dialysis treatments, suggest a potentially rapid return on investment for BSI prevention efforts. The study by Rosenblum et al4Rosenblum A. Wang W. Ball L.K. et al.Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative.Am J Kidney Dis. 2014; 63: 259-267Scopus (36) Google Scholar focused on the effectiveness of routine catheter “scrub-the-hub” procedures and use of chlorhexidine with alcohol for exit-site care to address intra- and extraluminal pathways of catheter contamination. However, there likely was some overlap with other CDC-recommended practices, such as staff education and competency assessments and catheter care audits, which were listed as part of the intervention implementation. The CDC recommends that education and competency assessments and catheter care audits be conducted on an ongoing basis to ensure that all staff understand and carry out procedures correctly and consistently over time, and has made resources available to help facilities implement these efforts.8Centers for Disease Control and Prevention. Infection prevention tools. http://www.cdc.gov/dialysis/prevention-tools/index.html. Accessed October 8, 2013.Google Scholar It is easy to imagine the particular importance of these recurring measures as part of the culture of ensuring safety in dialysis centers that can have high staff turnover rates. Finally, Rosenblum et al4Rosenblum A. Wang W. Ball L.K. et al.Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative.Am J Kidney Dis. 2014; 63: 259-267Scopus (36) Google Scholar performed an assessment of feasibility and acceptability of the selected interventions and found the procedures to be acceptable to staff, easy to implement, and potentially time-saving. Chlorhexidine was relatively well tolerated by patients, with a reported adverse-reaction rate of 2%.4Rosenblum A. Wang W. Ball L.K. et al.Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative.Am J Kidney Dis. 2014; 63: 259-267Scopus (36) Google Scholar Although not explicitly stated, it also is notable that the scrub-the-hub procedure was performed on thousands of patients with hemodialysis catheters, presumably with no significant associated adverse events, lending additional reassurance that this procedure can be performed safely by dialysis center staff. This is important because concerns regarding the inadvertent introduction of air or antiseptic solution into the bloodstream through the catheter have been cited by some as reasons to not disinfect catheter hubs without the caps in place. There are a few limitations to this study by Rosenblum et al.4Rosenblum A. Wang W. Ball L.K. et al.Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative.Am J Kidney Dis. 2014; 63: 259-267Scopus (36) Google Scholar The authors used an outcome measure—all positive blood culture results—that might have included BSIs that were not related to the vascular access or positive cultures that did not represent true BSIs. However, this measure's numerator is consistent with CDC's National Healthcare Safety Network (NHSN) BSI surveillance definition that is used by more than 5,600 dialysis centers nationally, it was applied equally in the intervention group and comparison group facilities, and, as previously mentioned, the reductions appeared to track with decreases in other meaningful outcomes, such as antibiotic use and hospitalizations. The authors chose 2 interventions that were specific to catheter care, but did not implement the use of antimicrobial ointment at the catheter exit site as one of their interventions despite the strong evidence that exists to support this recommended intervention.9Lok C.E. Stanley K.E. Hux J.E. Richardson R. Tobe S.W. Conly J. Hemodialysis infection prevention with polysporin ointment.J Am Soc Nephrol. 2003; 14: 169-179Crossref PubMed Scopus (149) Google Scholar, 10O'Grady N.P. Alexander M. Burns L.A. et al.Guidelines for the prevention of intravascular catheter-related infections.Clin Infect Dis. 2011; 52: 1087-1099Crossref PubMed Scopus (272) Google Scholar Had the authors chosen to implement use of a recommended antimicrobial ointment for catheter exit-site care, we suspect there may have been additional reductions in BSI rates and a beneficial impact on exit-site infections. The investigators' focus on patients at highest risk for BSI (evaluating only patients with central venous catheters) may have resulted in a missed opportunity to make broader improvements in infection control practices that could decrease overall BSI rates. The CDC's recommended approach to BSI prevention includes measures to reduce all access-related BSIs because as many as 38% of BSIs in hemodialysis patients may occur in patients with arteriovenous fistula or graft access.11Nguyen D.B. Lessa F.C. Belflower R. et al.Invasive methicillin-resistant Staphylococcus aureus infections among chronic dialysis patients in the United States, 2005-2011.Clin Infect Dis. 2013; 57: 1393-1400Crossref PubMed Scopus (61) Google Scholar Some CDC-recommended interventions, such as improving staff adherence to hand hygiene and regularly educating staff and patients, could further widen the impact of infection prevention. Collectively, results from these recent initiatives, including the impressive study conducted by Rosenblum et al,4Rosenblum A. Wang W. Ball L.K. et al.Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative.Am J Kidney Dis. 2014; 63: 259-267Scopus (36) Google Scholar should convince skeptics that implementing and adhering to CDC-recommended practices is an effective means of reducing BSIs in this setting. Reductions of 30%-50% are possible and can be achieved without resorting to routine use of antibiotic catheter lock solutions, a strategy that has been suggested by some12Boyce J.M. Prevention of central line-associated bloodstream infections in hemodialysis patients.Infect Control Hosp Epidemiol. 2012; 33: 936-944Crossref PubMed Scopus (26) Google Scholar but that has potential associated risks, including increasing antimicrobial resistance. There are other dialysis infection prevention initiatives underway for which results have not yet been published.13Oregon Patient Safety Commission. Quality Improvement Collaboratives: Northwest Dialysis BSI Prevention Collaborative. http://oregonpatientsafety.org/healthcare-professionals/improvement-collaboratives/. Accessed October 8, 2013.Google Scholar, 14Roys E. Scholz N. Parrotte C. et al.NOTICE initiative post- versus pre-infection control evaluation (ICE) results [abstract].J Am Soc Nephrol. 2013; 24: 738AGoogle Scholar, 15Van Wyck D.B. Culkin N. Pronovost P. Goeschel C.A. Krishnan M. Nissenson A.R. A pilot quality improvement program to minimize catheter-related bloodstream infection in an outpatient hemodialysis setting [abstract].J Am Soc Nephrol. 2013; 24: 178AGoogle Scholar One hopes that these efforts will reveal even more encouraging findings. However, dialysis providers need not wait for further evidence to engage effectively in critically important efforts to avoid preventable infections in their patients. The path is already clearer than ever. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Support: None. Financial Disclosure: The authors declare that they have no relevant financial interests. Hemodialysis Catheter Care Strategies: A Cluster-Randomized Quality Improvement InitiativeAmerican Journal of Kidney DiseasesVol. 63Issue 2PreviewThe prevalence of central venous catheters (CVCs) for hemodialysis remains high and, despite infection-control protocols, predisposes to bloodstream infections (BSIs). Full-Text PDF