Comparable rates of catheter-related bloodstream infections between non-tunneled and tunneled hemodialysis catheters: a retrospective single-center study

Background and Aims Patients undergoing hemodialysis (HD) through a tunneled central venous catheter are exposed to several risks. Catheter-related bloodstream infection (CR-BSI) is the second major cause of death in this population. To reduce the incidence of CR-BSI we conducted a non-randomized pre-post intervention study aimed to eliminate all preventable CR-BSI. Method A quasi-experimental study was conducted in an intra-hospital hemodialysis unit with 15 HD machines and attending 70 patients until March 2019, and 24 machines and 90 patients from that date until today. The CDC, CR-BSI criteria for dialysis event surveillance protocol, defined as the presence of a positive blood culture with the suspect source report as the vascular access or uncertain was used to define CR-BSI. A sequential implementation of evidence-based interventions, associated in literature with the reduction of CR-BSI rate, were developed between January 2011 and January 2020. The intervention package included: 1. Alcohol based gel delivery system fixed in every HD machine to enhance hand hygiene adherence 2. A new strict aseptic protocol for connecting/disconnecting HD lines that included: 2.1 Wrapping catheter rubs for 1-2 minutes with alcoholic chlorhexidine-saturated gauze before removal catheters caps 2.2 Nurses and patients wear masks during catheter manipulation 2.3 Apply a sterile fenestrate drape with sterile gloves before removing the caps 2.4 The scrub-the-hub aseptic technic after removing the caps with alcoholic chlorhexidine-saturated gauze 2.5 Precocious use of Tissue Plasminogen Activator (rTPA) to correct inadequate blood flow, avoiding excess of catheter manipulation 3. Use of chlorhexidine-impregnated dressing changed once a week 4. Training all nurse staff admitted, catheter care skill evaluation semiannually, re-training when necessary and monthly infection rate feedback 5. Use of citrate 30% as lock solution. Results During the follow-up period (January 2011 to January 2020) a mean of 45 patients (range 30-55) used tunneled catheter as vascular access each year. The mean age was 69±15 years (range 11-96 years), with 60% of patients been diabetic. After implementation the of the new strategies we observed a continuous reduction in the CR-BSI rate: 2010 the year before strategies implementation CR-BSI rate was 1.1/1000 catheter-days; 2011 CR-BSI rate 0.6/1000 catheter-days; 2012 CR-BSI rate 0.6/1000 catheter-days; 2013 CR-BSI rate 0.1/1000 catheter-days; 2014 CR-BSI rate 0.1/1000 catheter-days; 2015 CR-BSI rate 0.2/1000 catheter-days; 2016 CR-BSI rate 0.2/1000 catheter-days; 2017 CR-BSI rate 0.0/1000 catheter-days, 2018 CR-BSI rate 0.08/1000 catheter-days, and 2019 CR-BSI rate 0.06/1000 catheter-days. Between April 10th of 2016 and January 10th of 2020, a 1430 days period, we observed only 2 CR-BSI. Between April 10th of 2016 and January 3rd of 2018 there was a period of 633 days with no CR-BSI. Conclusion Implementation of several evidence-based practices and continuous education can reduce CR-BSI in HD patients to a very low level. Targeting zero infection proposing to eliminate all preventable infection should be the routine practice of all dialysis units.

Locking hemodialysis catheters with cefotaxime instead of gentamicin to avoid potential ototoxicity

Central venous catheter use is rising in chronic and acute hemodialysis. Catheter-related bloodstream infections are a major complication of central venous catheter use. This article examines clinical factors associated with catheter-related bloodstream infections incidence. In this retrospective, single-center study, 413 patients undergoing extracorporeal treatments between 1 February 2014 and 31 January 2017 with 560 central venous catheters were recruited. Clinical parameters, such as gender, age, kidney disease status, diabetes, immunosuppression, and vintage dialysis, were collected at study entry. An incidence rate ratio (95% confidence interval) was calculated to assess the association between catheter-related bloodstream infections incidence rate and each clinical variable/central venous catheter type. Significant associations at the univariate analyses were investigated with multivariate Cox models. During a cumulative time of 66,686 catheter-days, 54 catheter-related bloodstream infections (incidence rate: 0.81) events occurred. Gram negative bacteria were more frequent in patients with age < 80 years (16 (36%) vs. 0, p = 0.02). At the univariate analyses, male sex (incidence rate ratio: 1.9 (1.1-3.5), p = 0.03), age < 80 years (incidence rate ratio: 2.4 (1.1-5.5), p = 0.016) and acute kidney injury (incidence rate ratio: 5.6 (3.1-10), p < 0.0001) were associated with higher catheter-related bloodstream infections incidence rate. Compared with tunneled jugular central venous catheter, higher catheter-related bloodstream infections incidence rate was associated with non-tunneled jugular (incidence rate ratio: 6.45 (2.99-13.56), p < 0.0001) and non-tunneled femoral (incidence rate ratio: 12.90 (5.87-27.61), p < 0.0001) central venous catheter use; tunneled femoral central venous catheter was associated with higher non-significant incidence rate (incidence rate ratio: 2.45 (0.93-5.85), p = 0.07). The multivariate analyses showed that acute kidney injury (hazard ratio: 3.03 (1.38-6.67), p = 0.006), non-tunneled (hazard ratio: 3.11 (1.30-7.41), p = 0.01) and femoral (hazard ratio: 2.63 (1.36-5.07), p = 0.004) central venous catheter were associated with higher catheter-related bloodstream infections incidence rate. Central venous catheter characteristics and acute kidney injury are independently associated with higher catheter-related bloodstream infections rate.

Objectives and StudyPreserving venous access in children with intestinal failure (IF) requiring long-term parental nutrition (PN) can be critical for patient survival. Data regarding salvage of central venous catheter (CVC)...

Introduction: Catheter-Related Blood Stream Infections (CRBSI) are an important complication of both non tunnelled and tunnelled haemodialysis catheters, but are often poorly reported for tunnelled haemodialysis-catheters. Aim: To assess the rate, aetiology, and outcomes of CRBSI in patients using a tunnelled catheter at 12-month and 18-month audits at the newly-opened haemodialysis unit having care bundle as a part of routine catheter care. Materials and Methods: A retrospective cross-sectional study involving two audits of CRBSI risk (12-month and 18-month audit) was conducted by the dialysis unit doctors and nursing staff at Medanta Super-Specialty Private Hospital, Indore, Madhya Pradesh, India. Centres for Disease Control (CDC) and prevention core intervention/care bundle for Blood Stream Infections (BSI) reduction were incorporated as a part of routine catheter care. The 12-month (May 2018 to April 2019) and 18-month (May 2018 to November 2019) internal clinical audit were evaluated to assess the impact of care bundle on incidence of CRBSIs. Kidney-Disease- Outcome Quality-Initiative (KDOQI)-2006-criteria was used to define CRBSI. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 19.0 software (IBM Corporation, New York, United States). Descriptive and dispersion statistical analysis was done for studied variables. Results: Total patients in 12-months audit with tunnelled haemodialysis catheter were 14 (7 male and 7 female) with median age 64 years and in 18-months audit patient with tunnelled haemodialysis catheter were 18 (11 male and 7 female) with median age 67.5 years. CRBSI incidence was 2.58 per 1000 catheter days at the end of 12-month, with 132 (71.25-202.25) days of median catheter use. Over the 18-month, the incidence of CRBSI dropped to 1.99 per 1000 catheter days. Median period of catheter use increased to 149.5 (83.5-294.5) days. The primary organisms isolated were predominantly gram negative bacterias. Conclusion: Tunnelled catheters may be a reasonable alternative vascular access for haemodialysis in patients with arteriovenous fistula failure as implementation and maintenance of multidisciplinary care bundle reduces CRBSI rate in such patients.

Background: Home parenteral nutrition (HPN) has become a common therapy. There is still controversy regarding the possibility that peripherally inserted central catheters (PICCs) may diminish catheter-related blood stream infection (CRBSI) rates. Methods: We searched the PubMed database for studies reporting the rates of CRBSI with HPN. Study selection was performed independently by three investigators. Disagreements were discussed and resolved by consensus or by arbitration by an author not involved in the search. The National Institutes of Health Quality Assessment Tools was used to assess the methodological quality of the studies. Meta-analyses were performed using MetaXL 5.3 with the quality effects model. Results: Screening of the article titles and abstracts yielded 134 full text articles for evaluation. Only three prospective studies that included appropriate data were considered for the final analysis. The relative risk of the CRBSI rate was 0.41 (0.14–1.17) for PICC vs. tunneled catheters. The relative risk of the CRBSI rate was 0.16 (0.04–0.64) for PICC vs. ports. The relative risk of the thrombosis rate was 3.16 (0.20–49.67) for PICCs vs. tunneled. Conclusions: There is insufficient evidence to show a difference in CRBSI rates between PICCs and tunneled catheters. On the other hand, PICCs showed lower CRBSI rates than ports. There was also no difference in the rate of catheter-related thrombosis and mechanical complications.

<h3>Introduction</h3> The risk of blood stream infections may be increased in hospitalized patients receiving ready-made multi-chamber parenteral nutrition bags (MCB) compared to customized parenteral nutrition (PN); however, as highlighted in recent international guidelines, there are no comparable data relating to home PN (HPN). <h3>Methods</h3> Data from a prospectively maintained database were analysed to compare incidence rates of catheter-related blood stream infections (CRBSI) between patients receiving customized HPN compared to MCB HPN at a national UK referral centre between May 2018 and August 2020. Two patient cohorts were included: 1. Patients newly commenced on HPN (customized and MCB) for a 14 month period from July 2019. 2. Patients who were switched from customized to MCB HPN in July 2019. <h3>Results</h3> Sixty patients with chronic intestinal failure were commenced on MCB and 45 on customized HPN for a total of 5914 and 7641 catheter days respectively. No difference in CRBSI incidence was found (0.51/1000 catheter days for MCB, 0.39/1000 catheter days for customized HPN; incidence rate ratio 1.29, 95% CI 0.26-6.37). Eighteen patients were switched from customized HPN to MCB HPN. The study period covered 7401 catheter days on customized HPN and 4834 days on MCB. No significant change was noted in the CRBSI rates following this switch (0.27/1000 catheter days on customized HPN versus 0.21/1000 catheter days on MCB; incidence rate ratio 1.31, 95% CI 0.12-14.3). <h3>Conclusions</h3> The use of MCB for HPN patients is not associated with an increased risk of CRBSI. This study will inform international guidelines and provide reassurance for the continued, safe use of MCB HPN.

Nosocomial catheter related bloodstream infections (CR-BSI) increase morbidity and mortality in critically ill patients. Central venous catheters (CVC) coated with rifampin and minocycline (RM) decrease rates of colonization and CR-BSI. However, recent trials challenged the clinical impact of such catheters. We designed this trial to compare rates of colonization and CR-BSI in RM catheters and controls in a cohort of critically ill patients in Brazil. Prospective, controlled trial conducted in one medico-surgical ICU. Patients were assigned to receive a control or RM CVC. After removal, tips were cultured in association with blood cultures. Rates of colonization and CR-BSI were recorded. Among 120 catheters inserted, 100 could be evaluated, 49 in the uncoated and 51 in the coated group. Clinical characteristics of patients were similar in the two groups. Two cases of CR-BSI (3.9%) occurred in patients who received RM catheters compared with 5 (10.2%) in the uncoated group (p = 0.26). Six RM catheters (11.8%) were colonized compared with 14 (28.6%) control catheters (p = 0.036). Kaplan-Meier analysis showed no significant differences in the risk of colonization or CR-BSI. Rates of CR-BSI were 4.7 per 1000 catheter-days in the RM coated group compared to 11.4 per 1000 catheter days in the uncoated group (p = 0.45). In this pilot study, we showed lower rates of colonization in RM coated when compared with uncoated catheters. Incidence and rates of CR-BSI were similar in the two groups.

Antibiotic locks in catheter-dependent chronic hemodialysis patients reduce the rate of catheter-related blood stream infections (CRIs), but there are no data regarding the long-term consequences of this practice. Over a 4-year period, from October 1, 2002, to September 30, 2006, we initiated a gentamicin and heparin lock (GHL) protocol in 1410 chronic hemodialysis patients receiving dialysis through a tunneled catheter in eight outpatient units. Within the first year of the GHL protocol, our CRI rate decreased from 17 to 0.83 events per 1000 catheter-days. Beginning 6 months after initiation of the GHL protocol, febrile episodes occurred in 13 patients with coagulase-negative Staphylococcus bacteremia resistant to gentamicin. Over the 4 years of GHL use, an additional 10 patients developed 11 episodes of gentamicin-resistant CRI (including 7 with Enterococcus faecalis), in which there were 4 deaths, 2 cases of septic shock requiring intensive care unit admission, and 4 cases of endocarditis. Because of these events, the GHL protocol was discontinued at the end of 2006. Although the use of GHL effectively lowered the CRI rate in our dialysis population, gentamicin-resistant CRIs emerged within 6 months. Gentamicin-resistant infections are a serious complication of the long-term use of GHLs. Alternative nonantibiotic catheter locks may be preferable to decrease the incidence of CRIs without inducing resistant pathogens.

To compare colonization and catheter-related bloodstream infection (CR-BSI) rates among three insertion sites (subclavian, internal jugular, femoral) used for central venous catheter (CVC) placement. Twenty-four-month prospective study, with relative effects analyzed by Cox proportional hazards regression. Eight-bed intensive care unit. Four hundred and ten critically ill patients requiring CVC placement. All short-term multi-lumen CVCs, including antimicrobial-coated devices, were studied with management standardized. Six hundred and five CVCs (4,040 catheter days) were analyzed. Colonization and CR-BSI incidence were, respectively, 15.1 (95% CI 13.5-21.0) and 1.8 (95% CI 1.2-4.2) per 1,000 catheter-days. Colonization was higher at the internal jugular (HR 3.64; 95% CI 1.32-10.00; p=0.01) and femoral (HR 5.15; 95% CI 1.82-14.51; p=0.004) sites than at the subclavian site. The femoral site carried a greater risk of being colonized by non-S. epidermidis species than the subclavian and internal jugular sites combined (HR 4.15; 95% CI 1.79-9.61; p=0.001). CVCs inserted in the Department of Emergency Medicine were more colonized than those inserted in the ICU or operating room (HR 2.66; 95% CI 1.27-5.56; p=0.01), and CVCs were less colonized in females than in males (HR 0.49; 95% CI 0.26-0.89; p=0.02). No difference in CR-BSI rates was noted between the three sites. Colonization was lowest at the subclavian site. Regional differences exist with respect to type of pathogen isolated. Colonization was influenced by insertion location and gender. The incidence of CR-BSI was not different.

Background and Aims The use of central venous catheters as hemodialysis (HD) vascular access is a leading contributor to a high rate of bloodstream infection. Our dialysis unit in China has followed the China National Infection Control Policy for HD unit as well as developed its own specific dialysis catheter care protocol using the Centre for Disease Control and Prevention (CDC) guidelines as a template. By doing so, our HD unit has achieved a tunneled dialysis catheter (TDC)- related bloodstream infection rate of 0.0229 per 1000 catheter days in the past 5 years. This report, aims to share our experience with the other units. Method We have undertaken a retrospective analysis to determine our catheter-related bloodstream infection (CRBSI) rate. The local Ethics and Research Committee has approved the conduct of the retrospective study. In this study, the definition of a CRBSI is taken from Kidney Disease Outcomes Quality Initiative (KDOQI) Vascular Access-2019 update as 1) clinical manifestations (fever &amp;gt; 37.5°C or rigors or presence of clinical signs of infection); 2) confirmation of bacteremia (blood cultures growing the same organism from the dialysis catheter and a peripheral vein), with either positive semiquantitative (&amp;gt;15CFU/catheter segment), or quantitative (&amp;gt;102 CFU/catheter segment), differential period of catheter culture versus peripheral blood culture (BC) positivity of 2 hours; 3) exclusion of another source of infection. Information including patient demographics, causes of kidney failure, and duration of TDC was obtained. Results The Covidien Palindrome chronic catheters have been used in the majority of our patients during the study period. All tunneled dialysis catheters were placed by the nephrologists under radiological guidance in the Hospital's sterile Digital Subtraction Angiography (DSA) Suite. In the study period (2017-2021), an average of 235 prevalent patients were receiving dialysis in the HD unit. A total of 212 tunneled dialysis catheters have been inserted and managed according to our local dialysis access pathway and catheter care protocol. The TDC days have been calculated by adding all the catheter days until the catheters have been removed or the patients have been transferred out of our HD unit. There was a total of 43,585 catheter days. The average waiting time for arteriovenous fistula (AVF) surgery was two weeks. The mean duration of TDC use was 107.8±14.8 days, range 1-1827 days. The incidence of confirmed tunneled CRBSI was 0.0229/ 1000 catheter days. Conclusion Our local catheter care protocol is similar to the CDC's “scrub-the-hub” protocol. 2% chlorhexidine with 70% alcohol has been used for the scrubbing and disinfection but we have a few additional steps. In our practice, great attention is given to the cleansing of the clamps. 1) Prior to removal of the caps, the clamps are opened and the surroundings are cleaned and disinfected thoroughly. 2) Two nurses are assigned to connect the bloodlines to the hubs, hence the risk of hub contamination is reduced. 3) The point of connection between the hubs and the bloodlines is protected with a gauze dressing in 3 layers during the entire duration of the dialysis. We believe our success with a very low rate of CRBSI has been the result of strict adherence to 1) good and general hygiene, 2) a well-designed dialysis catheter care protocol, 3) good use of a vascular access nurse, 4) short-duration of TDC days, and 5) short waiting time for AVF. Limitations: We may have underestimated the true rate of CRBSI because of the inherent nature of the diagnostic criteria as mentioned above. Although it is unlikely that a blood culture would have been missed before intravenous antibiotics under our hospital's stringent antibiotics stewardship and continuous audit, it is still possible in theory. Finally, a small number of patients has been transferred out to other HD units due to their change of residence, hence the follow up data might be incomplete. However, such patients are very few in number and the long follow up of this study strengthens our findings and conclusion.

Objective To evaluate the role of evidence-based clinical care programs in reducing the catheter related bloodstream infection (CRBSI) rate. Methods Patients implanted with central venous catheter (CVC) were divided into two groups: the general care group (group GC) and the intensive care group (groupIC). Based on the catheter time, each group was divided into two subgroups: short-term group (catheter time was less than 28 days) and long-term group (catheter time was more than 28 days). Based on the guideline from Chinese Medical Association (CMA) and European Society for Parenteral and Enteral Nutrition (ESPEN),we revised the clinical CVC care programs following the standardization of sterilization and aseptic care and applied them to patients from group IC. Patients from group GC were cared according to current CVC nursing routines. The status of CRBSI in each group was compared. Results In group GC, the CRBSI rate in long-term catheter implanted patients increased slightly by 10.40% than that in short-term catheter implanted patients (6.37 vs. 5.77/1 000 catheter days). However, In group IC, the long-term catheter implanted patients experienced a remarkable increase in CRBSI rate with the extent of 108.87% than the short-term catheter implanted patients (5.18 vs. 2.48/1 000 catheter days). Compared with that of the fellows in group GC, the CRBSI rate of short-term catheter implanted patients from group IC declined significantly with the degree of 57.02% (5.77 vs. 2.48/1 000 catheter days). Whereas the CRBSI rate of long-term catheter implanted patients from group IC declined about 18.68% than that of the fellows in group GC (6. 37 vs. 5.18/1 000 catheter days). The difference between two groups had statistical significance (P ＜0. 01). Conclusions The evidence-based clinical CVC care programs following the standardization of sterilization and aseptic care could reduce the CRBSI rate in patients whose catheter day were less than 28 days, but not in patients whose catheter day were more than 28 days. Key words: Central venous catheter; Catheter related bloodstream infection; Prevention; Nursing

BackgroundIn hemodialysis (HD) patients, central venous catheter (CVC) related bloodstream infections are a major cause of morbidity and mortality. Hygienic precautions are a key aspect of dialysis care for infection prevention, but they are not sufficient to completely avoid the occurrence of CVC related infections. During the COVID-19 pandemic, hygienic precautions for preventing viral transmission have been markedly reinforced. We evaluated their effects on CVC-related infection rates.MethodsAn observational retrospective study was conducted in two hemodialysis units of the same institution treating 215 chronic hemodialysis patients, 71 of whom are currently (33%) using a CVC. In the CVC cohort, we compared data on catheter-related infection rates during the maximum spread of the COVID-19 pandemic in Italy (February to May 2020) with data from the same period of the previous year and with the whole of 2019.ResultsIn 2019, we recorded a catheter-related bloodstream infection (CRBSI) rate of 1.19 (95% CI 0.81–1.68)/1000 days [2.07 (95% CI 1.12–3.52)/1000 days in the Feb-May 2019 period] and a tunnel and exit-site infection rate of 0.82 (95% CI 0.51–1.24)/1000 days [1.04 (95% CI 0.41–2.15)/1000 days in the Feb–May 2019 period]. Infection rates drastically decreased during the COVID-19 pandemic, with just one catheter-related bloodstream infection being recorded. Catheter-related bloodstream infection rates showed a significant reduction to 0.20 (95% CI 0.01–0.9)/1000 days (p < 0.05 and p < 0.005 compared to 2019 and to Feb-May 2019, respectively) and a non-significant reduction in tunnel and exit-site infections to 0.6 (95% CI 0.15–1.6)/1000 days.ConclusionsThe observed 91% reduction in catheter-related bloodstream infections compared to the same period in 2019 [IRR 0.09 (95% CI 0.002–0.64)] and the 83% reduction compared to the whole of 2019 [IRR 0.17 (95% CI 0.004–1.009)] suggest that a stricter implementation of hygienic precautions in the dialysis setting can markedly improve the problem of CVC-related infections.Graphic abstract

This study compares the outcomes of tunneled catheters (TCs) and non-tunneled catheters (NTCs) in incident hemodialysis patients undergoing early arteriovenous fistula (AVF) creation. Adult incident ESKD patients were randomized in two catheter groups (TC and NTC) for hemodialysis initiation and were followed for 12 weeks from March 2021 in a 3-year study period. Catheter salvage was attempted in both the groups until AVF maturation in cases of catheter-related bloodstream infection (CRBSI) or mechanical dysfunction. Catheter insertion and removal dates, infection episodes, and mechanical dysfunction events were recorded. CRBSI rates, dysfunction rates, and catheter survival were compared. A total of 133 patients were randomized into TC (65) and NTC (68) groups. Seventy-six patients developed symptoms of CRBSI, of whom eight patients required catheter removal (TC: 2, NTC: 6). CRBSI episodes per 1000 catheter days were 15.14 for TCs and 16.85 for NTCs, but mechanical dysfunction rates were 0.96 and 1.68, respectively. By 6 weeks, one catheter was removed in the TC group (AVF maturation), and eight in the NTC group were removed (four due to AVF maturation, three due to CRBSI, and one due to mechanical dysfunction). Kaplan-Meier analysis showed significantly longer catheter survival for TCs compared to NTCs (66.9 vs. 57.9 days, p = 0.001). CRBSI rates and catheter patency were comparable between TCs and NTCs at 6 weeks, but TCs demonstrated better survival beyond this period. When early AVF creation is ensured, NTCs may serve as a viable short-term vascular access option, particularly in resource-limited settings.

To study the impact of a teaching intervention on the rate of central venous catheter-related bloodstream infections (CRBSI) in intensive care patients. Prospective before/after interventional cohort study on medical and surgical intensive care units. University hospital with five adult intensive care units. All patients with a central venous catheter on the five ICUs from September to December 2003 (baseline period) and from March to July 2004 (intervention period). Educational program with teaching of hand hygiene, standards of catheter care, and preparation of intravenous drugs. The primary outcome variable was the rate of CRBSIs per 1000 catheter days during a baseline period of 4 months and an intervention period of 5 months. The secondary outcome variable was compliance with hand hygiene. Of the patients, 499 patients with 6200 catheter days in the baseline period and 500 patients with 7279 catheter days were monitored in the intervention period. The incidence density of CRBSI decreased from 3.9 per 1000 catheter days in the preintervention phase to 1.0 per 1000 catheter days in the intervention phase (p < 0.001). The risk for CRBSI was significantly higher in the baseline period in both univariate and multivariate analysis. Other independent risk factors were hospitalization in the medical ICU and male gender. Time to CRBSI was significantly longer in the intervention period (median 9 days vs. 6.5 days, respectively; p = 0.02). Compliance with hand hygiene improved slightly from 59% in the baseline period to 65% in the intervention period, but the rate of correct performance of the practice increased from 22.5% to 42.6% (p = 0.003). Evidence-based catheter-care procedures, guided by healthcare workers' perceptions and including bedside teaching, reduce significantly the CRBSI rate and demonstrate that improving catheter care has a major impact on its prevention.