Access-related Bloodstream Infections Research Articles

Hemodialysis-Related Infections: A 4-Year Surveillance

Objective: To analyze the results from the surveillance of hemodialysis-related infections.Material and Methods: Data was prospectively gathered from outpatients attending a hemodialysis unit from April 2019 until March 2023. The National Healthcare Safety Network (NHSN) Dialysis Event Surveillance was used to identify three types of infection-related dialysis events. Event rates were calculated and stratified by vascular access type, standardized infection ratios for bloodstream infections (BSI), intravenous antimicrobial starts, and described pathogens identified among BSI.Results: A total of 2,288 patient-month follow-ups were included. There were 79 infection-related dialysis events (24 BSI; 46 intravenous antimicrobial starts, nine pus, redness, or increased swelling at the vascular access site). The incidence of BSI per 100 patient-months was 1.05 (0.59 arteriovenous fistula, 0.83 arteriovenous graft, and 2.22 central venous catheter). Seventeen BSI were vascular access-related. Access-related BSI per 100 patient-months was 0.74 (0.39 arteriovenous fistula, 0.41 arteriovenous graft, and 1.85 central venous catheter). Intravenous antimicrobial starts per 100 patient-months was 2.01 (0.98 arteriovenous fistula, 2.62 arteriovenous graft, and 3.14 central venous catheter). Most events occurred in patients with a central venous catheter. When benchmarked with the 2014 NHSN, the standardized infection ratio of BSI, access-related BSI, and intravenous antimicrobial starts were 1.40, 1.26, and 0.55, respectively. The most serious outcome was BSI; resulting in 83.3% hospitalizations, 25% loss of vascular access, and 15.8% deaths. Conclusion: Surveillance of infection-related dialysis events is important for prevention. These events were highest among patients with a central venous catheter compared with other vascular access types.

Multifaceted Quality Improvement Interventions to Prevent Hemodialysis Catheter–Related Bloodstream Infections: A Systematic Review

Central venous catheters (CVCs) are widely used for hemodialysis but are prone to burdensome and costly bloodstream infections. We determined whether multifaceted quality improvement interventions in hemodialysis units can prevent hemodialysis catheter-related bloodstream infections (HDCRBSI). Systematic review. PubMed, EMBASE, and CENTRAL were searched from inception to April 23, 2022, to identify randomized trials, time-series analyses, and before-after studies that examined the effect of multifaceted quality improvement interventions on the incidence of HDCRBSI or access-related bloodstream infections (ARBSI) among people receiving hemodialysis outside of the intensive care unit (ICU). Two people independently extracted data and assessed the risk of bias and quality of evidence using validated tools. Intervention effects, validity, and characteristics of studies with the same design were compared. Differences between study designs were described. We included 21 studies from 8,824 identified by our search. Among 15 studies that measured HDCRBSI, 2 methodologically heterogenous cluster randomized trials reported discordant intervention effects, 2 interrupted time-series analyses reported favorable interventions with discordant patterns of effect, and 11 before-after studies reported favorable interventions with a very high risk of bias. Among 6 studies that only measured ARBSI, 1 time-series analysis and 1 before-after study did not find a favorable intervention effect, and 4 before-after studies reported a favorable effect with a very high risk of bias. The overall quality of evidence was low for HDCRBSI and very low for ARBSI. Nine definitions of HDCRBSI were used. Ten studies included hospital-based and satellite facilities but did not report separate intervention effects for each type of facility. Multifaceted quality improvement interventions may prevent HDCRBSI outside the ICU. However, evidence supporting them is of low quality, and further carefully conducted studies are warranted. Registered at PROSPERO with registration number CRD42021252290. People with kidney failure rely on central venous catheters to facilitate life-sustaining hemodialysis treatments. Unfortunately, hemodialysis catheters are a common source of problematic bloodstream infections. Quality improvement programs have effectively prevented catheter-related infections in intensive care units, but it is unclear whether they can be adapted to patients using hemodialysis catheters in the community. In a systematic review that included 21 studies, we found that most quality improvement programs were reported to be successful. However, the findings were mixed among higher-quality studies, and overall the quality of evidence was low. Ongoing quality improvement programs should be complemented by more high-quality research.

Evaluating a Novel Hemodialysis Central Venous Catheter Cap in Reducing Bloodstream Infections: A Quality Improvement Initiative.

PurposeCentral line-associated bloodstream infection (CLABSI) is the second leading cause of death in hemodialysis patients. Patients dialyzed via central venous catheters (CVCs) are more susceptible to vascular access-related bloodstream infection (VRBSI), sepsis, and mortality when compared to patients with other dialysis accesses.Patients and MethodsA retrospective observational data analysis was conducted from 13 outpatient dialysis clinics in the United States to compare novel chlorhexidine-coated end caps to standard needlefree connectors for differences in CLABSI rates when utilizing CVCs for hemodialysis. There were two periods in this study: in the first study period over a 5-month period (May 2018 to September 2018), data were evaluated from a group of patients undergoing hemodialysis using chlorhexidine end-caps (‘chlorhexidine group’) as well as a group using standard needlefree connectors (‘standard group’). An initial assessment found that a substantial CLABSI rate reduction was seen with use of chlorhexidine-coated end caps; therefore, most patients were switched to chlorhexidine by February 2019 and data continued to be collected till June 2019. The second study period spanned 9 months from October 2018 to June 2019.ResultsAcross 13 dialysis centers, anonymized health records of 5934 patients who were dialyzed via CVCs between May 2018 and June 2019 were analyzed. The mean age was 61.3 and 47.1% of all patients were female. Study period one included 967 patients with chlorhexidine and 1044 patients with standard end caps, while there were 3647 chlorhexidine and 276 standard patients in the second period. The combined CLABSI rate in the chlorhexidine group was 0.09/1000 CVC days versus 0.63/1000 CVC days in the standard group (p<0.0001).ConclusionChlorhexidine-coated CVC caps may provide a therapeutic improvement in CVC hemodialysis management.

Prevalence and risk factors for vascular access infection among chronic hemodialysis patients in Al-Gharbia Governerate, Egypt

Background Chronic hemodialysis patients are at considerably high risk for vascular access-related blood stream infections that may be associated with serious complications. Infections are more frequent with central venous catheters and polytetrafluoroethylene grafts than with arteriovenous fistula. Aim We aim to evaluate the prevalence of vascular access infection among hemodialysis patients, risk factors, common causative microorganisms and their antibiotics sensitivity. Patients and method This cross-sectional study included 720 end-stage renal disease patients on hemodialysis recruited from six hemodialysis centers in Al-Gharbia Governorate from June 2019 to June 2020. Results The prevalence of vascular access infection was 27.77%. Sex, old age, and diabetes mellitus had a significant statistical association. Temporary catheters recorded the highest infection rate. Gram-positive bacteria were the most common organisms in 57.5% of cases, Gram negative in 39.5% while candida albicans in only 3% of the cases. The antibiotic sensitivity was higher to amikacin and imipenem. Conclusion Creation of native arteriovenous fistula is highly recommended to avoid catheter-related blood stream infections and their complications. Strict adherence to antiseptic measures and use of a rational antibiotic policy for the early diagnosis and better management of hemodialysis vascular access site infection is important.

Progress in Preventing Bloodstream Infections in Hemodialysis: Data From the National Healthcare Safety Network, 2014–2018

Background: More than 450,000 patients receive outpatient hemodialysis in the United States. Patients on hemodialysis are at high risk of bloodstream infections (BSIs), which are associated with significant morbidity and mortality. National prevention efforts targeting hemodialysis facilities have resulted in widespread changes in practice, including modifications to central venous catheter (CVC) maintenance procedures. We analyzed dialysis event surveillance data submitted to the CDC NHSN to describe changes in BSI rates among hemodialysis outpatients from 2014 to 2018. Methods: Outpatient hemodialysis facilities report BSIs (ie, positive blood cultures collected in the outpatient setting or within 1 calendar day after hospital admission) and the number of hemodialysis outpatients treated during the first 2 working days of each month to the NHSN. For each BSI, the suspected source (ie, vascular access, another site, contamination, or uncertain) and vascular access type are indicated: CVC, arteriovenous fistula (AVF) or arteriovenous graft (AVG). Pooled mean rates (per 100 patient months) were calculated for BSIs, access-related BSIs (ARBSIs), and BSIs and ARBSIs were stratified by vascular access type. Annual BSI rate trends were evaluated using a negative binomial regression model, which treated patient months as an offset variable and included access type, year, and an access-year interaction variable. Results: More than 6,000 outpatient hemodialysis facilities reported 134,961 BSIs from 2014 to 2018. Of these BSIs, 102,505 (76%) were categorized as access related. CVCs were present in 63% of BSIs and 70% of ARBSIs. Pooled mean BSI rates decreased 27% from 0.64 to 0.47 per 100 patient months; rates of ARBSIs decreased 27% from 0.49 to 0.36 per 100 patient months. Significant decreases in event rates occurred across vascular access strata (Fig. 1). The reduction in BSI and ARBSI burden was most pronounced among patients with CVCs. BSI rates in patients with CVCs decreased 32% from 2.16 per 100 patient months to 1.46 (annual average decrease, 9.5%), and ARBSI rates in patients with CVCs decreased 32% from 1.83 per 100 patient months to 1.24 (annual average decrease, 9.4%). Conclusions: Substantial reductions in BSI and ARBSI rates among hemodialysis outpatients occurred during this 5-year period, and these reductions appear to be most prominent among CVC and AVF patients. Improvements in infection prevention and control practices, including CVC care, have likely contributed to these reductions. Additional efforts to increase the uptake of known prevention practices and to identify new strategies for prevention might contribute to continued decreases in infections among this highly vulnerable population.Funding: NoneDisclosures: None

Risk of Vascular Access Infection Associated With Buttonhole Cannulation of Fistulas: Data From the National Healthcare Safety Network

Compared with conventional (rope-ladder cannulation [RLC]) methods, use of buttonhole cannulation (BHC) to access arteriovenous fistulas (AVFs) may be associated with increased risk for bloodstream infection and other vascular access-related infection. We used national surveillance data to evaluate the infection burden and risk among in-center hemodialysis patients with AVFs using BHC. Descriptive analysis of infections and related events and retrospective observational cohort study using National Healthcare Safety Network (NHSN) surveillance data. US patients receiving hemodialysis treated in outpatient dialysis centers. AVF cannulation methods, dialysis facility characteristics, and infection control practices. Access-related bloodstream infection; local access-site infection; intravenous (IV) antimicrobial start. Description of frequency and rate of infections; adjusted relative risk (aRR) for infection with BHC versus RLC estimated using Poisson regression. During 2013 to 2014, there were 2,466 access-related bloodstream infections, 3,169 local access-site infections, and 13,726 IV antimicrobial starts among patients accessed using BHC. Staphylococcus aureus was the most common pathogen, present in half (52%) of the BHC access-related bloodstream infections. Hospitalization was frequent among BHC access-related bloodstream infections (37%). In 2014, 9% (n=271,980) of all AVF patient-months reported to NHSN were associated with BHC. After adjusting for facility characteristics and practices, BHC was associated with significantly higher risk for access-related bloodstream infection (aRR, 2.6; 95% CI, 2.4-2.8) and local access-site infection (aRR, 1.5; 95% CI, 1.4-1.6) than RLC, but was not associated with increased risk for IV antimicrobial start. Data for facility practices were self-reported and not patient specific. BHC was associated with higher risk for vascular access-related infection than RLC among in-center hemodialysis patients. Decisions regarding the use of BHC in dialysis centers should take into account the higher risk for infection. Studies are needed to evaluate infection control measures that may reduce infections related to BHC.

An Environmental Scan of Canadian Quality Metrics for Patients on In-Center Hemodialysis.

Background:Quality metrics or indicators help guide quality improvement work by reporting on measurable aspects of health care upon which improvement efforts can focus. For recipients of in-center hemodialysis (ICHD) in Canada, it is unclear what ICHD quality indicators exist and whether they adequately cover different domains of health care quality.Objectives:To identify and evaluate current Canadian ICHD quality metrics to document a starting point for future collaborations and standardization of quality improvement in Canada.Design:Environmental scan of quality metrics in ICHD, and subsequent indicator evaluation using a modified Delphi approach.Setting:Canadian ICHD units.Participants:Sixteen-member pan-Canadian working group with expertise in ICHD and quality improvement.Measurements:We classified the existing indicators based on the Institute of Medicine (IOM) and Donabedian frameworks.Methods:Each metric was rated by a 5-person subcommittee using a modified Delphi approach based on the American College of Physicians/Agency for Healthcare Research and Quality criteria. We shared these consensus ratings with the entire 16-member panel for additional comments.Results:We identified 27 metrics that are tracked across 8 provinces, with only 9 (33%) tracked by multiple provinces (ie, more than 1 province). We rated 9 metrics (33%) as “necessary” to distinguish high-quality from low-quality care, of which only 2 were tracked by multiple provinces (proportion of patients by primary access and rate of vascular access-related bloodstream infections). Most (16/27, 59%) indicators assessed the IOM domains of safe or effective care, and none of the “necessary” indicators measured the IOM domains of timely, patient-centered, or equitable care.Limitations:The environmental scan is a nonexhaustive list of quality indicators in Canada. The panel also lacked representation from patients, administrators, and allied health professionals, with more representation from academic sites.Conclusions:Quality indicators in Canada mainly focus on safe and effective care, with little provincial overlap. These results highlight current gaps in quality of care measurement for ICHD, and this initial work should provide programs with a starting point to combine highly rated indicators with newly developed indicators into a concise balanced scorecard that supports quality improvement initiatives across all aspects of ICHD care.Trial Registration:not applicable.

Determinants and outcomes of access-related blood-stream infections among Irish haemodialysis patients; a cohort study

BackgroundInfections are the second leading cause of death and hospitalisation among haemodialysis (HD) patients. Rates of access-related bloodstream infections (AR-BSI) are influenced by patient characteristics and local protocols. We explored factors associated with AR-BSI in a contemporary cohort of HD patients at a tertiary nephrology centre.MethodsA retrospective cohort of 235 chronic HD patients was identified from a regional dialysis programme between Jan 2015 and Dec 2016. Data on demographics, primary renal disease, comorbid conditions and dialysis access type were obtained from the Kidney Disease Clinical Patient Management System (KDCPMS). Data on blood cultures were captured from the microbiology laboratory. Poisson regression with robust variance estimates was used to compare infection rates and relative risk of AR-BSI according to the site and type of vascular access.ResultsThe mean age was 65 (± 15) years, 77% were men, and the median follow up was 19 months (IQR: 10–24 months), accumulating 2030 catheter-months and 1831 fistula-months. Overall rates of AR-BSI were significantly higher for central venous catheter (CVC) compared to arteriovenous fistula (AVF), (2.22, 95% (CI): 1.62–2.97) versus 0.11 (0.01–0.39) per 100 patient-months respectively), with a rate ratio of 20.29 (4.92–83.66), p < 0.0001. This pattern persisted across age, gender and diabetes subgroups. Within the CVC subgroup, presence of a femoral CVC access was associated with significantly higher rates of AR-BSI (adjusted RR 4.93, 95% CI: 2.69–9.01). Older age (75+ versus < 75 years) was not associated with significant differences in rates of AR-BSI in the unadjusted or the adjusted analysis. Coagulase negative Staphylococcus (61%) and Staphylococcus aureus (23%) were the predominant culprits. AR-BSIs resulted in access loss and hospitalisation in 57 and 72% of events respectively, and two patients died with concurrent AR-BSI.ConclusionsRates of AR-BSI are substantially higher in CVC than AVF in contemporary HD despite advances in catheter design and anti-infective protocols. This pattern was consistent in all subgroups. The policy of AVF preference over CVC should continue to minimise patient morbidity while at the same time improving anti-infective strategies through better care protocols and infection surveillance.

Current Concepts in Hemodialysis Vascular Access Infections.

Infection-related causes are second only to cardiovascular events for mortality among end-stage renal disease patients. This review will provide an overview of hemodialysis catheter-, graft-, and fistula-related infections with emphasis on diagnosis and management in specific settings. Use of catheters at the initiation of dialysis has remained unchanged at 80%. Of all access-related bloodstream infections (BSIs), 70% occur in patients with catheters. The risk factors for BSIs in tunneled, cuffed catheters include the duration of the catheter, past catheter-related bacteremia, left-sided internal jugular vein catheters, hypoalbuminemia, and immunosuppression. Surprisingly, human immunodeficiency virus infection has not been associated with a higher risk of catheter-related bacteremia. Catheter-related bloodstream infection is a clinical definition that requires specific laboratory testing to identify the catheter as the source of the BSI. A central line-associated bloodstream infection is a primary BSI in a patient who had a catheter within the 48-h period before the development of the BSI with no other identifiable source. Guidewire exchange of catheter is a viable alternative in select patients to aid in preserving venous access sites. Catheter lock therapy can decrease infectious complications and mortality. Arteriovenous graft infections are prevalent with significant morbidity. Studies evaluating the impact of stent use in infection risks of the arteriovenous graft are sorely needed.

Surveillance of Dialysis Events: one-year experience at 33 outpatient hemodialysis centers in China

A multicenter prospective surveillance on dialysis events was carried in 33 dialysis centers in China. Maintenance hemodialysis (HD) outpatients who were dialyzed on the first two days of each month during 2014 were monitored for dialysis events and other infections. During the one-year period, 52,680 patient-months were monitored. Fistula and tunneled or non-tunneled central line were used for 73.70%, 15.70% and 8.85% of vascular access, respectively. There were 773 dialysis events occurred in 671 patients including 589 IV antimicrobial starts, 74 positive blood cultures and 110 local access site infections (LASI). The incidence of dialysis events was 1.47 per 100 patient-months. Among the 74 cases with bloodstream infection (BSI), 38 were access-related BSI (ARB) and there were therefore 148 cases with vascular-related infection (VAI; 38 ARB and 110 LASI). There were 740 cases (1.40 per 100 patient-months) with infections other than BSI and LASI, most (79.19%) of which were respiratory tract infections. For those with dialysis events, there were 425 cases (425/671, 63.34%) admitted to hospital and 12 cases of death (12/671, 1.79%). In conclusion, the surveillance revealed a relatively low incidence of dialysis events and the surveillance may be tailored to target those using central lines in resource-limited settings.

Sustained Infection Reduction in Outpatient Hemodialysis Centers Participating in a Collaborative Bloodstream Infection Prevention Effort.

Among dialysis facilities participating in a bloodstream infection (BSI) prevention collaborative, access-related BSI incidence rate improvements observed immediately following implementation of a bundle of BSI prevention interventions were sustained for up to 4 years. Overall, BSI incidence remained unchanged from baseline in the current analysis. Infect Control Hosp Epidemiol 2016;37:863-866.

High Risk of Prosthetic Valve Endocarditis and Death After Valve Replacement Operations in Dialysis Patients

Despite a high burden of dialysis access-related bloodstream infections and an increasing incidence of endocarditis, few data are available addressing the risk of prosthetic valve endocarditis (PVE) in the dialysis population. We sought to assess the risk of PVE and death after valve replacement operations in patients receiving long-term dialysis. A matched retrospective cohort study was conducted comprising patients admitted for valve replacement operations at two university hospitals. Patients without dialysis were matched 1:1 with dialysis patients by valve(s) replaced, year of operation, and presence of active endocarditis as the indication for valve replacement. Patient characteristics were compared using χ(2) and t tests. The development of PVE was defined by use of the modified Duke criteria and analyzed with Cox proportional hazards regression. Two hundred seventy-eight patients were included, with 139 in either cohort. The PVE risk per year of follow-up was 0.14 in the dialysis cohort and 0.03 in the nondialysis cohort. Dialysis remained a risk factor (adjusted hazard ratio 5.61 [95% confidence interval, 2.17 to 14.5], p= 0.0004) after age and race were controlled for. The 5-year survival rate was lower after valve replacement operation in the dialysis group (25.4%) than in the nondialysis group (75.9%, p < 0.001). The risk of PVE and death after valve replacement operations in dialysis patients is substantial and significantly higher than in patients without dialysis. These findings highlight the importance of a careful preoperative risk-benefit assessment and underscore the need to prevent hemodialysis-related bloodstream infections.

Reducing healthcare-associated infections in an ambulatory dialysis unit: Identification and alignment of work system factors

Patients undergoing hemodialysis have experienced a 43% increase in rate of hospitalization due to infection during the past 20 years. Research in other industries has shown that safe systems are achieved by considering the entire system to enable performance specifications to be met. A sociotechnical systems framework was applied through the Macroergonomic Analysis and Design method to evaluate a 54-chair ambulatory dialysis unit to decrease healthcare-associated infections. Fifty-seven system discrepancies across 6 healthcare-associated infection risk factors were identified. A multicomponent intervention was developed to address 44 of the variances across 4 of the risk factors. Access-related bloodstream infections and access site infections did not improve. Bacterial surface contamination decreased. Process measures for the individual components of the intervention demonstrated varying adherence to the intervention. Inconsistent compliance with interventions is hypothesized to be due to organizational and external environment factors.

Pediatric Fistula Initiative: Reducing Bloodstream Infections in an Outpatient Pediatric Hemodialysis Center.

Bloodstream infection is a major contributor to morbidity and mortality in children on hemodialysis (HD). From January 2009 through April 2011, the incidence of access-related bloodstream infections (ARBs) in pediatric patients on HD at our hospital was 3.45/1000 patient days. Almost all of these children were receiving HD via central line catheters, and none were receiving HD via arteriovenous fistulas (AVFs). In an effort to reduce the rate of infection in children receiving HD at our institution, we introduced the Pediatric Fistula Initiative, a program to increase creation and use of AVFs in children. Thirty-three children on HD were observed, 9 of whom received AVFs during the study period. The incidence of ARBs decreased to 1.30/1000 patient days (P < .001) during the 24-month intervention period from May 2011 through May 2013.

Bloodstream Infection Rates in Outpatient Hemodialysis Facilities Participating in a Collaborative Prevention Effort: A Quality Improvement Report

Bloodstream infections (BSIs) cause substantial morbidity in hemodialysis patients. In 2009, the US Centers for Disease Control and Prevention (CDC) sponsored a collaborative project to prevent BSIs in outpatient hemodialysis facilities. We sought to assess the impact of a set of interventions on BSI and access-related BSI rates in participating facilities using data reported to the CDC's National Healthcare Safety Network (NHSN). Quality improvement project. Patients in 17 outpatient hemodialysis facilities that volunteered to participate. Facilities reported monthly event and denominator data to NHSN, received guidance from the CDC, and implemented an evidence-based intervention package that included chlorhexidine use for catheter exit-site care, staff training and competency assessments focused on catheter care and aseptic technique, hand hygiene and vascular access care audits, and feedback of infection and adherence rates to staff. Crude and modeled BSI and access-related BSI rates. Up to 12 months of preintervention (January 2009 through December 2009) and 15 months of intervention period (January 2010 through March 2011) data from participating centers were analyzed. Segmented regression analysis was used to assess changes in BSI and access-related BSI rates during the preintervention and intervention periods. Most (65%) participating facilities were hospital based. Pooled mean BSI and access-related BSI rates were 1.09 and 0.73 events per 100 patient-months during the preintervention period and 0.89 and 0.42 events per 100 patient-months during the intervention period, respectively. Modeled rates decreased 32% (P = 0.01) for BSIs and 54% (P < 0.001) for access-related BSIs at the start of the intervention period. Participating facilities were not representative of all outpatient hemodialysis centers nationally. There was no control arm to this quality improvement project. Facilities participating in a collaborative successfully decreased their BSI and access-related BSI rates. The decreased rates appeared to be maintained in the intervention period. These findings suggest that improved implementation of recommended practices can reduce BSIs in hemodialysis centers.

Embracing collaboration: A novel strategy for reducing bloodstream infections in outpatient hemodialysis centers

The incidence of access-related bloodstream infections (AR-BSIs) in US outpatient hemodialysis centers is unacceptably high. This paper presents the implementation and results achieved from a multi-pronged strategy to reduce AR-BSIs in 1 outpatient hemodialysis center. The intervention, which took place between 2009 and 2011, involved membership in the Centers for Disease Control and Prevention Hemodialysis Bloodstream Infection Prevention Collaborative, implementation of a panel of infection prevention interventions, and use of positive deviance (PD) to engage staff. Changes in the incidence of AR-BSIs and infection prevention process measures between the pre- and postintervention time periods, as well as alterations in the center's social networks, were examined to assess impact. The incidence of all AR-BSIs dropped from 2.04 per 100 patient-months preintervention to 0.75 (P = .03) after employing the Collaborative interventions and to 0.24 (P < .01) after augmenting the Collaborative interventions with PD. Adherence rates increased significantly in 4 of 5 infection prevention process measure categories. The dialysis center's social networks became more inclusive and connected after implementation of PD. Participating in a Collaborative, employing a panel of infection prevention strategies, and engaging employees through PD resulted in a significant decline in AR-BSIs in this facility. Other hemodialysis facilities should consider a similar approach.

Vascular Access-Related Bloodstream Infections in First Nations, Community and Teaching Canadian Dialysis Units, and Other Centre-Level Predictors

Background/Aims: Vascular access-related bloodstream infection (BSI) is frequent among patients undergoing hemodialysis increasing their morbidity and mortality, but its occurrence across various dialysis centre types is not known. The aims of this study were to describe the incidence rates and assess the variability in BSI risk between dialysis centre types and other centre-level variables. Methods: We conducted a retrospective cohort study of 621 patients initiating hemodialysis in 7 Canadian dialysis centres. Cox regression models, where access type was continuously updated, were used to identify predictors of BSI occurrence. Results: During follow-up of the cohort (median age 68.1 years, 41.7% female, and 76.7% initiating with a central venous catheter, CVC), 73 patients had a BSI (rate: 0.21/1000 person-days). The BSI risk was not different in First Nation units (adjusted relative risk: 0.47, 95% confidence interval: 0.06–3.72) and teaching hospitals (1.33, 0.70–2.54) compared to community hospitals. No other centre-related variables were associated with the risk of BSI. Conclusion: We did not find differences in the BSI risk among dialysis unit types, or any other centre-related variables. The rates of BSI in our population were lower than those observed in other settings, but the high proportion of patients using CVCs is concerning.

Arteriovenous Fistulae as an Alternative to Central Venous Catheters for Delivery of Long-Term Home Parenteral Nutrition

The success of home parenteral nutrition (HPN) programs is compromised by complications of central venous catheters (CVCs), such as occlusions and bloodstream infections. We performed a retrospective analysis of complication rates of arteriovenous fistulae versus CVCs in patients on long-term HPN. Data were collected from 127 consecutive patients who received HPN between January 2000 and October 2006, comprising 344 access years of CVCs and 194 access years of arteriovenous fistulae. We evaluated access-related bloodstream infection and occlusion incidence rates (number of complications per access year) using Poisson-normal regression analysis. Complication incidence rate ratios were calculated by dividing complication incidence rates of CVCs by those of arteriovenous fistulae, adjusting for HPN frequency, medication use, infusion fluid composition, and underlying diseases. Bloodstream infection incidence rates were 0.03/year for arteriovenous fistulae, 1.37/year for long-term CVCs (Port-a-Caths and tunneled catheters), and 3.12/year for short-term CVCs (nontunneled catheters). Occlusion incidence rates were 0.60/year for arteriovenous fistulae, 0.35/year for long-term CVCs, and 0.93/year for shortterm CVCs. Adjusted incidence rate ratios of long-term CVCs over arteriovenous fistulae were 47 (95% confidence interval, 19-117) for bloodstream infections and 0.53 (95% confidence interval, 0.31-0.89) for occlusions. The occlusion incidence rate was higher for arteriovenous fistulae than for certain types of CVCs. The incidence rate of the most serious access-related complication (bloodstream infections) was much lower for arteriovenous fistulae than for all types of CVCs. Thus, arteriovenous fistulae are safe and valuable alternatives to CVCs for patients requiring long-term HPN.