Access Site Infection Research Articles

Use of suture‐mediated vascular closure devices for the management of femoral vein access after transcatheter procedures

Groin complications remain the most common complication of cardiac catheterization procedures. While the use of closure devices is increasing for arterial sheaths, venous sheaths tend to be removed and hemostasis achieved with manual compression. We report our experience using Perclose suture-mediated vascular closure device to achieve hemostasis and early mobility in patients who have had venous access as part of their procedure. There were a total of 42 patients (21 males; average age, 63.5 years) studied. The majority of the patients had 7 Fr sheaths (24), with access sites of sheaths up to 14 Fr being closed with this technique. Two patients developed complications at the access site: one patient requiring rehospitalization for intravenous antibiotics because of late access site infection, and one patient with deep venous thrombosis and pulmonary emboli. We conclude that the use of the Perclose suture-mediated closure device for closure of femoral venous access sites is feasible and should be considered especially in patients with larger venous sheaths and those at increased risk of groin complications.

Vascular complications associated with arteriotomy closure devices in patients undergoing percutaneous coronary procedures: A meta-analysis

ObjectivesThis study was designed to assess the safety of arteriotomy closure devices (ACDs) versus mechanical compression by meta-analysis in patients undergoing percutaneous transfemoral coronary procedures. BackgroundAlthough ACDs are widely applied for hemostasis after percutaneous endovascular procedures, their safety is controversial. MethodsRandomized, case-control, and cohort studies comparing access-related complications using ACDs versus mechanical compression were analyzed. The primary end point was the cumulative incidence of vascular complications, including pseudoaneurysm, arteriovenous fistula, retroperitoneal hematoma, femoral artery thrombosis, surgical vascular repair, access site infection, and blood transfusion. ResultsA total of 30 studies involving 37,066 patients were identified. No difference in complication incidence between Angio-Seal and mechanical compression was revealed in the diagnostic (Dx) setting (odds ratio [OR] 1.08, 95% confidence interval [CI] 0.11 to 10.0) or percutaneous coronary interventions (PCI) (OR 0.86, 95% CI 0.65 to 1.12). Meta-analysis of randomized trials only showed a trend toward less complications using Angio-Seal in a PCI setting (OR 0.46, 95% CI 0.20 to 1.04; p = 0.062). No differences were observed regarding Perclose in either Dx (OR 1.51, 95% CI 0.24 to 9.47) or PCI (OR 1.21, 95% CI 0.94 to 1.54) setting. An increased risk in complication rates using VasoSeal in the PCI setting (OR 2.25, 95% CI 1.07 to 4.71) was found. The overall analysis favored mechanical compression over ACD (OR 1.34, 95% CI 1.01 to 1.79). ConclusionsIn the setting of Dx angiography, the risk of access-site-related complications was similar for ACD compared with mechanical compression. In the setting of PCI, the rate of complications appeared higher with VasoSeal.

Relationship between oral bacteria and hemodialysis access infection

Controversy exists concerning the association between oral bacteria and infection of hemodialysis (HD) shunts. The purpose of this study was to determine the extent to which oral bacteria are associated with vascular access site infections in a group of HD patients.Microbial blood culture data for 87 HD patients were collected: 53 via chart review (retrospective), and 34 with newly suspected vascular access infections (prospective). The primary outcome was the nature (i.e., species) of the bacteria recovered from blood cultures of subjects with vascular access infection, specifically those bacteria considered to be oral flora.The predominant bacteria reported to cause HD vascular access infections were Staphylococcus (48.6%) and Enterococcus (17.6%) species. Most infections occurred in hemodialysis catheters (89%) compared with AV grafts (11%) and AV fistulas (0%). The subclavian venous access (41%) and the internal jugular venous access (38.9%) were more commonly infected than other sites. None of the bacteria identified by blood cultures were considered to be oral flora.The results suggest that oral bacteria rarely, if ever, cause vascular access infections in hemodialysis patients.

Causes and therapy of microinflammation in renal failure.

Microinflammation in renal failure has been the subject of numerous studies, but the causes of the inflammatory response in these patients are not clear. There are several potential causes and possible therapies for microinflammation, and they are discussed in this review with regard to uraemia and acidosis, heart failure and volume overload, oxidative stress and iron therapy, and bioincompatibility, especially regarding dialysis membranes. In addition, issues regarding dialysate contamination and access site infection are examined, followed by a discussion of possible drug therapy for microinflammation with angiotensin-converting enzyme inhibitors, angiotensin receptor antagonists, statins, aspirin, and antioxidants, such as vitamin E.

Incidence of bloodstream infection in multicenter inception cohorts of hemodialysis patients

Objective To assess incidence of and identify risk factors for bloodstream infection in patients starting hemodialysis or starting a new means of vascular access for hemodialysis. Method Two cohorts of patients, 1 initiating hemodialysis (new patients) and a 1:1 matching group of patients continuing hemodialysis but starting a new vascular access (continuing patients), were enrolled from 9 Canadian hemodialysis units and followed for 6 months. Bloodstream infection was defined using established criteria. A nested case-control study was carried out, using as cases those cohort patients diagnosed with infection. Each case was matched with a control having the same means of access and new or continuing status. Results A total of 527 patients (258 new, 269 continuing), were recruited and underwent 31,268 hemodialysis procedures during this 6-month follow-up. There were 96 bloodstream infections in 93 patients (11.97/10,000 days, 28.81/10,000 hemodialysis procedures), yielding a relative risk of infection of 3.33 (95% CI, 2.12-5.24) for patients with a previous bloodstream infection and 1.56 (95% CI, 1.02-2.38) for patients continuing hemodialysis by a new means of access. Survival analysis revealed that compared to arteriovenous fistula vascular access, the relative risk of bloodstream infection in patients was 1.47 (95% CI, 0.36-5.96) for arteriovenous grafts, 8.49 (95% CI, 3.03-23.78) for cuffed central venous catheters, and 9.87 (95% CI, 3.46-28.20) for uncuffed central venous catheters. The regression model of the case-control study identified earlier bloodstream infection (OR, 6.58), poor patient hygiene (OR, 3.48), and superficial access-site infection (OR, 4.36) as additional risk factors. Conclusion During the first 6 months there is a high rate of bloodstream infection in patients starting hemodialysis either for the first time or by a new means of vascular access. Previous hemodialysis bloodstream infection and continuing hemodialysis by a new means of vascular access are markers for an increased risk of infection, as is poor patient hygiene. Central venous catheter vascular access, whether cuffed or uncuffed, has a much higher infection risk. In this study, there was no difference in infection rate between cuffed and uncuffed central catheters.

Incidence of bloodstream infection in multicenter inception cohorts of hemodialysis patients

Objective To assess incidence of and identify risk factors for bloodstream infection in patients starting hemodialysis or starting a new means of vascular access for hemodialysis. Method Two cohorts of patients, 1 initiating hemodialysis (new patients) and a 1:1 matching group of patients continuing hemodialysis but starting a new vascular access (continuing patients), were enrolled from 9 Canadian hemodialysis units and followed for 6 months. Bloodstream infection was defined using established criteria. A nested case-control study was carried out, using as cases those cohort patients diagnosed with infection. Each case was matched with a control having the same means of access and new or continuing status. Results A total of 527 patients (258 new, 269 continuing), were recruited and underwent 31,268 hemodialysis procedures during this 6-month follow-up. There were 96 bloodstream infections in 93 patients (11.97/10,000 days, 28.81/10,000 hemodialysis procedures), yielding a relative risk of infection of 3.33 (95% CI, 2.12-5.24) for patients with a previous bloodstream infection and 1.56 (95% CI, 1.02-2.38) for patients continuing hemodialysis by a new means of access. Survival analysis revealed that compared to arteriovenous fistula vascular access, the relative risk of bloodstream infection in patients was 1.47 (95% CI, 0.36-5.96) for arteriovenous grafts, 8.49 (95% CI, 3.03-23.78) for cuffed central venous catheters, and 9.87 (95% CI, 3.46-28.20) for uncuffed central venous catheters. The regression model of the case-control study identified earlier bloodstream infection (OR, 6.58), poor patient hygiene (OR, 3.48), and superficial access-site infection (OR, 4.36) as additional risk factors. Conclusion During the first 6 months there is a high rate of bloodstream infection in patients starting hemodialysis either for the first time or by a new means of vascular access. Previous hemodialysis bloodstream infection and continuing hemodialysis by a new means of vascular access are markers for an increased risk of infection, as is poor patient hygiene. Central venous catheter vascular access, whether cuffed or uncuffed, has a much higher infection risk. In this study, there was no difference in infection rate between cuffed and uncuffed central catheters.

Outbreak of hemodialysis vascular access site infections related to malfunctioning permanent tunneled catheters: making the case for active infection surveillance.

To describe an outbreak of infections with permanent cuffed hemodialysis catheters recognized through ongoing surveillance and related to a specific malfunctioning permanent catheter. The outbreak was suspected from the results of prospective infection surveillance and confirmed by a retrospective cohort study using medical records for patients receiving dialysis between April 1, 1999, and March 31, 2000. Integrated network of six outpatient hemodialysis facilities in southern Idaho and eastern Oregon. Outpatients receiving long-term hemodialysis. During the 18 months prior to the outbreak, the overall infection rate was 4.1 infections per 1,000 dialysis sessions with a catheter rate of 8.9 per 1,000 dialysis sessions. During the 7 months of the outbreak, the overall rate increased to 5.8 per 1,000 dialysis sessions, whereas the catheter rate increased to 18.1 per 1,000 dialysis sessions. Reports of malfunctioning "Brand A" catheters prompted discontinuation of their placement. A manufacturer recall occurred in April 2000. During the 14 months after the outbreak, the overall infection rate decreased to 3.3 per 1,000 dialysis sessions and the catheter rate to 10.8 per 1,000 dialysis sessions. A 12-month retrospective cohort study recognized 96 patients with an identifiable catheter brand and 48 infections. Of these, 27 (56%) occurred in patients with Brand A catheters. The relative risk for infection when compared with other catheter brands was 1.96 (95% confidence interval, 1.32 to 2.92; P < .001). Ongoing infection surveillance in hemodialysis facilities can identify specific device-related outbreaks of infections and promote interventions to reduce infectious complications and promote patient safety. Surveillance for vascular access site infections is recommended as a routine activity in hemodialysis facilities.

Safety of femoral closure devices after percutaneous coronary interventions in the era of glycoprotein IIb/IIIa platelet blockade

We compared in-hospital femoral complications of Angio-Seal, Perclose, and manual compression in consecutive patients who underwent percutaneous coronary interventions in the era of glycoprotein IIb/IIIa platelet inhibition. Femoral closure devices have a similar overall risk profile as manual compression, even in patients treated with glycoprotein IIb/IIIa platelet inhibition, although certain rare complications such as retroperitoneal hemorrhage and severe access-site infection may be more common with the use of these devices.

Use of vascular sealing devices (VasoSeal and Perclose) versus assisted manual compression (Femostop) in transcatheter coronary interventions requiring Abciximab (ReoPro)

Transcatheter coronary interventions requiring abciximab (ReoPro) are associated with vascular access site complications. Several devices have been developed to aid in the closure of the femoral arteriotomy, including collagen plug devices (VasoSeal, AngioSeal), percutaneous suture closure (Perclose), and aids to manual compression (Femostop). In 185 patients who received abciximab plus aspirin and heparin for transcatheter coronary interventions, we compared femoral arteriotomy closure by three different methods: VasoSeal, Perclose, and Femostop. A composite endpoint of late complications defined as an access site-related bleed or hematoma that required blood transfusion or an extended hospital stay, pseudoaneurysm, arteriovenous fistula, arterial or venous thrombosis was compared. VasoSeal was initially successful in 41/52 patients (78.8%). The 11 patients who failed to have adequate hemostasis with VasoSeal required manual compression aided by Femostop, but had no late complications. There was one access site infection and one fatal retroperitoneal hematoma unrelated to the vascular access site (surgically explored). There were no late complications. Perclose was successful in 48/56 patients (85.7%). One Perclose failure required surgical repair for an extensive arteriotomy. The other Perclose failure required manual compression aided by Femostop, but had no late complications. There were no access site infections requiring intravenous antibiotics. There was one retroperitoneal bleed that extended the patient's hospital stay and for which a blood transfusion was required. Femostop was successful in 77/77 patients (100%). There were no infections. Late complications occurred in four patients. These included three episodes of bleeding or hematomas requiring blood transfusion, and one pseudoaneurysm. In patients receiving abciximab in addition to aspirin and heparin, VasoSeal and Perclose are at least as safe as Femostop when used to achieve homeostasis after sheath removal. VasoSeal and Perclose have a significantly lower initial rate of successful hemostasis than Femostop. The numbers of late complications between the VasoSeal, Perclose, and Femostop groups were not significantly different. In those patients in whom VasoSeal or Perclose failed, no late complications occurred. Access site infections were no different between VasoSeal, Perclose, and Femostop.

Risk Factors Associated with Permanent Access-Site Infections in Chronic Hemodialysis Patients

Risk Factors Associated with Permanent Access-Site Infections in Chronic Hemodialysis Patients

Clinical and Immunological Evaluation of Infection in Patients on Hemodialysis

Infection is a major complication associated with increased morbidity and mortality in patients on hemodialysis. We analyzed the incidence and type of infection occurring in 4841 patients on hemodialysis between 1986 and 1993 in our hospital and 11 other hemodialysis centers. Infection was noted in 193 patients (4.98 infections/1000 patients/year). Pneumonia (n=71) and bacteremia (n=24) were the 2 most common infections, followed by tuberculosis (n=14), herpes zoster infections (n=12) and infections at the vascular access site (n=12). The most commonly isolated organism in pneumonia, bacteremia and vascular access site infections wasStaphylococcus aureus. Analysis of the prognosis of patients with pneumonia showed a mortality rate of 50% in patients greater than 60 years old, which was significantly higher than that of younger patients (6.7%,P<0.01), whereas the mortality rate in patients with bacteremia was not different between the 2 age groups (60.0% vs. 57.9%, respectively). We also analyzed changes in immunological function and nutritional status in 16 patients on hemodialysis and 21 healthy control subjects. Although the phagocytic and bactericidal activities of neutrophils and monocytes were not different between the groups, superoxide production, the percentage of natural killer cells and the degree of blastoid transformation with phytohemagglutinin stimulation were significantly lower in hemodialysis patients. Low levels of Niderman's index and serum albumin and transferrin indicated poor nutritional status in these patients. Furthermore, the degree of Niderman's index and serum albumin significantly correlated with impairment of immunological function, such as reduced blastoid transformation and the number of lymphocytes. Our results suggest that analysis of the patterns of infection in patients on hemodialysis should provide better management and that improvement of malnutrition may ameliorate impaired immunity in hemodialysis patients.

Renal transplantation and chronic dialysis in children and adolescents: the 1993 annual report of the North American Pediatric Renal Transplant Cooperative Study.

The 1993 North American Pediatric Renal Transplant Cooperative Study annual report summarizes data voluntarily contributed by 82 participating centers on 3,223 pediatric patients who received 2,819 renal transplants from January 1987 through January 1993 and 999 independent courses of dialysis from January 1992 through January 1993. In addition to updating information regarding trends and outcomes in pediatric renal transplantation presented in previous annual reports, 1st-year registry data are presented regarding current practices and trends in chronic dialysis therapy for children and adolescents in North America. Living donor graft (LDG) survival rate was 90% at 1 year, 85% at 2 years and 75% at 5 years post transplant. Cadaver graft (CG) survival rates were 76%, 71% and 62% at 1, 2 and 5 years post transplant, respectively. Overall mortality post transplantation continues to be low (CG 6.8%, LDG 4%), mortality remains high in young infants. The dialysis cohort was generally younger than the transplantation cohort. In all age groups, peritoneal dialysis was utilized in the majority of pediatric patients and the overall incidence of peritonitis was 1 episode per 8.2 patients months. External percutaneous catheters were utilized as the predominant chronic hemodialysis access in the study, and access site infections ranged from 6.9% at 1 month to 13.5% at 6 months.

Splenic Abscess in Patients on Hemodialysis

We describe two patients on hemodialysis who developed staphylococcal splenic abscesses. Both patients previously had staphylococcal septicemia secondary to infection at the dialysis access site. We postulate that access-site infections may predispose hemodialysis patients to splenic abscess, and that these patients should be investigated for a splenic abscess if they should develop unexplained fever.

Staphylococcal infections in the hemodialysis unit: prevention using infection control principles.

Infections are a leading cause of death in patients on chronic hemodialysis, second only to cardiovascular disease.'-Staphylococcus aureus is the major pathogen and the leading cause of access-site infection, bacteremia, and endocarditis in hemodialysis patients and is responsible for more deaths than any other organism.3-5 In this issue of Infection Control and Hospital Epidemiology (pp 534-541), Kaplowitz et al report that S aureus caused four of five bacteremias and seven of nine access-site infections over

A Prospective Study of Infections in Hemodialysis Patients: Patient Hygiene and Other Risk Factors for Infection

We performed a prospective randomized study on 71 patients on chronic outpatient hemodialysis to determine whether a sterile technique was better than a clean technique for preparation of the skin over the vascular access site prior to cannulation. In addition, we wanted to determine overall and site-specific infection rates, microbial etiologies of infection, and risk factors for infection. The overall infection rate was 4.7 infections per 100 dialysis months; the vascular access-site infection rate was 1.3 infections per 100 dialysis months; and the rate for bacteremia was 0.7 cases per 100 dialysis months. Staphylococcus aureus was the most common pathogen, but infections were equally divided between gram-positive cocci and gram-negative bacilli. Advanced age (P = 0.02), a low Karnofsky activity score (P = 0.05), poor hygiene (P = 0.0004) and number of hospitalizations (P = 0.0002) were risk factors for infections in general while only poor hygiene (P = 0.002) was a risk factor for vascular access-site infection. Sterile preparation of the skin over the vascular access site was no more effective at preventing infection than was clean technique (P = 0.80). Maintenance of good personal hygiene may be one of the most important measures for prevention of infections in hemodialysis patients

Antibiotic releasing polymers

Catheters with two different antibiotic coating systems were evaluated. The first was a simple coating of an antibiotic (dicloxacillin) complexed with a quaternary amine. The second combined the latter with a polyurethane matrix. Both were coated onto polyurethane catheter substrates for testing. The objective of such systems is to deliver prophylactic antibiotic in high concentrations to the vascular access entry site and to the surrounding microenvironment of the insertion tunnel. By using a Kirby-Bauer technique and measuring inhibition zone size, it was found that both coating systems were effective in inhibiting Staphylococcus aureus. However, the half-life of the catheter antibiotic activity for the antibiotic-polymer matrix was 100% longer (24 h vs. 12 h) than the simple antibiotic-complex coated catheters. In vivo subcutaneous mouse model studies confirmed in vitro results of antimicrobial inhibition. These studies suggest that antibiotic releasing vascular access devices can decrease the potential for vascular access site infections.

Candida albicans Infection of an Arteriovenous Graft Used for Hemodialysis

To the Editor.— A major complication of hemodialysis is infection of the access site. Organisms implicated in accesssite infections have included Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, Streptococcus faecalis, Streptococcus viridans , a variety of gram-negative bacilli, Listeria monocytogenes , 1 and Legionella pneumophila . 2 We report a case of a hemodialysis patient with an arteriovenous-graft infection caused by Candida albicans and emphasize the importance of Gram's stain in early evaluation of access-site infections. Report of a Case.— A 67-year-old man was healthy until 1984, when bilateral ureteral obstruction with renal failure developed; maintenance hemodialysis was started. In 1986, an arteriovenous shunt using a Gortex prosthesis was created in his left arm. Two weeks after surgery the patient became confused and serous yellow material was found oozing from the surgical wound. He remained afebrile, but his white blood cell count was 17·1×10 9 /L (17 100/mm 3 ), with 0·65 (65%) neutrophils (10%

Septicemia in patients on chronic hemodialysis.

Bacterial sepsis, a major complication of chronic hemodialysis, is due mainly to infections of the vascular access site despite increasing use of internal fistulas. Sixty episodes of septicemia occurred in two chronic dialysis centers, with an incidence of 0.15 episodes of significant bacteremia per patient-dialysis-year in each. Forty-four of the 60 episodes were judged to be due to vascular access site infection by clinical, bacteriologic, and histologic criteria. Seventy percent (31 of 44) of the vascular access site-related episodes were due to staphylococci and 25% (11 of 44) to Gram-negative bacilli; nonvascular access site-related episodes were often due to transplant site infections caused by Gram-negative bacilli or streptococci. Mortality was about 18% in both vascular access site-related and nonrelated septic episodes. Bovine heterograft arteriovenous fistulas more often led to sepsis than did Brescia arteriovenous fistulas. Treatment with appropriate antibiotics was successful in most cases. Routine removal or ligation of the vascular access site was not necessary.