Haemodialysis Catheter-related Bloodstream Infections Research Articles

SAT-052 VIGILANCE, SURVEILLANCE AND EDUCATION REDUCES RATES OF TUNNELLED HAEMODIALYSIS CATHETER-RELATED BLOODSTREAM INFECTIONS

Tunnelled haemodialysis catheter-related bloodstream infections (CRBSI) are associated with significantly increased patient morbidity, mortality and health care costs. A policy-driven systematic approach to haemodialysis catheter care, vigilance and surveillance, and focussed education of staff, is a mandatory part of implementing best practice, optimising patient outcomes and minimising the health care burden. Infection rates of < 1 infection per 1000 catheter-days is considered an excellent benchmark to target (REF - Semin Dial. 2008; 21(6):528-38). International guidelines and studies address infection prevention procedures but day-to-day practices and procedures vary, and account for a range of infection rates between clinical centres. Our vigilance and surveillance program for infection rates noted an increase in CRBSI at our clinical centre. An evaluation and assessment of our catheter care techniques and a mandatory education program to standardise practices and procedures was implemented. Following implementation of an infection surveillance program, an increase in infection rates was noted (graph 1). A policy to implement in-centre standardised catheter care and staff education was introduced. Analysis of CRBSI was performed before and after the policy change. Senior haemodialysis nursing staff evaluated tunnelled haemodialysis catheter care techniques by piloting a competency assessment program. Standard practice included (a) the use of personal protective equipment and aseptic technique with connection and disconnection of tunnelled haemodialysis catheters (b) the application of dressings with topical antimicrobial preparations (chlorhexidine solution) applied to the insertion sites. The trial of a competency assessment ensured systematic and stringent practices that were standardised across our clinical centre. The mandatory use of an insertion site observation chart was also instituted. This chart acted as “trigger” for closer follow up, medical review, and microbiological cultures of the insertion site or blood cultures from the catheter lumen if infection was clinically suspected. The competency pilot was introduced through formal education sessions, mandated reminders at every nursing handover and regular electronic-mail reminders to all haemodialysis nurses. Rates of CRBSI decreased with the introduction of standardised tunnelled haemodialysis catheter care practices and procedures from 2.1 CRBSI episodes per 1000 catheter-days to 1.3 per 1000 catheter-days in the first six months of implementation. This demonstrates a fall in infection rates trending towards a desirable target of excellence (<1 infection per 1000 catheter-days). Our Quality Assurance program will maintain continued monitoring, evaluation and improved practice changes. Centre-wide systematic evaluation and education of haemodialysis tunnelled catheter-care techniques dramatically reduced the incidence rates of CRBSI. The implementation of a formalised policy and annual competency assessment of catheter care, vigilance and surveillance and education is an effective method of improving the rates of CRBSI, patient care and outcomes.

Generalized and Prolonged Use of Gentamicin-Lock Therapy Reduces Hemodialysis Catheter-Related Infections Due to Gram Negatives

Introduction: The incidence of catheter-related bloodstream infections (CRBSI) ranges from 2.2 to 5.5 episodes per 1,000 catheter-days. Our aim was to evaluate the utility of a generalized and prolonged gentamicin-lock therapy in patients undergoing hemodialysis (HD) in a third-level hospital for the reduction in CRBSI. Methods: A prospective cohort analyzed before and after intervention. During intervention periods after each HD-session, the catheter lumens were locked with gentamicin/heparin for all patients compared to nonintervention periods were the same procedure was performed without gentamicin. Active surveillance was performed for HD CRBSI. Microbiologic assessment and epidemiological data were gathered. Continuous hand hygiene and water quality monitoring were performed. Results: The rates of CRBSI were reduced from 1.28 to 0.2 cases per 1,000 catheter-days when the lock therapy was employed (p = 0.001) The greatest reduction was for CRBSI caused by Pseudomonas aeruginosa were no cases were recorded during the intervention periods (p = 0.001). There was a significant reduction in the total number of isolates; Gram-negative bacterial species (–97.2%) and Gram-positive bacterial species (–61.5%) although only the former reached statistical significance (p = 0.0001). The difference in the absolute risk reduction was 20.56% (95% CI 14.46–26.66%), the calculated Number Needed to Treat was 5 (95% CI 3.8–6.9). No adverse effects were noted. Conclusion: In the current study, gentamicin-lock therapy was associated with a significant reduction in CRBSI specially with P. aeruginosa and other Gram-negative bacteria. It proved to be safe and effective intervention when applied to the entire population of HD patients.

Effective prevention bundle to eliminate catheter-related bloodstream infections in ambulatory hemodialysis patients

Background: Hamad General Hospital (HGH) is the principal provider of dialysis in the state of Qatar, comprising a total of four facilities in different cities. Infection rates in dialysis patients are increasingly used as a surrogate marker for measuring patient safety and quality of healthcare. These infections are associated with substantial morbidity, mortality, and excess healthcare costs. We observed an elevated rate of hemodialysis catheter-related bloodstream infections (HD-CRBSI) in our outpatient dialysis facilities (1.4/1,000 Central Venous Catheter [CVC] days) in 2011. Our goal was to reduce our HD-CRBSI rate by 80% within a period of four years in HGH ambulatory dialysis facilities. Methods: HD-CRBSIs are defined as the presence of positive blood cultures in a febrile catheter-dependent patient in the absence of alternative sources of infection upon clinical evaluation. The project was led by the HGH quality improvement program director in coordination with a multidisciplinary team (nephrologists, nurses, vascular coordinators, a patient educator, and an infection control team) after implementation of a bundle of infection prevention measures. Results: The rate of HD-CRBSI was reduced from 1.4/1,000 CVC days in 2011 to 0.014 in 2017, achieving a 99% reduction rate (p &lt; 0.001). Conclusions: Strict implementation of our new infection prevention measures bundle is sufficient to significantly reduce HD-CRBSIs.

Bacterial Contamination of Hemodialysis Devices in Hospital Dialysis Wards.

Chronic care patients undergoing hemodialysis for treatment of end-stage renal failure experience higher rates of bloodstream-associated infection due to the patients' compromised immune system and management of the bloodstream through catheters. Staphylococcus species are acommon cause of hemodialysis catheterrelated bloodstream infections. We investigated environmental bacterial contamination of dialysis wards and contamination of hemodialysis devices to determine the source of bacteria for these infections. All bacterial samples were collected by the swab method and the agarose stamp method. And which bacterium were identified by BBL CRYSTAL Kit or 16s rRNA sequences. In our data, bacterial cell number of hemodialysis device was lower than environment of patient surrounds. But Staphylococcus spp. were found predominantly on the hemodialysis device (46.8%), especially on areas frequently touched by healthcare-workers (such as Touch screen). Among Staphylococcus spp., Staphylococcus epidermidis was most frequently observed (42.1% of Staphylococcus spp.), and more surprising, 48.2% of the Staphylococcus spp. indicated high resistance for methicillin. Our finding suggests that hemodialysis device highly contaminated with bloodstream infection associated bacteria. This study can be used as a source to assess the risk of contamination-related infection and to develop the cleaning system for the better prevention for bloodstream infections in patients with hemodialysis. J. Med. Invest. 66 : 148-152, February, 2019.

Construction of nursing-sensitive quality indicators for haemodialysis using Delphi method.

To provide a set of nursing-sensitive quality indicators (NSQIs) for the evaluation of clinical nursing quality in haemodialysis unit. There are no established objective indicators for evaluation of the quality of nursing care in haemodialysis units in China. We performed a literature search for eligible studies published from 2006-2016. A total of six studies were screened out from which 13 potential NSQIs were identified. Two rounds of Delphi surveys were conducted with the purpose of collecting opinions from a panel of independent experts. At last, 11 NSQIs were selected by consensus after exclusion of 8 NSQIs and addition of another 6 NSQIs. Two rounds of expert inquiry were conducted; the questionnaire recovery rate was 100%. The average authoritative coefficients Cr for the two rounds were 0.79 and 0.90, respectively. The Kendall W values ranged from 0.273-0.388 (p<0.001). Eleven NSQIs were identified: nurse-to-patient ratio, dialysis ultrafiltration rate compliance rate, KT/V compliance rate, incidence of emergency during haemodialysis, person-time incidence rate of haemodialysis catheter-related bloodstream infections, incidence of coagulation in extracorporeal circulation, incidence of blood loss in extracorporeal circulation, incidence of pseudoaneurysm induced by fistula puncture, incidence of falls among haemodialysis patients, emergency dialysis rate of outpatients and incidence of fistula complications. The identified NSQIs reflect three aspects of haemodialysis nursing quality: importance, rationality of calculation formula and applicability of data collection methods. The study provides a reference for the evaluation of clinical nursing quality in haemodialysis units.

Evaluating Approaches for the Diagnosis of Hemodialysis Catheter-Related Bloodstream Infections.

Guideline-recommended diagnostic criteria for hemodialysis (HD) catheter-related bloodstream infections (CRBSIs) are based on data from indwelling central catheters in patients not on HD and non-HD situations, and upon which peripheral vein cultures are the gold standard. We aimed to examine the validity of these criteria in patients on HD. Adult patients on in-center HD using catheters were prospectively followed from 2011 to 2014 at a large academic-based HD facility (Toronto, Canada). When a CRBSI was suspected, blood culture sets were obtained from four sites (peripheral vein, both catheter hubs, and HD circuit) to determine the guideline-recommended differential time to positivity (DTTP). DTTP criteria were met when catheter hub cultures turned positive ≥120 minutes before peripheral vein cultures. The sensitivity, specificity, and accuracy were first calculated using peripheral vein cultures as the gold standard and then these same calculations were repeated with additional information, including exit site/catheter tip and HD circuit cultures, as the true gold standard. The feasibility of obtaining peripheral vein cultures was determined. Of 178 suspected CRBSIs, 100 had peripheral vein blood cultures. Using the true gold standard, sensitivity, specificity, and accuracy of blood culture results were highest in samples from the HD circuit (93.5%, 100%, and 95%, respectively). The guideline recommended combination of peripheral vein and arterial hub blood cultures was the least sensitive, specific, and accurate (91.7%, 93.1%, and 92.7%, respectively). The diagnostic criteria using measured DTTP were met in less than one third of events. In patients on HD, blood culture results are the most sensitive, specific, and accurate for diagnosing CRBSIs when taken from the HD circuit and the venous catheter hub, and blood culture results are the least sensitive, specific, and accurate in any combination with peripheral vein cultures. The DTTP does not increase diagnostic accuracy, reducing the necessity for venipuncture and its potential vein damage. Future guidelines should consider the applicability of criterion on specific patient populations and tailor them accordingly.

The Incidence and Outcome of Hemodialysis Catheter-Related Blood Stream Infection and the Sensitivity Pattern of the Isolated Organisms to the Antibiotics in ESRD Patients

Background: Catheters are used in roughly 60- 80% of patients at the time of initiation and 25-30% of all prevalent patients as a bridge to permanent vascular access. Relative risk of mortality due to bacteremia is multiple folds higher with the use of hemodialysis catheters compared to av fistulas. The present study investigates the incidence, causative organisms and the final outcome of CRBSI in hemodialysis patients. Method: It is a retrospective cross-sectional study carried in a Tertiary care hospital in India which included adult (>18 years) ESRD patients with the diagnosis of HD catheter related blood stream infections (CRBSIs) over a period of 2 years. Results: Forty two episodes of infection were reported in 39 subjects. In our study, incidence of CRBSI in temporary uncuffed catheters (TUC) was 5.37 episodes per 1000 catheter days and 6.5 episodes per 1000 catheter days in case of permanent cuffed catheters. Gram positive organisms outnumbered others (57.8%). Gram negative organisms were seen in 40% of cases. Rise in Acinetobacter and citrobacter positive cases and growing resistance against third generation cephalosporin, carbapenems amongst gram negative organisms was noted in this study. Catheter removal was significantly more in TUCs and salvageability was significantly more in PUCs (p= 0.0035). Comorbidity had no influence on the likelihood of salvageability of the catheters. Conclusion: There is a growing incidence of gram negative infections with resistance to third generation cephalosporins and carbapenems. Hence, hospitals need to formulate their own antibiotic protocol as per the antibiograms.

Haemodialysis catheter-related blood stream infection in ESRD patients: incidence, outcome and antibiogram of the isolated organisms

Background: Catheters are used in roughly between 60- 80% of patients at the time of initiation and 25-30% of all prevalent patients as a bridge to permanent vascular access. Relative risk of mortality due to the dreaded complication of bacteraemia is multiple folds higher with the use of haemodialysis (HD) catheters compared to AV fistulas. In the present study we investigate the incidence, causative organisms and the final outcome of catheter related blood stream infections (CRBSI) in haemodialysis patients. Methods: It was a retrospective cross-sectional study carried in a tertiary care hospital in north India which included adult (>18 years) ESRD patients with the diagnosis of HD CRBSIs in a duration of 2 years . Results: Forty two cases of infection were reported in 39 subjects. In the temporary uncuffed catheter (TUC) group expired patients were older, had lower haemoglobin levels and longer hospital stay although none was significant. In the permanent cuffed catheter group expired patients had longer hospital stay, lower haemoglobin levels. Catheter removal was significantly more in TUCs and salvageability was significantly more in PUCs (p = 0.0035). The rise in Acinetobacter and Citrobacter positive cases and the growing resistance against third generation cephalosporin, carbapenems was a notable phenomenon amongst gram negative organisms. Conclusions: Hemodialysis patients with catheter as vascular access presenting with fever, the first differential diagnosis is CRBSI. They can be managed on an outpatient basis barring those with evidence of severe sepsis. Early removal of temporary uncuffed catheters can give good results in selected patients .

Prevention of hemodialysis catheter-related blood stream infections using a cotrimoxazole-lock technique.

This trial assessed the efficacy of cotrimoxazole lock solution in reducing catheter-related blood stream infections (CRBSIs) among hemodialysis (HD) patients who were dialyzed using tunneled catheters. Patients randomly received either heparin (2500 U/ml) (control group) or a mixture of 10 mg/ml cotrimoxazole (based on trimethoprim) and 2500 U/ml heparin (antibiotic group) as catheters lock solution. Compared with the control group, CRBSIs rates per 1000 catheter-days was significantly lower (0.58 vs 4.4 events; p = 0.002) and cumulative infection-free catheter survival was significantly higher (log rank statistic 5.88; p = 0.015) in the antibiotic group. There were no statistical differences regarding incidences of catheter removal (8.7% in the antibiotic group vs 22% in the control group; p = 0.116) or thrombosis (2.2% in the antibiotic group vs 9.8% in the control group; p = 0.129) between the two groups. cotrimoxazole containing catheter lock solution is effective in reducing CRBSIs incidence and prolonging dialysis catheter survival in HD patients.

Haemodialysis catheter-related bloodstream infections at Universitas Academic Hospital, Bloemfontein: should we change our empiric antibiotics?

Nosocomial bloodstream infections are only second to cardiovascular disease in causing mortality in patients with end-stage renal disease. The majority of these infections relate to haemodialysis catheters. Empiric antimicrobial treatment is instituted on the clinical suspicion of a catheter-related bloodstream infection (CRBSI) while awaiting the blood culture results. There is a paucity of local data on microbial resistance patterns to guide empiric antibiotic use. This prompted our study. A retrospective survey was performed of cultured organisms and their antibiograms from patients with haemodialysis catheters in the Nephrology Unit at Universitas Academic Hospital, Bloemfontein, between January and December 2012. A list of all blood cultures performed during 2012 at the nephrology unit was compiled from the National Health Laboratory Service's electronic record system. All positive blood cultures associated with CRBSI were included in this study. Duplicate cultures, as well as negative cultures, were...

What is the evidence for intraluminal colonization of hemodialysis catheters?

Hemodialysis catheter-related bloodstream infections are potentially devastating, leading to increased morbidity, mortality, and cost of care. Prospective studies published over the past 15 years shed light on the pathogenesis of these infections. The data suggest that the intraluminal microbial colonization of hemodialysis catheters often precedes bloodstream infection. This finding supports strategies aimed at preventing or eradicating intraluminal colonization.

Antibiogram for haemodialysis catheter-related bloodstream infections.

Background. Haemodialysis (HD) catheter-related bloodstream infections (CRBSIs) are a major complication of long-term catheter use in HD. This study identified the epidemiology of HD CRBSIs and to aid in the choice of empiric antibiotics therapy given to patients with HD CRBSIs. Methods. Patients with HD CRBSIs were identified. Their blood cultures were performed according to standard sterile technique. Specimens were sent to the microbiology lab for culture and sensitivity testing. Results were tabulated in antibiograms. Results. 18 patients with a median age of 61.0 years (IQR: 51.5–73.25) were confirmed to have HD CRBSIs based on our study criteria. Eight (44.4%) patients had gram-negative infections, 7 (38.9%) patients gram-positive infections, and 3 (16.7%) patients had polymicrobial infections. We noted that most of the gram-negative bacteria were sensitive to ceftazidime. Unfortunately, cloxacillin resistance was high among gram-positive organisms. Coagulase-negative Staphylococcus and Bacillus sp. were the most common gram-positive organisms and they were sensitive to vancomycin. Conclusion. Our study revealed the increased incidence of gram-negative organism in HD CRBSIs. Antibiogram is an important tool in deciding empirical antibiotics for HD CRBSIs. Tailoring your antibiotics accordingly to the antibiogram can increase the chance of successful treatment and prevent the emergence of bacterial resistance.

Anti-microbial locks increase the prevalence of Staphylococcus aureus and antibiotic-resistant Enterobacter: observational retrospective cohort study

Anti-microbial lock solutions (AML), in conjunction with systemic antibiotics, may successfully treat tunnelled haemodialysis catheter-related bloodstream infections (CR-BSI). It is unknown whether AML promote anti-microbial resistance. This is a retrospective cohort study of all CR-BSI (2003-2006) in our dialysis unit. Controls (n = 265) were treated with systemic vancomycin and gentamicin. In addition to the systemic antibiotics, the study group (n = 662) received AML containing vancomycin and gentamicin during inter-dialytic periods. Antibiotic sensitivity/resistance profiles of all organisms were analysed. Changes in the incidence of infection (chi-square test) and resistant organisms (Fisher's exact test) were calculated. The incidence of CR-BSI decreased from 8.50/1000 catheter days (controls) to 3.80 (study group; P < 0.0001), and the incidence of relapses decreased (P = 0.0027). The number needed to treat to prevent subsequent bacteraemia using an AML adjunct is 3 ± 0.4. The proportion of Gram-positive cultures increased (P < 0.0001), including Staphylococcus aureus (P = 0.03), but the proportion of methicillin-resistant S. aureus (P = 0.87) and vancomycin resistance (P = 0.90) did not. Increased gentamicin resistance (P < 0.0001) and ciprofloxacin resistance (P = 0.04) were observed in Gram-negative cultures. Gentamicin resistance [relative risk (RR) > 15.29; P < 0.0001] and ciprofloxacin resistance (RR = 6; P = 0.007) increased in Enterobacter species, but not Pseudomonas or Escherichia coli species. AML decrease CR-BSI incidence, although proportions of S. aureus and anti-microbial-resistant Enterobacter are increased.

Tunneled Hemodialysis Catheter-Related Bloodstream Infections: A Prospective Multicenter Cohort Study from Spain

Catheter-related bloodstream infections (CRBSI) are common among patients undergoing long-term hemodialysis (HD) worldwide. The aim of this study was look into the incidence, epidemiology, and risk factors for CRBSI in four medical centers and Spanish dialysis facilities following a common protocol for insertion and management of tunneled hemodialysis catheters (THCs). Prospective study including all THCs inserted from September-04 to October-05. Follow-up was from THC insertion to its withdrawal, onset of CRBSI or end of study. Data of all THCs, CRBSI episodes, and catheter complications were collected. A descriptive analysis of CRBSI incidence and etiology and multivariate Cox regression to identify risk factors for CRBSI was performed. A total of 130 THCs in 123 patients were inserted. There were 34 879 catheter-days. Twelve CRBSI in 11 patients with a CRBSI rate of 0.34/1000 catheter-days were recorded. CRBSI was caused by gram-positive coccus in 91.7% of the cases. Vascular cause of renal disease (HR 25.5 CI95% 5.5-117.2), and a previous THC (HR 5.1 CI95% 1.3-19.1) were identified as risk factors for CRBSI. CRBSI were satisfactorily resolved in 83.3% of the cases. Overall mortality was 14.6% (18/123), in two cases (2/11) death occurred within 30 days after CRBSI onset. Although some factors, such as vascular cause of renal disease and previous THC medical history, have been related to the onset of tunneled catheter-related bloodstream infections, the incidence of these bacteremia, mainly produced by gram-positive coccus, is low among hemodialysis patients and the mortality rate is not high.

Diagnosis, prevention and treatment of haemodialysis catheter-related bloodstream infections (CRBSI): a position statement of European Renal Best Practice (ERBP).

Nephrology Section, Department of Internal Medicine, University Hospital, Gent, Belgium, Nephrology, Dialysis and Intensive Care Unit, Lapeyronie University Hospital, Montpellier, France, Department of Renal Medicine, Royal Derby Hospital, Derby, UK, Nephrology, Cliniques Universitaires Saint-Luc, Universite Catholique de Louvain, Brussels, Belgium, Nephrology Department, Consorcio Hospital General Universitario, Valencia, Spain and Vascular Surgery, Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands

Bismuth coating of non-tunneled haemodialysis catheters reduces bacterial colonization: a randomized controlled trial

Background. Haemodialysis (HD) catheter-related blood stream infections are a major cause of morbidity and mortality in patients with acute and chronic renal failure.Methods. We conducted a randomized, prospective, double-blinded trial investigating the clinical value of bismuth-coated non-tunneled HD catheters in patients in need of temporary short-term vascular access. A standard catheter (SC) was compared to a surface-modified, bismuth-film-coated catheter (FCC). After removal of the catheter for any reason, both arterial and venous lumina were rinsed and the fluid cultured for detection of bacterial colony-forming units (CFU). The catheter tip was placed in a tube containing sterile saline, sonicated and shortly centrifuged to remove debris (3 min at 1000 g). The supernatant was cultured and assayed for DNA content.Results. Seventy-seven patients in three HD units were randomized. Thirteen patients suffered from acute renal failure, 60 patients from chronic renal failure, and four patients without renal insufficiency were treated with plasma exchange. The time to catheter removal was not significantly different between groups, with a mean of 18.5 ± 2 days for SC and 15.1 ± 2 days for FCC. In most cases, the reasons for catheter removal were related to no further need for extracorporeal therapy or establishment of a permanent vascular access. Six catheters for SC and four catheters for FCC were removed because of presumed infection. Bacterial colonization was significantly lower for coated catheters compared to standard catheters, both for cultured catheter tips as well as for CFU in rinse fluids (P < 0.05).Conclusions. Surface modification with bismuth film reduces bacterial colonization of temporary non-tunneled HD catheters in a clinical trial. Larger trials with these modified catheters are justified to further investigate the effect on catheter-related infections, complications and costs.

Incidence and risk factors for bloodstream infections stemming from temporary hemodialysis catheters

Catheter-related bloodstream infection (CR-BSI) is considered as an important complication of hemodialysis catheters. The purpose of this prospective study was to evaluate the incidence and risk factors of temporary hemodialysis catheter-related bloodstream infection. Materials and methods: Prospective data related to temporary hemodialysis catheters inserted in our institution were collected for duration of three years. The risk factors of CR-BSI of patients between the CR-BSI group and the control group were compared. Results: A total of 248 temporary hemodialysis catheters were inserted in 201 patients and remained in situ for a cumulative total of 5192 catheter days. There were 3254 dialysis sessions. CR-BSI was found in 63 cases. CR-BSI rate was 12.1/1000 catheter-days and 19.4/1000 dialysis sessions. In multivariate analysis, acute renal disease (OR = 2.29), administration of antibiotics at the time of catheterization (OR = 2.09), insertion in the femoral vein (OR = 2.14), emergency situation for catheter insertion (OR = 2.41), high number of catheter manipulation (OR = 2.49), and inadequate hand hygiene prior to catheter manipulations (OR = 3.02) were found to be risk factors of CR-BSI. The most frequently isolated microorganisms were coagulase-negative staphylococci (31.3%), S. aureus (26.9%), Enterococcus spp. (10.4%), and Pseudomonas aeruginosa (9.0%). Conclusion: This prospective study of temporary hemodialysis catheters has shown high rates of infectious complications. The education of both the patients and medical staff in prevention of CR-BSI is important.

Haemodialysis catheter-related bloodstream infections: current treatment options and strategies for prevention.

Regardless of the repeated reservations raised by countless researchers with reference to the use of catheters as vascular access for haemodialysis (HD), central venous catheters (CVCs) remain irreplaceable tools of the modern dialysis delivery system as a reliable option for the clinical situations requiring instant access to circulation, for various reasons. Patients on long-term haemodialysis are therefore at a significantly high risk for catheterrelated bloodstream infections (CRBSI) and ensuing serious complications. Although early systemic antibiotic treatment should include the coverage for Staphylococcus aureus, the pathogen with most devastating consequences including bacterial endocarditis; optimal treatment of CRBSI while preserving the catheter site, remains contentious. Nonetheless, catheter exchange over a guide wire and antimicrobial-anticoagulant "locks" have shown promising results as novel access salvage techniques. Despite the fact that a number of novel potentially useful strategies for the prevention of CRBSI are in the pipeline; equally essential however, remains the role of rigorous implementation of standard infection control measures for hygiene and aseptic handling of CVCs in long-term HD patients. The policy of increasing the AVF (arteriovenous fistula) prevalence beyond 50% while minimising the use of CVCs, dependent largely upon the timely referrals and prudently implemented pre-ESRD program - ought to have a positive impact on long-term HD outcomes.

Haemodialysis catheter-related bloodstream infections: current treatment options and strategies for prevention.

Regardless of the repeated reservations raised by countless researchers with reference to the use of catheters as vascular access for haemodialysis (HD), central venous catheters (CVCs) remain irreplaceable tools of the modern dialysis delivery system as a reliable option for the clinical situations requiring instant access to circulation, for various reasons. Patients on long-term haemodialysis are therefore at a significantly high risk for catheterrelated bloodstream infections (CRBSI) and ensuing serious complications. Although early systemic antibiotic treatment should include the coverage for Staphylococcus aureus, the pathogen with most devastating consequences including bacterial endocarditis; optimal treatment of CRBSI while preserving the catheter site, remains contentious. Nonetheless, catheter exchange over a guide wire and antimicrobial-anticoagulant "locks" have shown promising results as novel access salvage techniques. Despite the fact that a number of novel potentially useful strategies for the prevention of CRBSI are in the pipeline; equally essential however, remains the role of rigorous implementation of standard infection control measures for hygiene and aseptic handling of CVCs in long-term HD patients. The policy of increasing the AVF (arteriovenous fistula) prevalence beyond 50% while minimising the use of CVCs, dependent largely upon the timely referrals and prudently implemented pre-ESRD program - ought to have a positive impact on long-term HD outcomes.

An outbreak of methicillin-resistant Staphylococcus aureus infections related to central venous catheters for hemodialysis.

To determine risk factors for hemodialysis catheter-related bloodstream infections (HCRBSIs) and investigate whether use of maximal sterile barrier precautions would prevent HCRBSIs. Tertiary-care medical center hemodialysis unit. Open trial with historical comparison and case-control study of risk factors for HCRBSIs. Prospective surveillance was used to compare HCRBSI rates for 1 year before and after implementation of maximal sterile barrier precautions. A case-control study compared 50 case-patients with HCRBSI with 51 randomly selected control-patients. The HCRBSI rate was 1.6% per 100 dialysis runs (CI95, 1.1%-2.3%) in the first year and 0.77% (CI95, 0.5%-1.1%) in the second year (P = .0106). The most frequent cause of HCRBSI was MRSA in the first year (15 of 32) and MSSA in the second year (13 of 18). Ten MRSA blood isolates in the first year were identical by PFGE. Diabetes mellitus was a risk factor for HCRBSI. Age, gender, site of hemodialysis central venous catheter (CVC), other underlying diseases, coma score, APACHE II score, serum albumin level, and cholesterol level were not associated with HCRBSI and did not change between the 2 years. Hospital stay was prolonged for case-patients (32.78 +/- 20.96 days) versus control-patients (22.75 +/- 17.33 days), but mortality did not differ. Use of maximal sterile barrier precautions during the insertion of CVCs reduced HCRBSIs in dialysis patients and seemed cost-effective. Diabetes mellitus was associated with HCRBSI. An outbreak of MRSA in the first year was likely caused by cross-infection via medical personnel.