Vascular Access-related Infections Research Articles

A case of hemodialysis vascular access-related infection with endogenous bacterial endophthalmitis

A case of hemodialysis vascular access-related infection with endogenous bacterial endophthalmitis

Pattern of vascular access-related infection in hemodialysis patients

Background Vascular access-related infections (VARI) represent a substantial burden for patients undergoing hemodialysis (HD) that is unfortunately inevitable. The spectrum of causative organisms varies between different regions and centers, so it is necessary for each dialysis unit to have its database. This prospective descriptive multicenter study was conducted over a 6-month duration to delineate the pattern of VARI among patients undergoing HD units of Alexandria University Hospitals, and to determine the possible relationship between VARI, type of vascular access, pattern of causative organisms, and various risk factors. Materials and methods The study enrolled all patients with documented clinical and bacteriological evidence of VARI. Infection incidence-rate event/1000 dialysis session (ds) was calculated. Results During the study period, 877 HD patients were approached. A total of 66 VARI episodes were identified in 62 patients, with 58 bloodstream infection (BSI) episodes and 8 local-access infections, with an overall incidence rate of 4.64/1000 ds. About 64% of isolated organisms were Gram-negative bacilli, 33.3% Gram-positive cocci, and 2.8% fungi. The most frequent isolated pathogens were Klebsiella pneumonia, Escherichia coli, and methicillin-resistant Staphylococcus aureus (MRSA). Conclusion VARI rate was higher in HD patients with temporary central venous catheter compared with permanent tunneled catheters. Gram-negative microorganisms and MRSA were the most frequent identified organisms. Creation of arteriovenous fistula should not be delayed to avoid the use of temporary catheters, which carry high risk of VARI.

Epidemiology of bloodstream infections in a Scottish haemodialysis population with focus on vascular access method

Infection is the second highest cause of mortality in end-stage renal disease, with a significant proportion relating to haemodialysis (HD) vascular access-related infection (VARI). To report the rate and antimicrobial resistance (AMR) of all-source bloodstream infections (BSIs) by vascular access type in a Scottish HD cohort. Retrospective analysis was undertaken of data on adult patients attending seven HD units during 2017. Total HD days for each vascular access type were calculated. BSIs were analysed with rates expressed per 1000 HD days. AMR was verified using health board microbiology databases. Excluding contaminant organisms, there was an overall BSI rate of 0.57 per 1000 HD days. The highest all-source and vascular access-related infection (VARI) BSI rates per 1000 HD days were in the non-tunnelled central venous catheter (CVC) group (3.11 and 2.07 respectively), followed by tunnelled CVC (1.10 and 0.67), arteriovenous graft (0.51 and 0.31), and finally arteriovenous fistula (0.29 and 0.02). The non-VARI BSI rates were lowest in the arteriovenous graft group. Staphylococci comprised the majority of events, with Staphylococcus aureus implicated in 29%. Gram-negative BSIs were prevalent, particularly in CVC groups, and associated with higher mortality. Multidrug-resistant (MDR) S.aureus and carbapenem resistance were relatively low. MDR Gram-negatives were high compared with the Scottish population. Arteriovenous fistula access is confirmed as having lowest all-source and VARI BSI rates, and arteriovenous graft access the lowest non-VARI BSI rates. Staphylococci remain the prevailing genus; however, the contributions of Gram-negative BSIs, the higher mortality, and proportion of MDR organisms in this group are notable.

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.

Bacteriology of the Buttonhole Cannulation Tract in Hemodialysis Patients: A Prospective Cohort Study

The buttonhole cannulation technique for arteriovenous fistulas is widely used, but has been associated with an increased rate of vascular access-related infections. We describe the frequency and type of bacterial colonization of the buttonhole tract over time and associated clinical infections. A prospective observational cohort study with 9 months of follow-up. 84 in-center hemodialysis patients using the buttonhole cannulation technique at 2 Danish dialysis centers. Bacterial growth from the buttonhole tract and dialysis cannula tip and clinically important infections during follow-up. On 3 occasions 1 month apart, cultures before dialysis (from the skin surrounding the buttonhole before disinfection and from the cannulation tract after disinfection and scab removal) and the cannula tip after dialysis. Patients with positive cultures from the buttonhole tract or cannula tip had repeat cultures within 1 week, along with blood cultures. Growth from the cannulation tract and/or cannula tip at each of the 3 monthly sets of cultures was found in 18%, 20%, and 17% of patients, respectively. 38% of patients had at least 1 positive culture from the buttonhole tract. Sustained growth was detected in 11% of patients, whereas asymptomatic bacteremia was seen in 30% of those with positive buttonhole cultures. Staphylococci species were the most common pathogens (Staphylococcus aureus, 25%; and Staphylococcus epidermidis, 41%). Colonization-positive buttonholes had more localized redness and slightly more tenderness. During follow-up, significantly more access-related infections were diagnosed among those with positive buttonhole cultures (P<0.001). No comparison to area puncture cannulation technique. Blood cultures were obtained only from patients with positive buttonhole bacteriology. Transient or sustained colonization of the buttonhole tract by staphylococci and asymptomatic bacteremia is common in hemodialysis patients, implying a substantial risk for access-related infections among patients using a buttonhole cannulation technique. These findings suggest the possible value of surveillance of buttonhole colonization.

Home hemodialysis associated infection-The "Achilles' Heel" of intensive hemodialysis.

Home hemodialysis (HHD) is emerging as an important alternate renal replacement therapy. Although there are multiple clinical advantages with HHD, concerns surrounding increased risks of infection in this group of patients remain a major barrier to its implementation. In contrast to conventional hemodialysis, infection related complication represents the major morbidity in this mode of renal replacement therapy. Vascular access related infection is an important cause of infection in this population. Use of central vein catheters and buttonhole cannulation in HHD are important modifiable risk factors for HHD associated infection. Several preventive measures are suggested in the literature, which will require further prospective validation.

Hemodialysis patients' satisfaction and perspectives on complications associated with vascular access related interventions: are we listening?

To understand the patient's perspective on complications associated with vascular access-related interventions. A multi-stage comprehensive questionnaire of over 150 items was administered to 140 in-center hemodialysis patients in a large, Toronto-based academic-based facility from May 1, 2011 until July 1, 2014. The questionnaire was divided into three domains: physical complications, disruption to routine, and infection. For each of the 12 prespecified vascular access interventions, there were 9 items about the associated complications. The level of bother associated with complications was measured using a 5-point Likert scale. The mean Likert value (5 = extremely bothered) for the physical complications domain was highest for grafts at 1.92, followed closely by fistulas at 1.87, and catheters at 1.56. The mean Likert value for the "disruption of routine" domain was highest for catheters at 1.44, followed by grafts at 1.37, and fistulas at 1.33. For infectious complications of all vascular access-related interventions the mean Likert value was highest at 1.76 for catheters as compared to fistulas at 1.23 and grafts at 1.22. For hemodialysis patients, the physical complications associated with needle cannulation of fistulas and grafts are a major source of dissatisfaction, while infectious complications, including catheter-related infections, are not a significant source of their concerns. Future research should focus on developing methods to effectively: (i) reduce the fear and pain associated with cannulation and (ii) educate patients about the risks associated with vascular access-related infection.

The use of vascular access audit and infections in home hemodialysis.

Vascular access-related infection is an important adverse event in home hemodialysis (HHD). We hypothesize that errors in self-cannulation or manipulation of dialysis vascular access are associated with increased incidence of access-related infection. We conducted a retrospective cohort study of all prevalent HHD patients at the University Health Network. All vascular access-related infections were recorded from 2006 to 2013. Errors in dialysis access were ascertained by nurse-administered vascular access checklist. Ninety-two patients had completed at least one vascular access audit. Median HHD vintage was 2.3 (0.9-5.0) years in patients with appropriate vascular access technique and 5.8 (1.5-9.4) years in patients with erroneous vascular access technique. The overall rate of infection between patients with and without appropriate vascular access technique was similar (0.27 and 0.28 infections per year, P = 0.166). Among patients who were identified with errors in dialysis access manipulation, patients with five or more errors were associated with higher rate of access-related infection (mean of 0.47 vs. 0.16 infection per patient-year, P < 0.001). The use of vascular access audit is a feasible strategy, which can identify errors in vascular access technique. Patients with a longer median HHD vintage are associated with higher risk of inappropriate vascular access technique. Patients with multiple errors in vascular access technique are associated with a higher risk of dialysis access-related infection. Prospective evaluation of the impact of vascular access audit on adverse vascular access events is warranted.

Association between acetylsalicylic acid and the risk of dialysis-related infections or septicemia among incident hemodialysis patients: a nested case-control study.

BackgroundVascular access-related infections and septicemia are the main causes of infections among hemodialysis patients, the majority of them caused by Staphylococcus species. Acetylsalicylic acid (ASA) has recently been reported with a probable antistaphylococcal activity. This study aimed to evaluate the effect of ASA on the risk of dialysis-related infection and septicemia among incident chronic hemodialysis patients.MethodsIn a nested case–control study, we identified 449 cases of vascular access-related infections and septicemia, and 4156 controls between 2001 and 2007 from our incident chronic hemodialysis patients’ cohort. Cases were defined as patients hospitalized with a main diagnosis of vascular access-related infection or septicemia on the discharge sheet (ICD-9 codes). Up to ten controls per case were selected by incidence density sampling and matched to cases on age, sex and follow-up time. ASA exposure was measured at the admission and categorized as: no use, low dose (80–324 mg/d), high dose (≥325 mg/d). Odds ratios (OR) for infections were estimated using multivariable conditional logistic regression analysis, adjusting for potential confounders.ResultsCompared to no use, neither dose of ASA was associated with a decreased risk of infection: low dose (OR 1.03, 95 % CI 0.82-1.28) and high dose (OR 1.30, 95 % CI 0.96-1.75). However, diabetes (OR = 1.32, 95 % CI = 1.07–1.62) and anticoagulant use (OR = 1.62, 95 % CI = 1.30–2.02) were associated with a higher risk.ConclusionAmong hemodialysis patients, ASA use was not associated with a reduced risk of hospitalizations for dialysis-related infections or septicemia. However, ASA may remain beneficial for its cardiovascular indications.

Clinical Usefulness of ¹⁸F-FDG PET/CT for the Detection of Infections of Unknown Origin in Patients Undergoing Maintenance Hemodialysis.

Patients with end-stage renal disease undergoing maintenance hemodialysis (MHD) are highly prone to infections. The potential clinical usefulness of (18)F-FDG PET/CT for the detection of infections of unknown origin in this patient population remains unclear. This study was designed to investigate this issue. Between October 2011 and July 2014, a total of 104 adult MHD patients with sepsis underwent (18)F-FDG PET/CT for the detection of unknown infection foci. Follow-up was continued until October 2014. Positive (18)F-FDG PET/CT findings and mortality served as the main outcome measures. Of the 104 study patients, 73 (70.2%) had positive (18)F-FDG PET/CT findings, and a total of 95 major infection foci were identified. Eighteen patients (24.6%) had at least 2 infection foci on (18)F-FDG PET/CT scans. Seven (53.8%) of the 13 patients with primary vascular access-related infections had concurrent metastatic foci. Twenty-eight patients (26.9%) had their treatments modified by (18)F-FDG PET/CT results. Multivariate logistic regression analysis demonstrated that low hemoglobin and high C-reactive protein levels at diagnosis were the independent predictors of positive (18)F-FDG PET/CT results. Twenty-seven patients (26.0%) died during their hospital stay, and 24 of them had positive (18)F-FDG PET/CT findings (P = 0.014). Positive (18)F-FDG PET/CT results were an independent predictor of mortality (hazard ratio, 3.896; 95% confidence interval, 1.039-14.613; P = 0.044). Our results suggest that (18)F-FDG PET/CT may be clinically useful for detecting occult infection foci in end-stage renal disease patients undergoing MHD. In this population, positive (18)F-FDG PET/CT findings may lead to a significant change in clinical management and independently predict mortality.

Microbiology and audit of vascular access-associated bloodstream infections in multi-ethnic Asian hemodialysis patients in a tertiary hospital

Background: In view of high mortality and morbidity rates associated with vascular access-associated bloodstream infection (VAABSI) in hemodialysis patients, clinical practice guidelines recommend empiric antibiotic therapy for suspected vascular access-related infections. We aim to describe the microbiology of confirmed VAABSI and evaluate the choice of empiric antibiotics, and whether they are prescribed in concordance with the in-house antibiotic guidelines. Methods: This was a single-center, retrospective, observational study conducted in a tertiary hospital. All adult hemodialysis patients aged 21 years and above who had confirmed VAABSI with positive blood culture results dated from January 2011 to June 2012 were recruited. Relevant information was retrieved electronically from the hospital patient online database, SCM 5.5 Sunrise Enterprise Gateway. Results: A total of 144 episodes of VAABSI were recorded from 118 patients. Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) accounted for 64.2% (68/106) of the gram-positive infections. Gram-negative organisms grew in 26.4% (38/144) of blood cultures and Pseudomonas aeruginosa was the most common organism isolated. The recommended in-house guideline was used as empiric therapy in 24 episodes of VAABSI (16.7%). Five patients died due to VAABSI and none were prescribed antibiotics in concordance with in-house guidelines. Conclusions: Empiric antibiotics against MSSA and MRSA, as well as gram-negative organisms, especially P. aeruginosa, should be used in patients with suspected vascular access-related infections in our institution. Monitoring of microbiological profile is necessary to guide timely administration of appropriate empiric antibiotics. Further studies are necessary to evaluate the relationship between adherence to in-house guidelines and patients’ outcomes.

Morbidity and mortality of black HIV-positive patients with end-stage kidney disease receiving chronic haemodialysis in South Africa.

There are few published data from South Africa (SA) on the outcomes of black HIV-positive patients receiving chronic haemodialysis. This retrospective study compared the incidences of vascular and infectious morbidity and mortality in black HIV-positive patients with those in a group of HIV-negative patients matched for ethnicity, age and gender. All the patients were receiving chronic haemodialysis in the medically insured healthcare sector of SA. The incidence of tuberculosis and hospital admission rates for vascular access-related infections were significantly higher in the HIV-positive group than the HIV-negative group. The HIV-positive group had significantly lower albumin (p&lt;0.05) and haemoglobin levels (p&lt;0.01), but this did not impact on mortality. Survival in both groups was excellent. In the HIV-positive group, viral suppression rates were suboptimal with &lt;50% of patients on antiretroviral therapy completely virally suppressed. This study has shown that black HIV-positive patients receiving chronic haemodialysis in a healthcare-funded environment in SA have excellent overall survival in spite of higher hospital admission rates and higher infectious morbidity compared with HIV-negative patients.

Deformity of Buttonhole Entry Site Causes Higher Frequency of Vascular Access-Related Infection.

Vascular access-related infection is more frequent in patients using the buttonhole method for cannulation of the arteriovenous access for hemodialysis. Deformity of buttonhole entry sites is frequently observed among patients on the buttonhole method for extended periods of time. With deformed buttonhole entry sites, moreover, scabs are often incompletely removed at the time of buttonhole cannulation. In 166 patients using the buttonhole method at Hino Clinic in Osaka, Japan as of June 30, 2014, the shapes of buttonhole entry sites were categorized into the following 3 types: flat, depressive deformity, and bulging deformity. A multivariate logistic regression method was used to analyze associations between various data including shapes of buttonhole entry sites and occurrence of access-related infection. We also examined microscopic features of the buttonhole entry site tissue that was removed from a patient who died after 3 years of buttonhole cannulation. For the flat buttonhole entry sites, frequency of access-related infection was 0.12 events/1,000 arteriovenous fistulas as compared to 0.47 events/1,000 arteriovenous fistulas for the entry sites with bulging deformity. Such infection did not occur for the entry sites with depressive deformity. The multivariate logistic regression analysis revealed a significant association between an entry site with bulging deformity and occurrence of access-related infection (odds ratio = 5.369, p = 0.0085). Furthermore, the microscopic section showed granulations beneath the skin at the buttonhole entry site and around the buttonhole tract. A significant association was shown between an entry site with bulging deformity and occurrence of access-related infection. The microscopic features of the buttonhole entry site of the patient on the buttonhole method for 3 years suggest that the entity of bulging deformity at the entry site is hypertrophic granulation.

Relationship between Years Elapsed after Initial Buttonhole Cannulation and Frequency of Vascular Access-Related Infections.

A reason for the higher frequency of vascular access-related infections in buttonhole cannulation patients remains to be elucidated. If the higher frequency of infections is associated with a factor(s) inherent to the buttonhole method (e.g. existence of a buttonhole track or other factors), the frequency of such infections is expected to increase upon starting buttonhole cannulation. On the other hand, if the higher frequency of the infections is associated with a factor(s) developing secondarily while performing buttonhole cannulation for months or years (e.g. deformity of the buttonhole entry site or other factors), the frequency is expected to rise after a certain time elapses from initiation of buttonhole cannulation. In case the higher frequency of the infections is associated with a factor(s) developing secondarily, the problem may potentially be solved. Thus, the present study is to clarify whether there is 'an infection calm period' after buttonhole cannulation is started. The relationship between the time (in years) after buttonhole cannulation is started and frequency of vascular access-related infections was investigated. Frequency of access-related infections was almost constant for 6 years after buttonhole cannulation was started. At the sixth year from initiation of buttonhole cannulation, however, the frequency of access-related infections started rising. The rise in frequency of vascular access-related infections in buttonhole cannulation may not be directly associated with inherent factor(s) of the method, but rather a factor(s) developing secondarily while performing buttonhole cannulation over a period of years.

È Possibile Ridurre Le Complicanze Infettive Dei CVC per Dialisi? Se Sì, Come?

The number of patients using a central venous catheter (CVC) for hemodialysis is too high, being far above 10% also in Italy. There are several complications associated with CVC use, among which infectious events are the most important, since they are related with relevant morbidity and mortality. A recent meta-analysis, performed by Zhao, has shown that, considering the incidence of CVC-related infections, the citrate lock was better than heparin when used in association with antimicrobial agents (such as gentamicin or taurolidine) and at low to moderate concentration. Moreover, citrate use reduced bleeding episodes, while there were no differences in terms of exit-site infection and the use of thrombolytic treatment. Results from a recent comparative effectiveness evaluation using a prospective, cluster-randomized design have underlined the importance of an adequate care of CVC and exit-site. The use of 2% chlorhexidine with 70% alcohol swab sticks for exit-site care and 70% alcohol pads to perform “scrub the hub” resulted in a significant 20% lower rate of central line-associated infections compared to the controls; this was accompanied by a significantly lower need of antibiotic therapy and lower hospitalization rates for both sepsis and vascular access–related infections and complications. Either way, new trials and techniques are urgently needed to further improve the prognosis of patients performing hemodialysis using a CVC.

Infection and Hemodialysis Access: An Updated Review.

The incidence of end-stage renal disease (ESRD) has almost doubled over past 2 decades. Despite decreasing overall hospital admission rates for ESRD population, the rate of infection-related hospitalizations has steadily increased. Infection remains the second most common cause of mortality in this patient population. Specifically, in the hemodialysis (HD) patients, the vascular access related infections are the most common identifiable source of infection. This concise review provides an update on the bacteremia related to vascular access primarily the catheters (Catheter Related Blood Stream Infection- CRBSI) in HD patients emphasizing on the determinants ranging from the epidemiology to pathogenesis, risk factors, cost implications and prevention. Staphylococcus aureus, coagulase negative Staphylococci, and Enterococci are the most common causative microorganisms implicated in CRBSI. The pathogenesis of CRBSI includes organism entry into the blood stream followed by adherence to catheter, colonization and biofilm formation. Vascular access type, catheter position, and prior bacteremic episodes are strongly associated with blood stream infection. Preventive measures should be multidisciplinary in nature and should include avoidance of central venous catheters, best practices for catheter care, surveillance, antimicrobial catheter lock solutions, and use of antibiotic impregnated catheters.

Clinical and Economic Value of Performing Dialysis Vascular Access Procedures in a Freestanding Office‐Based Center as Compared with the Hospital Outpatient Department among Medicare ESRD Beneficiaries

Dialysis vascular access (DVA) care is being increasingly provided in freestanding office-based centers (FOC). Small-scale studies have suggested that DVA care in a FOC results in favorable patient outcomes and lower costs. To further evaluate this issue, data were drawn from incident and prevalent ESRD patients within a 4-year sample (2006-2009) of Medicare claims (USRDS) on cases who receive at least 80% of their DVA care in a FOC or a hospital outpatient department (HOPD). Using propensity score matching techniques, cases with a similar clinical and demographic profile from these two sites of service were matched. Medicare utilization, payments, and patient outcomes were compared across the matched cohorts (n=27,613). Patients treated in the FOC had significantly better outcomes (p<0.001), including fewer related or unrelated hospitalizations (3.8 vs. 4.4), vascular access-related infections (0.18 vs. 0.29), and septicemia-related hospitalizations (0.15 vs. 0.18). Mortality rate was lower (47.9% vs. 53.5%) as were PMPM payments ($4,982 vs. $5,566). This study shows that DVA management provided in a FOC has multiple advantages over that provided in a HOPD.

EDITORIAL (Thematic Issue: Infection Control: A Paradigm Shift)

Centers for Disease Control and Prevention (CDC) defines hospital-acquired infections (HAIs) as infections caused by bacteria, viruses or fungi that occur during the course of receiving medical care [1]. This is a rapidly evolving field with tremendous interest from the public, regulatory bodies and the policymakers alike. The overall annual direct medical costs of HAIs to US hospitals is estimated between 30 and 45 Billion US$ [2]. The majority of HAIs are preventable with adequate planning and follow up. The availability of the details of HAIs in the public domain has resulted in robust infection control measures by medical facilities across the US. The Medicare non-payment for HAIs has also bolstered the overall infection control efforts. In this issue, the reviews are a mix of traditional reviews, dynamic clinical experience and promising new technology. Porkywka and Byers focus on traffic in the operating room [3]. A topic that is well established as a risk for surgical site infection (SSI) with little literature available. Yassin and Gupta review Hepatitis B virus (HBV) infection in hemodialysis (HD) units. [4] They summarize in detail the infection prevention measures from practical application perspective. Ferrelli and DiCuccio enumerate a successful strategy in promoting hand hygiene at an academic institution in a step-by-step fashion [5]. The experience with hand hygiene adherence exploring the implementation of novel strategy provides a different aspect of a commonly discussed topic. Clair and Colatrella present an excellent review of Infection control measures from the perspective of construction (new and maintenance of existing ones) in a healthcare setup [6]. Kandiah and colleagues review monochloramine use in prevention of Legionella in hospital water system [7]. This combines information on new technology and actual experience as the first medical center in the USA using an innovative delivery system. Qureshi and Yassin discuss the use of Ultraviolet (UV) radiation for environmental surface disinfection [8]. They describe the role of environmental surfaces in the spread of infections and provide updates on the usage of UV radiation in disinfection. Bacteremia in HD patients remains a major problem that requires multidisciplinary approach for its containment. Gupta and Yassin provide an updated concise review regarding prevention of vascular access related infection in HD patients [9]. The article spans through the various guidelines provided by societies ranging from infection control- Infectious Disease Society of America (IDSA), Healthcare Infection Control Practices Advisory Committee (HICPAC), CDC, Association for Professionals in Infection Control and Epidemiology (APIC) to primarily renal organization like the National Kidney Foundation (NKF), providing trans-societal, multispecialty recommendations. These articles were chosen to interest general medical or nursing reader as well as the specialists in the field of infection control. These reviews not only provide excellent appraisal of literature but also enumerate practically useful tips for providers working in the field. REFERENCES

Surveillance for infections and other adverse events in dialysis patients in southern Gran Canaria.

Bacterial infections pose a major challenge to risk management activities in the area of chronic haemodialysis, as vascular access-related infections are the main cause of mortality among these patients. Prospective surveillance study lasting 7 months (March-September, 2008) at two haemodialysis units in a district health area Gran Canaria, Spain. We used the methodology proposed by CDC´s Dialysis Surveillance Network. 1545 patients/month were recorded, 60.5% with an arteriovenous fistula (AVF), 35.5% with a permanent catheter (PC), 3.0% with grafts and 1.0% with temporary catheters. The rate of adverse events was 8.6 cases per 100 patients/month, 9.1 for AVF patients, and 2.9 for PC. Nevertheless, the other types of infections (respiratory, urinary tract, skin and chronic ulcers) showed similar rates. Microbiological cultures were taken in 82.2%, but this rate increased to 91.0% when a vascular access-related infection was suspected. Empirical treatment was adjusted to antibiogram results in 90.0% of occasions. A low incidence of multi-resistant microbes was observed. Gram-positive and gram-negative bacteria appeared in similar proportions. Vascular access is the main risk factor for infectious events. Epidemiological surveillance has allowed us to detect areas of improvement in different settings, acting as a key element in risk management and patient safety.

Medicare Reimbursement Policies and Hemodialysis Vascular Access Outcomes

In March 2010, the Center for Medicare and Medicaid Services (CMS) convened several clinical technical expert panels (C-TEP) to provide recommendations for improving various aspects of hemodialysis management. One of the C-TEPs was tasked with recommending measures to decrease vascular access-related infections. The members of this C-TEP, who are the authors of this manuscript, concluded unanimously that the single most important measure would be to remove financial and regulatory barriers to timely placement and revision of hemodialysis fistulas and the concurrent avoidance of catheter use. The following position paper outlines the financial barriers to improved vascular access outcomes and our proposals for a future CMS demonstration project.