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Li X, Mantell MD, Trerotola SO. Surgical Referral for Hemodialysis Access Maintenance. Cardiovasc Intervent Radiol 2023; 46:1192-1202. [PMID: 36849837 DOI: 10.1007/s00270-023-03380-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 01/27/2023] [Indexed: 03/01/2023]
Abstract
Hemodialysis access is the lifeline for end-stage renal disease patients. However, dialysis access is associated with a host of complications, including thrombosis, recurrent stenosis, infection, aneurysmal changes and bleeding. Although endovascular therapy remains the first-line treatment owing to its less invasive nature, there are certain situations where surgical referral is recommended or even necessary. Regardless, management of dialysis access complications requires a multidisciplinary approach. Interventional radiologists should be familiar with the appropriate timing for surgical referral to better serve the complex patient population.
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Affiliation(s)
- Xin Li
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street 1 Silverstein, Philadelphia, PA, 19104, USA
| | - Mark D Mantell
- Division of Vascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Scott O Trerotola
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street 1 Silverstein, Philadelphia, PA, 19104, USA.
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2
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Sinclair MR, Souli M, Ruffin F, Park LP, Dagher M, Eichenberger EM, Maskarinec SA, Thaden JT, Mohnasky M, Wyatt CM, Fowler VG. Staphylococcus aureus Bacteremia Among Patients Receiving Maintenance Hemodialysis: Trends in Clinical Characteristics and Outcomes. Am J Kidney Dis 2022; 79:393-403.e1. [PMID: 34303771 PMCID: PMC8783931 DOI: 10.1053/j.ajkd.2021.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 06/06/2021] [Indexed: 12/12/2022]
Abstract
RATIONALE & OBJECTIVE Staphylococcus aureus (Saureus) bacteremia (SAB) is associated with morbidity and mortality in patients receiving maintenance hemodialysis (HD). We evaluated changes in clinical and bacterial characteristics, and their associations with clinical outcomes with SAB in this population over a 21-year period. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS 453 hospitalized, non-neutropenic adults receiving maintenance HD who developed monomicrobial SAB between 1995 and 2015. EXPOSURE Clinical characteristics and bacterial genotype. OUTCOME All-cause and SAB-attributable mortality, persistent bacteremia, and metastatic complications. ANALYTICAL APPROACH Proportions of participants experiencing each outcome were calculated overall and by calendar year. Secular trends were estimated using binomial risk regression, a generalized linear model with the log link function for a binomial outcome. Associations with outcomes were estimated using logistic regression. RESULTS Over the 21-year study period, patients receiving maintenance HD experienced significant increases in age- and diabetes-adjusted SAB-attributable mortality (0.45% [95% CI, 0.36%-0.46%] per year), persistent bacteremia (0.86% [95% CI, 0.14%-1.55%] per year), metastatic complications (0.84% [95% CI, 0.11%-1.56%] per year), and infection with the virulent Saureus clone USA300 (1.47% [95% CI, 0.33%-2.52%] per year). Over time, the suspected source of SAB was less likely to be a central venous catheter (-1.32% [95% CI, -2.05 to-0.56%] per year) or arteriovenous graft (-1.08% [95% CI, -1.54 to-0.56] per year), and more likely to be a nonvascular access source (1.89% [95% CI, 1.29%-2.43%] per year). Patients with a nonvascular access suspected source of infection were more likely to die as a result of their S aureus infection (OR, 3.20 [95% CI, 1.36-7.55]). The increase in USA300 infections may have contributed to the observed increase in persistent bacteremia (OR, 2.96 [95% CI, 1.12-7.83]) but did not explain the observed increases in SAB-attributable mortality (OR, 0.83 [95% CI, 0.19-3.61]) or metastatic complications (OR, 1.34 [95% CI, 0.53-3.41]). LIMITATIONS Single-center, inpatient cohort. CONCLUSIONS The clinical and molecular epidemiology of SAB in patients receiving maintenance HD has changed over time, with an increase in SAB-attributable mortality and morbidity despite a decline in catheter-related infections.
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Affiliation(s)
- Matthew R. Sinclair
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Nephrology, Duke University Medical Center, Durham, North Carolina,Duke Clinical Research Institute, Durham, North Carolina
| | - Maria Souli
- Duke Clinical Research Institute, Durham, North Carolina
| | - Felicia Ruffin
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Lawrence P. Park
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina,Duke Global Health Institute, Durham, North Carolina
| | - Michael Dagher
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Emily M. Eichenberger
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Stacey A. Maskarinec
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Joshua T. Thaden
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Michael Mohnasky
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Christina M. Wyatt
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Nephrology, Duke University Medical Center, Durham, North Carolina,Duke Clinical Research Institute, Durham, North Carolina
| | - Vance G. Fowler
- Department of Medicine, Duke University Medical Center, Durham, North Carolina,Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina,Duke Clinical Research Institute, Durham, North Carolina
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Predictors of Mortality within 24 Months of Initial Arteriovenous Access Creation. Ann Vasc Surg 2021; 81:258-266. [PMID: 34752850 DOI: 10.1016/j.avsg.2021.08.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/27/2021] [Accepted: 08/29/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION End Stage Renal Disease is increasingly common, with approximately 785,880 patients currently dialysis dependent in the United States. 86% of these patients utilize hemodialysis. Arteriovenous (AV) access with either a fistula or graft is preferred over a catheter due to lowered complication risk. The purpose of this paper is to identify mid- term predictors of mortality to guide the type of AV access in patients with suboptimal cephalic veins. METHODS This is a retrospective review of patient characteristics at the time of initial AV access placement. All patients receiving first time AV access were reviewed. Mortality data was found via electronic medical records review, social security death index review, and internet search. Patients in whom mortality data could not be found were excluded from the final analysis. Univariate analysis using Chi-Squared testing and Student T-Test was performed. Binary logistic regression analysis was also performed for multivariate investigation. RESULTS A total of 176 patients underwent first time AV access during the study period. Two year mortality data was available for 149 of these patients. Mortality occurred within 2 years for 27% of patients. Advanced age (70 vs. 61, P < 0.01), arrhythmia (48% vs. 24%, P < 0.01), abnormal EKG (36% vs.14%, P < 0.01), CHF (47% vs. 24%, P < 0.01), white, non-Hispanic race (51% vs. 22%, P < 0.01) and history of smoking (48% vs. 15%, P < 0.01) were statistically significant univariate predictors of 2-year mortality. Advanced age, white race and smoking were multivariate predictors with smoking having the largest impact (multivariate adjusted OR 11.8, P < 0.001). CONCLUSIONS History of tobacco smoking has a profoundly negative effect on two year survival in patients undergoing initial AV access. Absence of smoking history provides significant 2-year mortality protection and thorough attempt at autologous AVF creation should be made in these patients. Cardiac disease and advanced age continue to be lead predictors of mortality in ESRD patients.
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Nielsen TL, Pilely K, Lund KP, Warming PE, Plesner LL, Iversen KK, Garred P. Hemodialysis leads to plasma depletion of lectin complement pathway initiator molecule ficolin-2. Hemodial Int 2021; 25:479-488. [PMID: 34132045 DOI: 10.1111/hdi.12948] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 03/22/2021] [Accepted: 05/23/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION This study aimed to investigate changes in complement system-related molecules in patients undergoing hemodialysis. METHODS Patients >18 years of age on maintenance hemodialysis were included. Using enzyme-linked immunosorbent assays (ELISA) methods complement related molecules ficolin-1, ficolin-2, ficolin-3 mannose-binding lectin, long pentraxin 3, complement activation products C3c, and complement activation potentials were measured before and after a single hemodialysis treatment. All patients were dialyzed with synthetic high flux filters >1.6 m2 , respectively, Polyamix and Polysulfone, and the Kt/V was maintained >1.3. FINDINGS Three hundred and four patients were included. There was a modest decrease in plasma level of ficolin-1 (p < 0.001). Ficolin-2 was virtually depleted with median 3.9 (interquartile range [IQR]: 2.6-6.1, range 0.3-13.5) μg/ml before dialysis to median 0.0 (IQR: 0.0-0.5, range 0.0-5.5) μg/ml after dialysis (p < 0.001). No significant difference before and after hemodialysis was seen for mannose-binding lectin and long pentraxin 3 (p > 0.05). In a random subgroup of 160 patients ficolin-2-binding, ficolin-3-mediated lectin pathway capacity and classical pathway capacity were significantly decreased due to hemodialysis. The complement capacity of the alternative pathway was increased after hemodialysis (p = 0.0101), while mannose-binding lectin-mediated lectin pathway capacity was unaltered (p = 0.79). There was an increase in the complement activation product C3c (p < 0.0001), while the concentration of total C4 and C3 did not change (p > 0.158). Multivariate Cox proportional hazard analyses showed an increased risk for all-cause mortality with increasing ficolin-2 (p = 0.002) after hemodialysis. DISCUSSION Plasma ficolin-2 was virtually depleted from the circulation after hemodialysis. However, elevated plasma ficolin-2 levels after hemodialysis was independently associated with increased mortality.
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Affiliation(s)
- Ture Lange Nielsen
- Laboratory of Molecular Medicine, Department of Clinical Immunology, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, Herlev Hospital, Herlev, Denmark
| | - Katrine Pilely
- Laboratory of Molecular Medicine, Department of Clinical Immunology, University of Copenhagen, Copenhagen, Denmark
| | - Kit P Lund
- Laboratory of Molecular Medicine, Department of Clinical Immunology, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | - Peter Garred
- Laboratory of Molecular Medicine, Department of Clinical Immunology, University of Copenhagen, Copenhagen, Denmark
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5
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Maksimov AV, Gaĭsina ÉA, Feĭskhanov AK. [Complications of permanent vascular access for haemodialysis]. ANGIOLOGIIA I SOSUDISTAIA KHIRURGIIA = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:165-174. [PMID: 35050263 DOI: 10.33529/angio2021411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Permanent vascular access is the basis of renal replacement therapy by the method of programmed haemodialysis, on whose stable functioning depends the life of patients with end-stage renal disease. At the present time, there is significant deficit of scientific and methodological Russian-language literature on this problem, with no Russian consensus documents concerned. This article is a review of the contemporary world literature dedicated to the problem of permanent vascular access, including currently in force European (2018) and North American (2019) guidelines for good clinical practice, also discussing the problems of strategy and tactics of creating a permanent vascular access, monitoring its dysfunction, pathophysiology of functioning of arteriovenous fistulas. Presented herein are unified approaches to diagnosis and treatment of thrombolytic and haemorrhagic complications associated with the access, as well as local infectious and non-infectious complications. Special attention is paid to indications for the operation and rational therapeutic decision-making.
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Affiliation(s)
- A V Maksimov
- Department of Vascular Surgery, Republican Clinical Hospital of the Ministry of Public Health of the Republic of Tatarstan, Kazan, Russia; Kazan State Medical Academy - Branch of the Russian Medical Academy of Continuous Professional Education under the RF Ministry of Public Health, Kazan, Russia
| | - É A Gaĭsina
- Department of Vascular Surgery, Republican Clinical Hospital of the Ministry of Public Health of the Republic of Tatarstan, Kazan, Russia
| | - A K Feĭskhanov
- Department of Vascular Surgery, Republican Clinical Hospital of the Ministry of Public Health of the Republic of Tatarstan, Kazan, Russia
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6
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Tseng YH, Wong MY, Huang TY, Lin BS, Tung CW, Huang YK. Molecular characterization of clinical isolates from vascular access infection: A single-institution study. Microbiologyopen 2020; 9:e1126. [PMID: 33006272 PMCID: PMC7658447 DOI: 10.1002/mbo3.1126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 12/12/2022] Open
Abstract
Hemodialysis requires repeated, reliable access to the systemic circulation; therefore, a well‐functioning vascular access (VA) procedure is crucial for stable hemodialysis. VA infections (VAIs) constitute the most challenging complication and cause considerable morbidity, loss of access, and even death. In this study, we investigated the molecular profiles of different bacterial isolates retrieved from various types of VA grafts. We collected clinical isolates from hemodialysis patients with VAIs in our institution for the period between 2013 and 2018. We identified the bacterial isolates using standard biochemical procedures; we used a polymerase chain reaction for coagulase‐negative staphylococci (CoNS) and Burkholderia cepacia complex (BCC) species identification. The antibiotic resistance and molecular profile were analyzed using the disk diffusion method and multilocus sequence typing, respectively. We studied 150 isolates retrieved from patients with VAI and observed that Staphylococcus aureus was the predominant bacterial species, followed by S. argenteus, BCC, and CoNS. According to multilocus sequence typing data, we identified a wide variety of sequence types (STs) in S. aureus isolates, with ST59, ST45, and ST239 being the predominant types. Burkholderia cepacia with two new ST types, namely ST1723 and ST1724, accounted for most of the BCC infections, along with ST102 B. contaminans, which were mainly isolated from infected tunneled‐cuffed catheters. In summary, the increased incidence of S. argenteus and BCC infections provides insights into their potential clinical effects in VAIs. The various STs identified in different bacterial species indicate the high genetic diversity of bacterial species isolated from VAIs in our institution.
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Affiliation(s)
- Yuan-Hsi Tseng
- Division of Thoracic and Cardiovascular Surgery, Chiayi Chang Gung Memorial Hospital, Puzi City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Min Yi Wong
- Division of Thoracic and Cardiovascular Surgery, Chiayi Chang Gung Memorial Hospital, Puzi City, Taiwan.,Microbiology Research and Treatment Center, Chiayi Chang Gung Memorial Hospital, Puzi City, Taiwan.,Institute of Imaging and Biomedical Photonics, College of Photonics, National Chiao Tung University, Tainan, Taiwan
| | - Tsung-Yu Huang
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Microbiology Research and Treatment Center, Chiayi Chang Gung Memorial Hospital, Puzi City, Taiwan.,Division of Infectious Diseases, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, Puzi City, Taiwan
| | - Bor-Shyh Lin
- Institute of Imaging and Biomedical Photonics, College of Photonics, National Chiao Tung University, Tainan, Taiwan
| | - Chun-Wu Tung
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Department of Nephrology, Chiayi Chang Gung Memorial Hospital, Puzi City, Taiwan
| | - Yao-Kuang Huang
- Division of Thoracic and Cardiovascular Surgery, Chiayi Chang Gung Memorial Hospital, Puzi City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Microbiology Research and Treatment Center, Chiayi Chang Gung Memorial Hospital, Puzi City, Taiwan
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7
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Jhee JH, Hwang SD, Song JH, Lee SW. The Impact of Comorbidity Burden on The Association between Vascular Access Type and Clinical Outcomes among Elderly Patients Undergoing Hemodialysis. Sci Rep 2019; 9:18156. [PMID: 31796787 PMCID: PMC6890785 DOI: 10.1038/s41598-019-54191-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 11/06/2019] [Indexed: 11/13/2022] Open
Abstract
The optimal vascular access type for elderly hemodialysis patients is controversial. We evaluated the impact of comorbidity burden on the association between vascular access type and mortality risk among 23,100 hemodialysis patients aged ≥65 years from the Korean Society of Nephrology End-Stage Renal Disease registry data. Subjects were stratified into tertiles according to the simplified Charlson comorbidity index (sCCI), and the survival and hospitalization rates were compared with respect to vascular access type: arteriovenous fistula (AVF), arteriovenous graft (AVG), and central venous catheter (CVC). Among all tertiles of sCCI, CVC use showed highest risk of mortality than AVF use. In the lowest to middle tertile, no difference was observed in survival rates between the use of AVF and AVG. However, in the highest tertile, AVG use showed higher risk of mortality than AVF use. When subjects were classified according to a combination of sCCI tertile and access type (AVF vs. AVG), patients with the highest CCI with AVG showed 1.75-folded increased risk of mortality than those with the lowest sCCI with AVF. Hospitalization rates due to access malfunction were highest in patients with CVC in all sCCI tertiles. In the highest tertile, patients with AVG showed increased rates of hospitalization compared to those with AVF due to access malfunction. However, hospitalization rates due to access infection were highest in patients with AVG in all tertiles. The use of AVF may be of benefit and switching to AVF should be considered in elderly hemodialysis patients with a high burden of comorbidity.
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Affiliation(s)
- Jong Hyun Jhee
- Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seun Deuk Hwang
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University, College of Medicine, Incheon, Korea
| | - Joon Ho Song
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University, College of Medicine, Incheon, Korea
| | - Seoung Woo Lee
- Division of Nephrology and Hypertension, Department of Internal Medicine, Inha University, College of Medicine, Incheon, Korea.
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Agrawal V, Valson AT, Mohapatra A, David VG, Alexander S, Jacob S, Bakthavatchalam YD, Prakash JAJ, Balaji V, Varughese S. Fast and furious: a retrospective study of catheter-associated bloodstream infections with internal jugular nontunneled hemodialysis catheters at a tropical center. Clin Kidney J 2019; 12:737-744. [PMID: 31583098 PMCID: PMC6768464 DOI: 10.1093/ckj/sfy138] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Nontunneled hemodialysis catheters (NTHCs) remain the preferred vascular access at hemodialysis (HD) initiation in developing countries. We studied the incidence, risk factors and microbiological spectrum of jugular NTHC-associated bloodstream infections (CABSIs) at a tertiary care center in South Asia. METHODS In this retrospective cohort study, all adult (≥18 years) incident patients who underwent jugular NTHC insertion for HD between January 2016 and June 2017, had no prior history of temporary vascular access insertion and were followed up for ≥14 days were included. RESULTS A total of 897 patients underwent NTHC insertion during the study period and 169 patients fulfilled the inclusion criteria and contributed 7079 patient days of follow-up. CABSI incidence was 7.34 episodes per 1000 catheter days and median infection-free survival and time to CABSI were 96 and 24.5 days, respectively. In multivariate Cox regression analysis, immunosuppressive medication {hazard ratio [HR] 2.87 [95% confidence interval (CI) 1.09-7.55]; P = 0.033} and intravenous cefazolin use [HR 0.51 (95% CI 0.28-0.94); P = 0.031] was independently associated with CABSI. The cumulative hazard of CABSI was 8.3, 13.3, 17.6 and 20.9% at Weeks 1, 2, 3 and 4, respectively. Gram-negative organisms were the most common etiological agents (54.7%) and 40.3% of CABSIs were caused by drug-resistant organisms. Gram-negative and Gram-positive CABSIs were associated with neutrophil left shift and higher procalcitonin compared with coagulase-negative staphylococcal CABSIs. CONCLUSION In South Asia, NTHC-associated CABSIs occur early and are predominantly Gram negative. We hypothesize that poor hygiene practices may play a role in this phenomenon.
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Affiliation(s)
- Varun Agrawal
- Department of Nephrology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Anna T Valson
- Department of Nephrology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Anjali Mohapatra
- Department of Nephrology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Vinoi George David
- Department of Nephrology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Suceena Alexander
- Department of Nephrology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Shibu Jacob
- Department of Nephrology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | | | | | - Veeraraghavan Balaji
- Department of Microbiology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Santosh Varughese
- Department of Nephrology, Christian Medical College Hospital, Vellore, Tamil Nadu, India
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9
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Loomba G, Dhandapani M, Kaur S, Ghai S, Biswal M, Ramachandran R, Gupta KL. The Effectiveness of Personal Hygiene Practices on Non-Cuffed Central Vein Catheter-Related Infection in Patients Undergoing Hemodialysis: A Randomized Controlled Trial. Indian J Nephrol 2019; 29:267-271. [PMID: 31423061 PMCID: PMC6668307 DOI: 10.4103/ijn.ijn_92_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Infection of the internal jugular vein (IJV) catheter continues to be a common cause of death in patients with end-stage renal disease undergoing hemodialysis (HD). The present study aimed to evaluate the effectiveness of personal hygiene on the incidence of IJV catheter-related bloodstream infection (CRBSI). A randomized, controlled, parallel, and non-inferiority trial was conducted on patients initiated on maintenance HD via right IJV catheter. Patients were randomly allocated to control and intervention group via computer-generated random table. Intervention package for the intervention group included hand washing (2–4 hourly and whenever visibly dirty), feet washing (12 hourly), and axillary shave (at any point during the study, no hair growth in axilla). Patients were provided with a pamphlet and reinforced to continue package till IJV catheter was in situ. Patients were followed up twice a week for one month from the date of catheter insertion for the incidence of CRBSI. The primary outcome of the study was percentage of patients free from CRBSI. On intention-to-treat analysis, the percentage of patients without CRBSI was 53.7% and 29.3% in the intervention and control arm, respectively [P = 0.04; 25.12% (1.43–45.28%)]. Positive blood cultures were higher in control (73.3%) as compared to the intervention group (28.6%) (P = 0.19). Personal hygiene interventions are an effective method to reduce the incidence of CRBSIs among population undergoing maintenance HD via non-cuffed IJV catheter.
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Affiliation(s)
| | | | - Sukhpal Kaur
- National Institute of Nursing Education, Chandigarh, India
| | - Sandhya Ghai
- National Institute of Nursing Education, Chandigarh, India
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10
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Alhazmi SM, Noor SO, Alshamrani MM, Farahat FM. Bloodstream infection at hemodialysis facilities in Jeddah: a medical record review. Ann Saudi Med 2019; 39:258-264. [PMID: 31381376 PMCID: PMC6838644 DOI: 10.5144/0256-4947.2019.258] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Bloodstream infections (BSI) are a major complication of hemodialysis. The risk of infection among hemodialysis patients is usually associated with the dialysis procedure itself, specifically the means of vascular access. OBJECTIVES Estimate the rate of BSI and assess factors possibly associated with BSI. DESIGN Analytical retrospective medical record review. SETTING Hemodialysis unit in a tertiary care center. PATIENTS AND METHODS Adult patients (18-60 years old) who had hemodialysis as first renal replacement therapy in the 20-month period from January 2014 to August 2016 were included in this study. Demographic and clinical characteristics were used in a multivariate logistic regression to assess factors that might be associated with BSI. MAIN OUTCOME MEASURES The rate of BSI and associated factors among chronic hemodialysis outpatients. SAMPLE SIZE AND CHARACTERISTICS 160 outpatients on hemodialysis, median (IQR) age 47.7 (37.0-56.0) years, males (60.6%). RESULTS The rate of BSI was 0.4 per 100 patient-months. Multivariate logistic regression revealed that patients who had central venous catheters had the highest risk for BSI (odds ratio: 10.088; 95% CI= 2.595-39.215; P=.001) compared with arteriovenous fistulas. Gram-negative bacteria were isolated in 54.6% of cases, with coagulase-negative Staphylococcus the most frequent isolate (18.2%), followed by Klebsiella pneumoniae and Enterobacteriaceae (15.2%, each). CONCLUSIONS The type of vascular access type is the main risk factor associated with BSI in hemodialysis patients. The arteriovenous fistula, which has a lower infection rate compared to the catheter, is the best available option for hemodialysis patients. LIMITATIONS Retrospective, single center and relatively small sample size. CONFLICT OF INTEREST None.
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Affiliation(s)
| | - Samah Omar Noor
- From the Faculty of Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Majid Mousa Alshamrani
- From the Infection Prevention and Control, King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh and Jeddah, Saudi Arabia
| | - Fayssal Mostafa Farahat
- From the Infection Prevention and Control, King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh and Jeddah, Saudi Arabia
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11
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Gork I, Gross I, Cohen MJ, Schwartz C, Moses AE, Elhalel MD, Benenson S. Access-related infections in two haemodialysis units: results of a nine-year intervention and surveillance program. Antimicrob Resist Infect Control 2019; 8:105. [PMID: 31244996 PMCID: PMC6582529 DOI: 10.1186/s13756-019-0557-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/10/2019] [Indexed: 01/08/2023] Open
Abstract
Background Access-related infections are a major cause of morbidity and mortality in haemodialysis patients. Our goal was to decrease the rate of these infections by implementing an intervention and surveillance program. Methods This intervention took place in two haemodialysis units (Units A and B) and was a joint effort by the haemodialysis staff and the unit for infection prevention and control. It included reviewing the work methods and work space, observations on compliance with standard precautions and handling of the vascular access, creating a checklist and a designated kit for handling the vascular access and prospective surveillance of access-related infections. Results During a nine-year period, the haemodialysis units A and B treated 4471 and 7547 patients (mean number of patients per year: 497 (range 435–556) and 839 (range 777–1055), respectively). For most patients, the procedure was done through an arteriovenous fistula (66.7%, range 50.3–81.5%). The access-related infection rate decreased significantly in both haemodialysis units: from 3 to 0.9% (trend: p < 0.05, linear regression: p < 0.001) in Unit A and from 0.9 to 0.2% (trend: p < 0.05, linear regression: p = 0.01) in Unit B. Conclusions An intervention which included introduction of a checklist and designated kit, together with ongoing surveillance and feedback, resulted in a significant decrease in the access-related infection rates in both haemodialysis units.
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Affiliation(s)
- Ittamar Gork
- 1Department of Nephrology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ilana Gross
- 2Department of Clinical Microbiology and Infectious Diseases, Hadassah - Hebrew University Medical Center, POB 12000, 9112001 Jerusalem, Israel
| | - Matan J Cohen
- 2Department of Clinical Microbiology and Infectious Diseases, Hadassah - Hebrew University Medical Center, POB 12000, 9112001 Jerusalem, Israel
| | - Carmela Schwartz
- 2Department of Clinical Microbiology and Infectious Diseases, Hadassah - Hebrew University Medical Center, POB 12000, 9112001 Jerusalem, Israel
| | - Allon E Moses
- 2Department of Clinical Microbiology and Infectious Diseases, Hadassah - Hebrew University Medical Center, POB 12000, 9112001 Jerusalem, Israel
| | | | - Shmuel Benenson
- 2Department of Clinical Microbiology and Infectious Diseases, Hadassah - Hebrew University Medical Center, POB 12000, 9112001 Jerusalem, Israel
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12
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Chaudry MS, Gislason GH, Kamper AL, Rix M, Larsen AR, Petersen A, Andersen PS, Skov RL, Fosbøl EL, Westh H, Schønheyder HC, Benfield TL, Fowler VG, Torp-Pedersen C, Bruun NE. Increased risk of Staphylococcus aureus bacteremia in hemodialysis-A nationwide study. Hemodial Int 2019; 23:230-238. [PMID: 30779302 DOI: 10.1111/hdi.12728] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 12/09/2018] [Accepted: 12/09/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Staphylococcus aureus bacteremia (SAB) is a high-risk infection and feared complication related to hemodialysis. This study aimed to investigate incidence and risk factors for SAB depending on hemodialysis access type. METHODS The Danish National Registry on Regular Dialysis and Transplantation was used to identify patients from January 1, 1996 to December 31, 2011 with end-stage kidney disease. Patients were followed until death, the first episode of SAB, or end of study (December 31, 2011). Independent risk factors were assessed by multivariable Poisson regression with time-updated exposure variables. FINDINGS Total of 9997 patients were included. The initial modality of renal replacement therapy was hemodialysis in 6826 patients and peritoneal dialysis in 2882 patients; 289 patients had preemptive kidney transplantation. SAB occurred in 1278 patients (12.8%). The incidence rate of SAB declined after 90 days and leveled off after 270 days in hemodialysis, peritoneal dialysis, and kidney transplanted. As compared to peritoneal dialysis, the adjusted rate ratio (RR) for SAB was 7.42 (95% CI 5.63-9.79) in uncuffed central venous catheter (CVC), 5.68 (95% CI 4.39-7.36) in cuffed CVC, 4.43 (95% CI 2.10-9.53) in arteriovenous graft, and 3.40 (95% CI 2.79-4.15) in arteriovenous fistula. SAB risk did not differ between uncuffed and cuffed CVC. The risk of SAB was increased during the first three months of renal replacement therapy especially for CVC (RR 11.37 [95% CI7.09-18.22]) compared with peritoneal dialysis. Diabetes mellitus (RR 1.35 [95% CI 1.20-1.51]) and male sex (RR 1.15 [95% CI 1.03-1.29]) were also associated with SAB. DISCUSSION Patients on hemodialysis had a high incidence rate of SAB, particularly those undergoing hemodialysis via CVC. SAB risk was comparable for cuffed and uncuffed CVC. Diabetes mellitus, male sex, and the first three months in renal replacement therapy were independently associated with SAB.
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Affiliation(s)
- Mavish S Chaudry
- Department of Cardiology, Herlev-Gentofte Hospital University of Copenhagen, Copenhagen, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Herlev-Gentofte Hospital University of Copenhagen, Copenhagen, Denmark.,The National Institute of Public Health, University of Southern Denmark and The Danish Heart Foundation, Odense, Denmark
| | - Anne-Lise Kamper
- Department of Nephrology, University Hospital Copenhagen Rigshospitalet, Copenhagen, Denmark
| | - Marianne Rix
- Department of Nephrology, University Hospital Copenhagen Rigshospitalet, Copenhagen, Denmark
| | - Anders R Larsen
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Andreas Petersen
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Paal S Andersen
- Department of Veterinary and Animal Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Robert L Skov
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Emil L Fosbøl
- The Heart Centre, University Hospital Copenhagen Rigshospitalet, Copenhagen, Denmark
| | - Henrik Westh
- Department of Clinical Microbiology, Hvidovre Hospital, Copenhagen, Denmark
| | - Henrik C Schønheyder
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark.,Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Thomas L Benfield
- Department of Clinical Microbiology, Hvidovre Hospital, Copenhagen, Denmark
| | - Vance G Fowler
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Epidemiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Niels E Bruun
- Department of Cardiology, Herlev-Gentofte Hospital University of Copenhagen, Copenhagen, Denmark.,Clinical Institute, Aalborg University, Aalborg, Denmark
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13
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Kim SH, Weaver SJ, Yang T, Rosen MA. Managing creativity and compliance in the pursuit of patient safety. BMC Health Serv Res 2019; 19:116. [PMID: 30755191 PMCID: PMC6373136 DOI: 10.1186/s12913-019-3935-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 01/29/2019] [Indexed: 11/22/2022] Open
Abstract
Background Are creativity and compliance mutually exclusive? In clinical settings, this question is increasingly relevant. Hospitals and clinics seek the creative input of their employees to help solve persistent patient safety issues, such as the prevention of bloodstream infections, while simultaneously striving for greater adherence to evidence-based guidelines and protocols. Extant research provides few answers about how creativity works in such contexts. Methods Cross-sectional survey data were collected from employees in 24 different U.S.-based outpatient hemodialysis clinics. Linear mixed-effects models were utilized to test study hypotheses. Professional status, clinic climate variables, and interaction terms were modeled as fixed effects, with a random effect for clinic included in all models. Results Our results show that high status employees contributed more creative patient safety improvement ideas compared to low status employees. However, when high status employees were part of clinics with a stronger safety climate of compliance, they contributed fewer creative ideas compared to their counterparts working in clinics with a reduced compliance orientation. We also predicted low status employees working in less punitive clinics would contribute more creative ideas, but this hypothesis was not fully supported. Conclusions This study suggests that in hospitals and clinics that rely on strict protocols and formal hierarchies to meet their goals, the factors that promote creativity may be distinctively context-dependent. Implications for theory, practice, as well as future directions for research examining creativity in healthcare and safety critical contexts are discussed. Electronic supplementary material The online version of this article (10.1186/s12913-019-3935-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sharon H Kim
- Johns Hopkins University Carey School of Business, 100 International Drive, Baltimore, MD, 21202, USA.
| | - Sallie J Weaver
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 750 E. Pratt Street, Baltimore, MD, 21202, USA
| | - Ting Yang
- Department of Medicine, Division of Rheumatology, Lyme Disease Research Center, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Michael A Rosen
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 750 E. Pratt Street, Baltimore, MD, 21202, USA
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14
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Abstract
Hemodialysis patients are at increased risk of infections, which are common adverse events among this patient population. We review factors contributing to infections among hemodialysis patients and epidemiology of common infections and outbreaks, including bloodstream infections, vascular access infections, and infections caused by bloodborne pathogens. Recommendations for prevention are discussed with emphasis on essential infection control practices for hemodialysis settings.
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15
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Avila-Danguillecourt N, Moodley AA, Makinga P. Prevalence and outcomes of central venous catheter-related bacteraemia in HIV-infected versus non-HIV-infected patients undergoing haemodialysis treatment for end-stage kidney disease. South Afr J HIV Med 2018; 19:859. [PMID: 30568839 PMCID: PMC6295969 DOI: 10.4102/sajhivmed.v19i1.859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/13/2018] [Indexed: 11/26/2022] Open
Abstract
Background Central venous catheter (CVC) haemodialysis (HD) to implement renal replacement therapy is the preferred choice in the urgent setting. Unfortunately, CVC placement is associated with multiple complications including nosocomial bloodstream infections. There is a paucity of data on the prevalence and pattern of pathogenic organisms in haemodialysed HIV-infected versus non-HIV-infected patients with end-stage kidney disease. Method and results We undertook a retrospective study of 228 patients who were dialysed using a CVC at a tertiary referral hospital in KwaZulu-Natal, South Africa. Seventy-eight patients (34.2%) complicated with bacteraemia and sepsis requiring antibiotics. Removal of the catheter was necessary in 58 patients (74.0%). The most common organisms isolated were Staphylococcus aureus (30.8%), Staphylococcus epidermidis (24.4%) and Klebsiella pneumoniae (15.4%). There was no statistically significant difference between HIV-infected and non-infected patients with regards to infection rate, time interval from insertion of CVC to infection and final outcome. However, HIV-infected patients took longer to recover; 54.3% of non-infected patients versus 10.3% HIV-infected patients had their sepsis controlled within one week. Acidosis, hypotension, line malfunction and line discharge were infrequent signs of sepsis. Fever, rigors and raised white cell count occurred in over 80.0% of patients. Conclusion The infection rate in CVC HD is not more frequent in HIV-infected patients, provided that CD4+ count is ≥ 200 cells/µL and the patient is virologically suppressed. Outcomes following intravenous antibiotic and removal of the CVC are similar in HIV-infected and non-infected patients but response to treatment is slower in HIV-infected patients. A high index of suspicion is needed in detecting CVC-related bacteraemia.
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Affiliation(s)
| | - Anand A Moodley
- Department of Medicine, University of the Free State, South Africa
| | - Polycarpe Makinga
- Department of Family Medicine, Ladysmith Hospital, University of KwaZulu-Natal, South Africa
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16
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Disruptive technological advances in vascular access for dialysis: an overview. Pediatr Nephrol 2018; 33:2221-2226. [PMID: 29188361 DOI: 10.1007/s00467-017-3853-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/15/2017] [Accepted: 11/16/2017] [Indexed: 12/31/2022]
Abstract
End-stage kidney disease (ESKD), one of the most prevalent diseases in the world and with increasing incidence, is associated with significant morbidity and mortality. Current available modes of renal replacement therapy (RRT) include dialysis and renal transplantation. Though renal transplantation is the preferred and ideal mode of RRT, this modality may not be available to all patients with ESKD. Moreover, renal transplant recipients are constantly at risk of complications associated with immunosuppression and immunosuppressant use, and posttransplant lymphoproliferative disorder. Dialysis may be the only available modality in certain patients. However, dialysis has its limitations, which include issues associated with lack of vascular access, risks of infections and vascular thrombosis, decreased quality of life, and absence of biosynthetic functions of the kidney. In particular, the creation and maintenance of hemodialysis vascular access in children poses a unique set of challenges to the pediatric nephrologist owing to the smaller vessel diameters and vascular hyperreactivity compared with adult patients. Vascular access issues continue to be one of the major limiting factors prohibiting the delivery of adequate dialysis in ESKD patients and is the Achilles' heel of hemodialysis. This review aims to provide a critical overview of disruptive technological advances and innovations for vascular access. Novel strategies in preventing neointimal hyperplasia, novel bioengineered products, grafts and devices for vascular access will be discussed. The potential impact of these solutions on improving the morbidity encountered by dialysis patients will also be examined.
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17
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Decreased percentage of memory B cells is independently associated with increased susceptibility to infection in patients on maintenance hemodialysis. Int Urol Nephrol 2018; 50:2081-2090. [PMID: 30276601 DOI: 10.1007/s11255-018-1977-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/05/2018] [Indexed: 12/13/2022]
Abstract
PURPOSE Infection is a common complication and cause of death in patients on maintenance hemodialysis (MHD). B lymphocytes, which are an important component of the immune system, play a significant role in defending against pathogen invasion. However, in patients on MHD, the connection between infection and B cell subsets remains largely unknown. Our study aims to clarify the potential role of the distribution of B cell subsets in the infection process in patients on MHD. METHODS In this cross-sectional study, basic information was collected from 175 patients on MHD from July 2016 to July 2017 at Zhongshan Hospital, Fudan University. The distributions of the B cell subsets in patients with and without infection were analyzed using flow cytometry to determine the role of B lymphocyte subsets in the infection process in patients on MHD. RESULTS Among the 175 patients, 45 suffered from infection. The respiratory tract was the most common infection site, accounting for 67.86% of all infections. After adjustment using multivariate logistic regression models, memory B cells [per 1% increase, odds ratio [95% confidence interval (CI)]: 0.949 (0.915, 0.984), P < 0.01], switched memory B cells [per 1% increase, odds ratio (95% CI): 0.939 (0.898, 0.982), P < 0.01], naïve B cells [per 1% increase, odds ratio (95% CI): 1.042 (1.009, 1.075), P < 0.05] and IgG titers [per 1 g/L increase, odds ratio (95% CI): 0.779 (0.630, 0.963), P < 0.05] were independent risk factors for infection in dialysis patients. CONCLUSION A decrease in memory B cells is independently associated with an increased risk of infection in patients on dialysis.
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18
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Blood-Stream Infection among Chronic Hemodialysis Patients: Review Article. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2017. [DOI: 10.22207/jpam.11.4.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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19
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Epidemiology of infections and antimicrobial use in Australian haemodialysis outpatients: findings from a Victorian surveillance network, 2008–2015. J Hosp Infect 2017; 97:93-98. [DOI: 10.1016/j.jhin.2017.05.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 05/24/2017] [Indexed: 11/22/2022]
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20
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Nguyen DB, Shugart A, Lines C, Shah AB, Edwards J, Pollock D, Sievert D, Patel PR. National Healthcare Safety Network (NHSN) Dialysis Event Surveillance Report for 2014. Clin J Am Soc Nephrol 2017; 12:1139-1146. [PMID: 28663227 PMCID: PMC5498356 DOI: 10.2215/cjn.11411116] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 03/20/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Persons receiving outpatient hemodialysis are at risk for bloodstream and vascular access infections. The Centers for Disease Control and Prevention conducts surveillance for these infections through the National Healthcare Safety Network. We summarize 2014 data submitted to National Healthcare Safety Network Dialysis Event Surveillance. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Dialysis facilities report three types of dialysis events (bloodstream infections; intravenous antimicrobial starts; and pus, redness, or increased swelling at the hemodialysis vascular access site). Denominator data consist of the number of hemodialysis outpatients treated at the facility during the first 2 working days of each month. We calculated dialysis event rates stratified by vascular access type (e.g., arteriovenous fistula, arteriovenous graft, or central venous catheter) and standardized infection ratios (comparing individual facility observed with predicted numbers of infections) for bloodstream infections. We described pathogens identified among bloodstream infections. RESULTS A total of 6005 outpatient hemodialysis facilities reported dialysis event data for 2014 to the National Healthcare Safety Network. These facilities reported 160,971 dialysis events, including 29,516 bloodstream infections, 149,722 intravenous antimicrobial starts, and 38,310 pus, redness, or increased swelling at the hemodialysis vascular access site events; 22,576 (76.5%) bloodstream infections were considered vascular access related. Most bloodstream infections (63.0%) and access-related bloodstream infections (69.8%) occurred in patients with a central venous catheter. The rate of bloodstream infections per 100 patient-months was 0.64 (0.26 for arteriovenous fistula, 0.39 for arteriovenous graft, and 2.16 for central venous catheter). Other dialysis event rates were also highest among patients with a central venous catheter. Facility bloodstream infection standardized infection ratio distribution was positively skewed with a median of 0.84. Staphylococcus aureus was the most commonly isolated bloodstream infection pathogen (30.6%), and 39.5% of S. aureus isolates tested were resistant to methicillin. CONCLUSIONS The 2014 National Healthcare Safety Network Dialysis Event data represent nearly all United States outpatient dialysis facilities. Rates of infection and other dialysis events were highest among patients with a central venous catheter compared with other vascular access types. Surveillance data can help define the epidemiology of important infections in this patient population.
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Affiliation(s)
- Duc B Nguyen
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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21
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Yadav P, England D, Vanderkolk C, Iroh Tam PY. Improving water quality in a dialysis unit using root cause analysis. Am J Infect Control 2017; 45:799-804. [PMID: 28302433 DOI: 10.1016/j.ajic.2017.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/07/2017] [Accepted: 02/07/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Water quality levels from hemodialysis (HD) and reverse osmosis (RO) machines in dialysis units must meet standards set by the American Association of Medical Instrumentation. Researchers used a root cause analysis (RCA) approach to identify and address factors affecting water quality in the HD and portable RO machines at our institution. METHODS A multidisciplinary team reviewed processes, interviewed staff members, and identified opportunities to improve the current sampling and machine disinfection processes. The RCA team identified and implemented 5 interventions, of which 3 were process (changes in water sampling technique, machine disinfection processes, and allocation of machine maintenance duties) and 2 were structural (regular cleaning of water sampling tubes and spigots and addition of new water sampling sites in the system) measures. RESULTS Postimplementation of new protocols, 100% of water cultures of HD and RO machines consistently met the required regulatory standards as recorded over a period of 8 months. CONCLUSIONS RCA approach helped improve patient safety, quality of care, streamlined processes, and improved efficiencies of work for staff within the HD program.
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22
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Oikonomou KG, Alhaddad A. Isolation Rate and Clinical Significance of Uropathogens in Positive Urine Cultures of Hemodialysis Patients. J Glob Infect Dis 2017; 9:56-59. [PMID: 28584456 PMCID: PMC5452552 DOI: 10.4103/0974-777x.204691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Hemodialysis (HD) patients are known to be vulnerable to infections. However, there are limited data on the urine microbiology spectrum among patients with end-stage renal disease and on the development of antimicrobial resistance of uropathogens in these patients. MATERIALS AND METHODS A single-center, retrospective study was conducted to assess the spectrum and antimicrobial resistance profile of microorganisms isolated in urine cultures of HD patients who were hospitalized between September 2008 and August 2015 with an admitting diagnosis of fever, sepsis, or urinary tract infection. Characteristics of patients were recorded, and associations between the aforementioned parameters were assessed with Fisher's exact test. RESULTS We included 75 HD patients (33 males, mean age 73.6 ± 16.6 years) with positive urine cultures. Despite urine culture positivity, the urinary tract was the confirmed source of infection in only 31 (41.3%) patients. Among the different pathogens, Escherichia coli was the predominant microorganism. Identification of E. coli as the involved uropathogen was associated neither with a growth of ≥105 CFU/ml, presence of fever, sepsis, urinary catheter use nor with higher antimicrobial resistance. E. coli growth, however, was significantly associated with polycystic kidney disease (P = 0.027). Extended antimicrobial resistance was noted in 29 (38.7%) patients but was associated neither with higher incidence of fever or sepsis nor with urinary catheter use. CONCLUSIONS In our series of HD patients with positive urine cultures, the isolation rates of different uropathogens do not seem to differ from the most commonly encountered ones in nondialysis patients although resistance to antimicrobials may be more frequently observed.
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Affiliation(s)
- Katerina G Oikonomou
- Department of Medicine, NYU Lutheran Medical Center, New York University School of Medicine, Brooklyn Campus, Brooklyn, NY, USA
| | - Adib Alhaddad
- Department of Medicine, NYU Lutheran Medical Center, New York University School of Medicine, Brooklyn Campus, Brooklyn, NY, USA
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23
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Al-Jaishi AA, Liu AR, Lok CE, Zhang JC, Moist LM. Complications of the Arteriovenous Fistula: A Systematic Review. J Am Soc Nephrol 2016; 28:1839-1850. [PMID: 28031406 DOI: 10.1681/asn.2016040412] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 11/25/2016] [Indexed: 11/03/2022] Open
Abstract
The implementation of patient-centered care requires an individualized approach to hemodialysis vascular access, on the basis of each patient's unique balance of risks and benefits. This systematic review aimed to summarize current literature on fistula risks, including rates of complications, to assist with patient-centered decision making. We searched Medline from 2000 to 2014 for English-language studies with prospectively captured data on ≥100 fistulas. We assessed study quality and extracted data on study design, patient characteristics, and outcomes. After screening 2292 citations, 43 articles met our inclusion criteria (61 unique cohorts; n>11,374 fistulas). Median complication rates per 1000 patient days were as follows: 0.04 aneurysms (14 unique cohorts; n=1827 fistulas), 0.11 infections (16 cohorts; n>6439 fistulas), 0.05 steal events (15 cohorts; n>2543 fistulas), 0.24 thrombotic events (26 cohorts; n=4232 fistulas), and 0.03 venous hypertensive events (1 cohort; n=350 fistulas). Risk of bias was high in many studies and event rates were variable, thus we could not present pooled results. Studies generally did not report variables associated with fistula complications, patient comorbidities, vessel characteristics, surgeon experience, or nursing cannulation skill. Overall, we found marked variability in complication rates, partly due to poor quality studies, significant heterogeneity of study populations, and inconsistent definitions. There is an urgent need to standardize reporting of methods and definitions of vascular access complications in future clinical studies to better inform patient and provider decision making.
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Affiliation(s)
- Ahmed A Al-Jaishi
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada.,Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Aiden R Liu
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada.,Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; and
| | - Charmaine E Lok
- Department of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Joyce C Zhang
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada.,Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; and
| | - Louise M Moist
- The Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, Ontario, Canada; .,Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; and
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24
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Patel PR, Shugart A, Mbaeyi C, Goding Sauer A, Melville A, Nguyen DB, Kallen AJ. Dialysis Event Surveillance Report: National Healthcare Safety Network data summary, January 2007 through April 2011. Am J Infect Control 2016; 44:944-7. [PMID: 27040568 DOI: 10.1016/j.ajic.2016.02.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 02/01/2016] [Accepted: 02/04/2016] [Indexed: 11/17/2022]
Abstract
A total of 24,092 adverse events in hemodialysis outpatients during January 2007 through April 2011 were reported to the National Healthcare Safety Network. Of 2,656 bloodstream infections, 67.3% were in patients with central venous catheters. For all events, rates associated with central venous catheters were higher than for other vascular access types.
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Affiliation(s)
- Priti R Patel
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Alicia Shugart
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Chukwuma Mbaeyi
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ann Goding Sauer
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Anna Melville
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Duc B Nguyen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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25
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Colville LA, Lee AH. Retrospective Analysis of Catheter-Related Infections in a Hemodialysis Unit. Infect Control Hosp Epidemiol 2016; 27:969-73. [PMID: 16941325 DOI: 10.1086/507821] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2005] [Accepted: 06/30/2005] [Indexed: 11/03/2022]
Abstract
Objective.To compare the incidence rates of catheter-related bloodstream infection associated with different vascular access methods in patients receiving hemodialysis.Setting.Tertiary care public hospital in Western Australia.Design.Retrospective analysis of surveillance data collected by the hospital's infection control department.Methods.The number of confirmed bloodstream infections for each type of vascular access was identified for the period from July 2002 through June 2003. The corresponding number of patient-days was determined to calculate the infection incidence rates. The serially correlated data were then analyzed using Poisson generalized estimating equations.Results.A total of 32 confirmed bloodstream infections were identified. Infection rates, in number of infections per 1,000 patient-days, were as follows: 0.4 for native arteriovenous fistulae; 2.86 for synthetic arteriovenous grafts; 4.02 for permanent, tunneled, cuffed central venous catheters; and 20.2 for temporary, nontunneled, noncuffed central venous catheters. Compared with permanent catheters, the monthly infection rate associated with the temporary catheters was significantly higher (incident rate ratio [IRR], 5.025 [95% confidence interval {CI}, 1.532-16.484]; P = .008) and that of arteriovenous fistulae was significantly lower (IRR, 0.099 [95% CI, 0.030-0.324]; P = .001). The monthly infection rate for arteriovenous grafts was not significantly different from that for permanent central venous catheters (IRR, 0.702 [95% CI, 0.246-2.008]; P = .510).Conclusions.A hierarchy of infection risk associated with vascular access type is evident. Native arteriovenous fistulae should be recommended for all patients receiving chronic hemodialysis, to minimize infection.
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Affiliation(s)
- Linda A Colville
- School of Public Health, Curtin University of Technology, Perth, Australia
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Percival SL, Kite P, Eastwood K, Murga R, Carr J, Arduino MJ, Donlan RM. Tetrasodium EDTA as a Novel Central Venous Catheter Lock Solution Against Biofilm. Infect Control Hosp Epidemiol 2016; 26:515-9. [PMID: 16018425 DOI: 10.1086/502577] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AbstractBackground:Central venous catheter (CVC)-related bloodstream infections (BSIs) are known to increase rates of morbidity and mortality in both inpatients and outpatients, including hematology-oncology patients and those undergoing hemodialysis or home infusion therapy. Biofilm-associated organisms on the lumens of these catheters have reduced susceptibility to antimicrobial chemotherapy. This study tested the efficacy of tetrasodium EDTA as a catheter lock solution on biofilms of several clinically relevant microorganisms.Methods:Biofilms ofStaphylococcus epidermidis, methicillin-resistantS. aureus, Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, andCandida albicanswere grown to levels of approximately 1 × 105colony-forming units (CFU)/cm−1on CVC segments in a model system, then subjected to the tetrasodium EDTA lock treatment.Results:Comparisons of biofilms before and after exposure to the 40-mg/mL−1tetrasodium EDTA lock for 21 hours showed that the biofilm viable cell counts of all organisms tested were significantly reduced (P< .05) after exposure to the treatment.Conclusion:Antimicrobial lock treatment using 40 mg/mL−1of tetrasodium EDTA for at least 21 hours could significantly reduce or potentially eradicate CVC-associated bio-films of clinically relevant microorganisms (Infect Control Hosp Epidemiol2005;26:515-519).
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Affiliation(s)
- Steven L Percival
- Department of Microbiology, Leeds Teaching Hospitals, Leeds, United Kingdom
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Samanipour A, Dashti-Khavidaki S, Abbasi MR, Abdollahi A. Antibiotic resistance patterns of microorganisms isolated from nephrology and kidney transplant wards of a referral academic hospital. J Res Pharm Pract 2016; 5:43-51. [PMID: 26985435 PMCID: PMC4776546 DOI: 10.4103/2279-042x.176559] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Antibiotic use pattern and emergence of resistant bacteria are major concerns in clinical settings. This study aimed to detect common bacteria and their antibiotic sensitivity patterns in nephrology and kidney transplant wards. METHODS This 1-year, observational study was performed in the nephrology and kidney transplant wards of Imam Khomeini Hospital Complex, Tehran, Iran. All patients treated with antimicrobial agents for confirmed or suspected infections were included. Their demographic, clinical, and laboratory data (including biological media used for microbial culture, growth organisms, and antibiograms) were collected. Adherence of antimicrobial regimen to standard guidelines was also assessed. FINDINGS About half of the patients received antibiotic. The most common infecting bacteria were Escherichia coli followed by Enterococcus sp. and Staphylococcus aureus. E. coli showed high rate of sensitivity to carbapenems and nitrofurantoin and high rate of resistance to co-trimoxazole and ciprofloxacin. Enterococcus sp. in both wards had high rate of resistance to ampicillin and were all sensitive to linezolid. Unlike to the nephrology ward, more than 50% of Enterococcus sp. from kidney transplant ward was resistant to vancomycin. The most common type of S. aureus in this nephrology ward was methicillin-resistant S. aureus (MRSA). Most commonly-prescribed antibiotics were carbapenems followed by vancomycin, ciprofloxacin, and ceftriaxone. Antibiotic regimens were 75% and 83%, 85% and 91%, and 80% and 87% compatible with international guidelines in antibiotic types, dosages, and treatment durations, respectively, in nephrology and kidney transplant wards, respectively. CONCLUSION MRSA, fluoroquinolone-resistant E. coli, and vancomycin resistant Enterococcus species are major threats in nephrology and kidney transplant wards. Most commonly-prescribed antibiotics were carbapenems that necessitate providing internal guidelines by the teamwork of clinical pharmacist, infectious disease specialists, and nephrologists to avoid the widespread use of broad-spectrum antibiotics.
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Affiliation(s)
- Atieh Samanipour
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Simin Dashti-Khavidaki
- Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran; Center of Excellence in Nephrology, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad-Reza Abbasi
- Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran; Center of Excellence in Nephrology, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Abdollahi
- Department of Pathology, Vali-e-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Kukita K, Ohira S, Amano I, Naito H, Azuma N, Ikeda K, Kanno Y, Satou T, Sakai S, Sugimoto T, Takemoto Y, Haruguchi H, Minakuchi J, Miyata A, Murotani N, Hirakata H, Tomo T, Akizawa T. 2011 update Japanese Society for Dialysis Therapy Guidelines of Vascular Access Construction and Repair for Chronic Hemodialysis. Ther Apher Dial 2015; 19 Suppl 1:1-39. [PMID: 25817931 DOI: 10.1111/1744-9987.12296] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Evaluation of sterilization using the MEH200® (cotton pack) in vascular access puncture. J Vasc Access 2015; 16 Suppl 10:S70-3. [PMID: 26349880 DOI: 10.5301/jva.5000414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2015] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In recent years, chlorhexidine-alcohol has been attracting increasing attention for its role in skin antisepsis. There have been few reports on the infection frequency associated with vascular access and no reports on the infection frequency associated with antiseptics. AIMS We investigated skin disinfection during vascular access puncture in patients on chronic hemodialysis (HD). METHODS We analyzed patients on chronic HD with arteriovenous fistula (AVF) and arteriovenous graft (AVG) between January 2006 and December 2010. RESULTS The MEH200® (cotton pack including alcohol and chlorhexidine gluconate) was used in 97% of patients. A total of 1130 patients were analyzed, including 911 with AVF and 219 with AVG. Of these, seven with AVF had an infection attributed to the insertion site, which represented a rate of 0.008% of patients per year. Twenty patients with AVG had an infection attributed to the insertion site, which represented a rate of 9.1% of patients per year. The frequency was not higher than that previously reported. CONCLUSIONS In HD patients, the MEH200® may be effective for the prevention of bacteremia.
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Chidambaram R. A Cautionary Tale on the Central Venous Catheter: Medical Note for Oral Physicians. Malays J Med Sci 2015; 22:78-84. [PMID: 28239272 PMCID: PMC5295746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 06/03/2015] [Indexed: 06/06/2023] Open
Abstract
Complexity in the health status of patients with kidney disease forces to seek the aid of medical devices such as the central venous catheter (CVC) that is essential in order to perform hemodialysis. Elementary information about the CVC, as required for the oral healthcare professionals, has been documented so as to serve as a medical manual. This communication is the first of its kind that conjointly delineates vital considerations, which precede dental maneuvers in patients implanted with a CVC.
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Affiliation(s)
- Ramasamy Chidambaram
- Correspondence: Dr Ramasamy Chidambaram, BDS (Annamalai University), MDS (Sri Ramachandra University), Department of Prosthodontics, Faculty of Dentistry, AIMST University, Semeling 08100, Jalan Bedong, Kedah Darul Aman, Malaysia, Tel: +9016–472 4370, Fax: +604-429 8009,
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Evaluation of Catheter Infection Rates in Converted Dialysis Catheters versus de Novo Placement in the Setting of Chlorhexidine Use. J Vasc Access 2015; 17:162-6. [DOI: 10.5301/jva.5000490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2015] [Indexed: 11/20/2022] Open
Abstract
Purpose Prior studies have reported infection rates of converting non-tunneled dialysis catheters (NTDCs) to tunneled dialysis catheters (TDCs) versus de novo placement of TDCs using povidone-iodine. Chlorhexidine, per the Center of Disease Control guidelines, has been exclusively used in our institution since 2005. Therefore, our study aims to determine whether there is a difference in infection rates between conversion and de novo placement when utilizing chlorhexidine. Materials and Methods A retrospective analysis from 1/1/2009 to 8/10/2012 was performed of patients who underwent placement of NTDCs, which were subsequently converted to TDCs and those who underwent de novo TDC placement. To assess the rate of infection, the following data points were collected: date of procedure(s), indication, outcomes, site of catheter insertion, pre- and post-procedure laboratory values, complications, infection rates within the life of the initially placed catheter, catheter days, and survival. Results The conversion cohort was composed of 205 patients, 135 of whom were lost to follow-up, leaving 70 patients. The de novo cohort included 70 randomly selected patients. Of the 70 patients who underwent conversion, 23 developed a catheter-related infection, with an infection rate of 0.26 events per 100 catheter days. Of the 70 de novo catheters, 20 developed infection with an infection rate of 0.25 events per 100 catheters days. Conclusion In this series, there is no difference in infection rates between conversion and de novo TDC placement when utilizing chlorhexidine as the sterilization agent. However, these infection rates are superior to those reported when using povidone-iodine.
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Kanaa M, Wright MJ, Akbani H, Laboi P, Bhandari S, Sandoe JAT. Cathasept Line Lock and Microbial Colonization of Tunneled Hemodialysis Catheters: A Multicenter Randomized Controlled Trial. Am J Kidney Dis 2015; 66:1015-23. [PMID: 26141306 DOI: 10.1053/j.ajkd.2015.04.047] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 04/28/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Catheter-related bloodstream infections (CRBSIs) cause morbidity and mortality in hemodialysis (HD) patients. Cathasept (tetra-sodium EDTA) solution has antimicrobial and anticoagulant activities. STUDY DESIGN Multicenter prospective randomized controlled study. SETTING & PARTICIPANTS 117 maintenance HD patients with confirmed uncolonized tunneled HD catheters from 4 HD centers. INTERVENTION Patients were randomly assigned to receive Cathasept 4% locks (Cathasept group) or stayed with heparin 5,000 U/mL locks (heparin group), filled thrice weekly according to catheter lumen volume until the catheter was removed or for a maximum of 8 months. OUTCOMES Primary outcome was clinically significant microbial colonization of the catheter, defined as a through-catheter quantitative blood culture yielding ≥ 1,000 colony-forming units/mL of bacteria or yeast. Secondary outcomes included CRBSI rate, catheter patency, and biomarkers of inflammation and anemia. MEASUREMENTS Weekly through-catheter quantitative blood culture, high-sensitivity C-reactive protein fortnightly, and full blood count and ferritin monthly. RESULTS Incidence rates of catheter colonization were 0.14/1,000 catheter-days in the Cathasept group and 1.08/1,000 catheter-days in the heparin group (incidence rate ratio [IRR], 0.13; 95% CI, 0.003-0.94; P=0.02). CRBSI rates were 0.28/1,000 catheter-days in the Cathasept group and 0.68/1,000 catheter days in the heparin group (IRR, 0.40; 95% CI, 0.08-2.09; P=0.3). The proportion of dialysis sessions with achieved prescribed blood flow rate was significantly lower in the Cathasept group (66.8% vs 75.3%; P<0.001), with more patients requiring thrombolytic locks or infusions to maintain catheter patency (22 vs 9; P=0.01). Mean high-sensitivity C-reactive protein level was 11.6±5.3 (SE) mg/L lower for patients in the heparin group (P=0.03). Anemia marker levels were similar in both groups. LIMITATIONS Study was underpowered to assess effect on CRBSI, terminated early due to slow recruitment, and not double blinded. CONCLUSIONS Cathasept significantly reduced tunneled hemodialysis catheter colonization, but the reduction in CRBSIs was not statistically significant, and it was associated with more thrombotic complications. Its safety profile was comparable to heparin lock solution.
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Affiliation(s)
- Muhammad Kanaa
- Doncaster & Bassetlaw Hospitals NHS Foundation Trust, Doncaster Royal Infirmary, Doncaster, South Yorkshire, United Kingdom.
| | - Mark J Wright
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Habib Akbani
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - Paul Laboi
- York Teaching Hospital NHS Foundation Trust, York, United Kingdom
| | - Sunil Bhandari
- Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School, Hull, United Kingdom
| | - Jonathan A T Sandoe
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom; University of Leeds, Leeds, United Kingdom
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Revest M, Camou F, Senneville E, Caillon J, Laurent F, Calvet B, Feugier P, Batt M, Chidiac C. Medical treatment of prosthetic vascular graft infections: Review of the literature and proposals of a Working Group. Int J Antimicrob Agents 2015; 46:254-65. [PMID: 26163735 DOI: 10.1016/j.ijantimicag.2015.04.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 04/07/2015] [Accepted: 04/21/2015] [Indexed: 02/07/2023]
Abstract
More than 400000 vascular grafts are inserted annually in the USA. Graft insertion is complicated by infection in 0.5-4% of cases. Vascular graft infections (VGIs) are becoming one of the most frequent prosthesis-related infections and are associated with considerable mortality, ranging from 10 to 25% within 30 days following the diagnosis. Treatment of VGI is based on urgent surgical removal of the infected graft followed by prolonged antibiotherapy. Data regarding the best antibiotherapy to use are lacking since no well designed trial to study antimicrobial treatment of VGI exists. Moreover, since VGIs demonstrate very specific pathophysiology, guidelines on other material-related infections or infective endocarditis treatment cannot be entirely applied to VGI. A French multidisciplinary group gathering infectious diseases specialists, anaesthesiologists, intensivists, microbiologists, radiologists and vascular surgeons was created to review the literature dealing with VGI and to make some proposals regarding empirical and documented antibiotic therapy for these infections. This article reveals these proposals.
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Affiliation(s)
- M Revest
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France; CIC Inserm 1414, Rennes 1 University, Rennes, France
| | - F Camou
- Intensive Care Unit, Saint-André University Hospital, Bordeaux, France
| | - E Senneville
- Infectious Diseases Department, Gustave Dron Hospital, Tourcoing, Lille 2 University, France
| | - J Caillon
- Bacteriology Department, EA 3826 Nantes University, Hôtel Dieu University Hospital, Nantes, France
| | - F Laurent
- Bacteriology Department, International Center for Infectiology Research (CIRI) - INSERM U1111, CNRS UMR5308, Lyon 1 University, ENS de Lyon, Hospices Civils de Lyon, Lyon, France
| | - B Calvet
- Anesthesiology Department, Beziers, France
| | - P Feugier
- Department of Vascular Surgery, University Claude Bernard Lyon 1, Hospices Civils de Lyon, Lyon, France
| | - M Batt
- Department of Vascular Surgery, University of Nice-Sophia Antipolis, Nice, France
| | - C Chidiac
- Infectious Diseases Department, University Claude Bernard Lyon 1, Hospices Civils de Lyon, Inserm U1111, Lyon 1 University, Lyon, France.
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Kapoian T, Meyer KB, Johnson DS. Infection prevention and the medical director: uncharted territory. Clin J Am Soc Nephrol 2015; 10:863-74. [PMID: 25710803 PMCID: PMC4422234 DOI: 10.2215/cjn.06050614] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Infections continue to be a major cause of disease and contributor to death in patients on dialysis. Despite our knowledge and acceptance that hemodialysis catheters should be avoided and eliminated, most patients who begin dialysis initiate treatment through a central vein hemodialysis catheter. Dialysis Medical Directors must be the instrument through which our industry changes. We must lead the charge to educate our dialysis staff and our dialysis patients. We must also educate ourselves so that we not only know that our facility policies are consistent with the best evidence available, but we must also know where local and federal regulations differ. When these differences impact on patient care, we must speak out and have these regulations changed. But it is not enough to know the rules and write them. We must lead by example and show our patients, our nephrology colleagues and our dialysis staff that we always follow these same policies. We need to practice what we preach and be willing and available to redirect those individuals who have difficulty following the rules. In order to effectively change process meaningful data must be collected, analyzed and acted upon. Dialysis Medical Directors must direct and lead the quality improvement process. We hope this review provides Dialysis Medical Directors with the necessary tools to effectively drive this process and improve care.
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Affiliation(s)
- Toros Kapoian
- Associate Professor of Medicine, Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Division of Nephrology New Brunswick, New Jersey; Medical Director, Dialysis Clinic, Inc., North Brunswick, New Jersey
| | - Klemens B Meyer
- Professor of Medicine, Division of Nephrology, Tufts University School of Medicine, Medford, Massachusetts; Director, Dialysis Services, Tufts Medical Center, Boston, Massachusetts; and
| | - Douglas S Johnson
- Vice-Chairman of the Board, Dialysis Clinic Inc., Nashville, Tennessee
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Moghaddas A, Abbasi MR, Gharekhani A, Dashti-Khavidaki S, Razeghi E, Jafari A, Khalili H. Prevention of hemodialysis catheter-related blood stream infections using a cotrimoxazole-lock technique. Future Microbiol 2015; 10:169-78. [DOI: 10.2217/fmb.14.116] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Background & aim: 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. Method: 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. Results: 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. Conclusion: cotrimoxazole containing catheter lock solution is effective in reducing CRBSIs incidence and prolonging dialysis catheter survival in HD patients.
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Affiliation(s)
- Azadeh Moghaddas
- Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Afshin Gharekhani
- Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Effat Razeghi
- Nephrology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Atefeh Jafari
- Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hossein Khalili
- Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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Rao CY, Pachucki C, Cali S, Santhiraj M, Krankoski KLK, Noble-Wang JA, Leehey D, Popli S, Brandt ME, Lindsley MD, Fridkin SK, Arduino MJ. Contaminated Product Water as the Source ofPhialemonium curvatumBloodstream Infection among Patients Undergoing Hemodialysis. Infect Control Hosp Epidemiol 2015; 30:840-7. [DOI: 10.1086/605324] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective.We investigated a cluster of cases of bloodstream infection (BSI) due to the moldPhialemoniumat a hemodialysis center in Illinois and conducted a cohort study to identify risk factors.Design.Environmental assessment and cohort study.Setting.A hemodialysis center in a tertiary care hospital.Methods.A case patient was defined as a person who underwent dialysis at the center and had a blood sample that tested positive forPhialemonium curvatumon culture. We reviewed microbiology and medical records and tested water, surface, and dialysate samples by culture. Molds isolated from environmental and clinical specimens were identified by their morphological features and confirmed by sequencing DNA.Results.We identified 2 case patients with BSI due toP. curvatum. Both became febrile and hypotensive while undergoing dialysis on the same machine at the same treatment station, although on different days. Dialysis machines were equipped with waste handling option ports that are used to discard dialyzer priming fluid. We isolatedP. curvatumfrom the product water (ie, water used for dialysis purposes) at 2 of 19 treatment stations, one of which was the implicated station.Conclusion.The source ofP. curvatumwas likely the water distribution system. To our knowledge, this is the first report of patients acquiring a mold BSI from contaminated product water. The route of exposure in these cases of BSI due toP. curvatummay be related to the malfunction and improper maintenance of the waste handling option ports. Waste handling option ports have been previously implicated as the source of bacterial BSI due to the backflow of waste fluid into a patient's blood line. No additional cases of infection were noted after remediation of the water distribution system and after discontinuing use of waste handling option ports at the facility.
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Gao JJ, Wei JM, Gao YH, Li S, Na Y. Central venous catheter infection-induced Henoch-Schönlein purpura in a patient on hemodialysis. Ren Fail 2014; 36:1145-7. [PMID: 24845224 DOI: 10.3109/0886022x.2014.917765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A 69-year-old man, who had been dialyzed using a permanent central venous catheter for 2 years, presented with Henoch-Schönlein purpura and positive perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA). He was diagnosed with catheter-related infection by Staphylococcus aureus. After administration of antibiotic and steroid therapy, purpura disappeared and p-ANCA gradually became negative. This case supports the conclusion that infection can be pathogenesis of the vasculitis, including ANCA-positive HSP. Additionally, impregnation of catheters with antibiotics can be an effective treatment for catheter infections.
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Affiliation(s)
- Jian Jun Gao
- Department of Nephrology, the 306th Hospital of Chinese PLA , Beijing , China
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Albuquerque SEKD, Cavalcante RDS, Ponce D, Fortaleza CMCB. Epidemiology of healthcare-associated infections among patients from a hemodialysis unit in southeastern Brazil. Braz J Infect Dis 2013; 18:327-30. [PMID: 24275375 PMCID: PMC9427539 DOI: 10.1016/j.bjid.2013.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 09/29/2013] [Accepted: 10/12/2013] [Indexed: 11/04/2022] Open
Abstract
Patients submitted to hemodialysis are at a high risk for healthcare-associated infections (HAI). Presently there are scarce data to allow benchmarking of HAI rates in developing countries. Also, most studies focus only on bloodstream infections (BSI) or local access infections (LAI). Our study aimed to provide a wide overview of HAI epidemiology in a hemodialysis unit in southeastern Brazil. We present data from prospective surveillance carried out from March 2010 through May 2012. Rates were compared (mid-p exact test) and temporally analyzed in Shewhart control charts for Poisson distributions. The overall incidence of BSI was 1.12 per 1000 access-days. The rate was higher for patients performing dialysis through central venous catheters (CVC), either temporary (RR = 13.35, 95% CI = 6.68–26.95) or permanent (RR = 2.10, 95% CI = 1.09–4.13), as compared to those with arteriovenous fistula. Control charts identified a BSI outbreak caused by Pseudomonas aeruginosa in April 2010. LAI incidence was 3.80 per 1000 access-days. Incidence rates for other HAI (per 1000 patients-day) were as follows: upper respiratory infections, 1.72; pneumonia, 1.35; urinary tract infections, 1.25; skin/soft tissues infections, 0.93. The data point out to the usefulness of applying methods commonly used in hospital-based surveillance for hemodialysis units.
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Affiliation(s)
- Silvia Eduara Kennerly de Albuquerque
- Comissão de Controle de Infecção Relacionada à Assistência em Saúde, Hospital das Clínicas da Faculdade de Medicina de Botucatu, UNESP - Univ Estadual Paulista, City of Botucatu, Brazil.
| | - Ricardo de Souza Cavalcante
- Comissão de Controle de Infecção Relacionada à Assistência em Saúde, Hospital das Clínicas da Faculdade de Medicina de Botucatu, UNESP - Univ Estadual Paulista, City of Botucatu, Brazil; Departamento de Doenças Tropicais e Diagnóstico por Imagem, Faculdade de Medicina de Botucatu, UNESP - Univ Estadual Paulista, City of Botucatu, Brazil
| | - Daniela Ponce
- Disciplina de Nefrologia, Departamento de Clínica Médica, Faculdade de Medicina de Botucatu, UNESP - Univ Estadual Paulista, City of Botucatu, Brazil
| | - Carlos Magno Castelo Branco Fortaleza
- Comissão de Controle de Infecção Relacionada à Assistência em Saúde, Hospital das Clínicas da Faculdade de Medicina de Botucatu, UNESP - Univ Estadual Paulista, City of Botucatu, Brazil; Departamento de Doenças Tropicais e Diagnóstico por Imagem, Faculdade de Medicina de Botucatu, UNESP - Univ Estadual Paulista, City of Botucatu, Brazil
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Patibandla BK, Narra A, Desilva R, Chawla V, Vin Y, Brown RS, Goldfarb-Rumyantzev AS. Disparities in arteriovenous fistula placement in older hemodialysis patients. Hemodial Int 2013; 18:118-26. [PMID: 24118883 DOI: 10.1111/hdi.12099] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The benefits of an arteriovenous fistula (AVF) as the preferred vascular access for hemodialysis have been clearly demonstrated. However, only about 20% of patients in the United States initiate hemodialysis with an AVF. In this study, we assessed whether disparities exist in the type of first hemodialysis access placed prior to dialysis start (rather than that used at dialysis initiation), to detect whether certain disadvantaged groups might have lower likelihood of AVF placement. Study cohort of 118,767 incident hemodialysis patients ≥67 years of age (1/2005-12/2008) derived from the United States Renal Data System was linked with Medicare claims data to identify the type of initial access placed predialysis. We used logistic regression model with outcome being the initial predialysis placement of an AVF as opposed to an arteriovenous graft or a central venous catheter. Increasing age, female sex, black race, lower body mass index, urban location, certain comorbidities, and shorter pre-end-stage renal disease nephrology care are all associated with a significantly lower likelihood of AVF placement as initial access predialysis. Our study suggests the presence of significant disparities in the placement of an AVF as initial hemodialysis vascular access. We suggest that additional attention should be paid to these patient groups to improve disparities by patient education, earlier referral, and close follow-up.
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Affiliation(s)
- Bhanu K Patibandla
- Department of Medicine, Saint Vincent Hospital, University of Massachusetts School of Medicine, Worcester, Massachusetts, USA
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Lok CE, Thumma JR, McCullough KP, Gillespie BW, Fluck RJ, Marshall MR, Kawanishi H, Robinson BM, Pisoni RL. Catheter-related infection and septicemia: impact of seasonality and modifiable practices from the DOPPS. Semin Dial 2013; 27:72-7. [PMID: 24400803 DOI: 10.1111/sdi.12141] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hemodialysis (HD) catheter-related infection (CRI) and septicemia contribute to adverse outcomes. The impact of seasonality and prophylactic dialysis practices during high-risk periods remain unexplored. This multicenter study analyzed DOPPS data from 12,122 HD patients (from 442 facilities) to determine the association between seasonally related climatic variables and CRI and septicemia. Climatic variables were determined by linkage to National Climatic Data Center of National Oceanic and Atmospheric Administration data. Catheter care protocols were examined to determine if they could mitigate infection risk during high-risk seasons. Survival models were used to estimate the adjusted hazard ratio (AHR) of septicemia by season and by facility catheter dressing protocol. The overall catheter-related septicemia rate was 0.47 per 1000 catheter days. It varied by season, with an AHR for summer of 1.46 (95% CI: 1.19-1.80) compared with winter. Septicemia was associated with temperature (AHR = 1.07; 95% CI: 1.02-1.13; p < 0.001). Dressing protocols using chlorhexidine (AHR of septicemia = 0.55; 95% CI: 0.39-0.78) were associated with fewest episodes of CRI or septicemia. Higher catheter-related septicemia in summer may be due to seasonal conditions (e.g., heat, perspiration) that facilitate bacterial growth and compromise protective measures. Extra vigilance and use of chlorhexidine-based dressing protocols may provide prophylaxis against CRI and septicemia.
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Affiliation(s)
- Charmaine E Lok
- Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
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Grudzinski A, Mendelssohn D, Pierratos A, Nesrallah G. A Systematic Review of Buttonhole Cannulation Practices and Outcomes. Semin Dial 2013; 26:465-75. [DOI: 10.1111/sdi.12116] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | - David Mendelssohn
- Department of Nephrology; Humber River Regional Hospital; Toronto Canada
- Division of Nephrology; University of Toronto; Toronto Canada
| | - Andreas Pierratos
- Department of Nephrology; Humber River Regional Hospital; Toronto Canada
- Division of Nephrology; University of Toronto; Toronto Canada
| | - Gihad Nesrallah
- Division of Nephrology; Western University; London Canada
- Department of Nephrology; Humber River Regional Hospital; Toronto Canada
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Wise ME, Lovell C. Public health surveillance in the dialysis setting: opportunities and challenges for using electronic health records. Semin Dial 2013; 26:399-406. [PMID: 23721477 DOI: 10.1111/sdi.12098] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The US Centers for Disease Control and Prevention has conducted public health surveillance for healthcare-associated infections (HAIs) in dialysis facilities since the 1970s, evolving from facility-level surveys to patient-level surveillance systems. The Centers for Medicare and Medicaid Services (CMS) recently implemented incentives for all end-stage renal disease (ESRD) facilities to monitor and report patient-level quality indicators to the Centers for Disease Control and Prevention's (CDC's) National Healthcare Safety Network (NHSN) in accordance with the NHSN Dialysis Event Protocol. These CMS incentives have led to a rapid increase in dialysis facility NHSN enrollment during 2012. Ongoing challenges to HAI surveillance in this setting include variability in the surveillance process, assurance of data quality, and staff time and resource requirements. Use of existing electronic health records (EHR), especially in conjunction with detection algorithms, has increasingly been shown to produce valid and reliable estimates of HAI frequency in acute care hospitals. Given the large number of dialysis facilities that are now beginning to conduct surveillance using NHSN, the typical lack of dedicated infection prevention personnel in those facilities, and the widespread use of EHR in large dialysis provider organizations, the use of EHR will probably become a cornerstone of surveillance in these settings. Implemented properly, the use of EHR to support public health surveillance has enormous potential to focus and strengthen infection prevention activities in dialysis facilities. Systematic, ongoing validation efforts will be vital to ensure that reported data are accurate, permit valid comparisons of facility performance, and effectively support improved outcomes for dialysis patients.
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Affiliation(s)
- Matthew E Wise
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA
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D'Amato-Palumbo S, Kaplan AA, Feinn RS, Lalla RV. Retrospective study of microorganisms associated with vascular access infections in hemodialysis patients. Oral Surg Oral Med Oral Pathol Oral Radiol 2013; 115:56-61. [PMID: 23217535 DOI: 10.1016/j.oooo.2012.08.445] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 08/08/2012] [Accepted: 08/11/2012] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The aim of this study was to assess microorganisms associated with vascular access-associated infections (VAIs) in hemodialysis patients, with respect to possible origin from the mouth. STUDY DESIGN A retrospective and comparative analysis of the microbes associated with VAI in hemodialysis patients treated during a 10-year period was performed with the Human Oral Microbiome Database (HOMD). RESULTS Of 218 patient records identified, 65 patients collectively experienced 115 VAI episodes. The most common microorganisms involved were Staphylococcus aureus (49.6% of infections), Staphylococcus epidermidis (10.4%), Serratia marcescens (10.4%), Pseudomonas aeruginosa (9.6%), and Enterococcus faecalis/fecum (8.7%). None of these was found in ≥1% of HOMD clone libraries, indicating that they very rarely colonize the teeth or plaque. CONCLUSIONS Most VAIs were associated with microorganisms more likely to originate from other body sites than from the oral cavity. The risk of a VAI being caused by microorganisms originating from the oral cavity is very small.
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Affiliation(s)
- Sandra D'Amato-Palumbo
- Dental Hygiene Program, College of Arts and Sciences, University of New Haven, West Haven, Connecticut, USA
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Fysaraki M, Samonis G, Valachis A, Daphnis E, Karageorgopoulos DE, Falagas ME, Stylianou K, Kofteridis DP. Incidence, clinical, microbiological features and outcome of bloodstream infections in patients undergoing hemodialysis. Int J Med Sci 2013; 10:1632-8. [PMID: 24151435 PMCID: PMC3804789 DOI: 10.7150/ijms.6710] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 09/04/2013] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Infection is a common cause of death among hemodialysis patients. The study investigated incidence, risk factors, clinical features and outcome of bloodstream infections (BSIs) in haemodialysis patients. METHODS The records of haemodialysis patients from 1999 to 2005 were reviewed. Risk factors were investigated by multivariate analysis. RESULTS There were identified 148 bacteremic episodes, in 102 patients. The BSI rate was 0.52 per 1000 patient-days. Of the 148 episodes, 34 occurred in patients with permanent fistulae (0.18/1000 patient-days); 19 in patients with grafts (0.39/1000 patient-days); 28 in patients with permanent tunneled central catheters (1.03/1000 patient-days); and 67 in those with temporary-catheter (3.18/1000 patient-days). With fistula as reference, the BSI ratio was 1.84 with arteriovenous graft (P=.029), 4.85 with permanent central venous catheter (P<.001), and 14.88 with temporary catheter (P <.001). Catheter related were 41 episodes (28%). Gram positive organism were responsible for 96 episodes (65%), with S. aureus ( 55%) the most frequent, followed by S. epidermidis (26%) and Gram-negative for 36 (23%), with E. coli (39%) the most frequent. Infection was polymicrobial in 14 (9.5%). Diabetes (p<0.001), low serum albumin (p=0.040) and low hemoglobin (p<0.001) were significant risk factors. During hospitalization 18 patients (18%) died. Septic shock (p<0.001) and polymicrobial infection (p=0.041) were associated with in-hospital mortality. CONCLUSION The risk of BSI in patients undergoing hemodialysis is related to the catheter type and vascular access. Septic shock and polymicrobial infection predispose to unfavourable outcome.
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Affiliation(s)
- Maria Fysaraki
- 2. Department of Nephrology, University Hospital of Heraklion, Crete, Greece
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Daptomycin pharmacokinetics and pharmacodynamics in a pooled sample of patients receiving thrice-weekly hemodialysis. Antimicrob Agents Chemother 2012. [PMID: 23208714 DOI: 10.1128/aac.02000-12] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
While the pharmacokinetic (PK) properties of daptomycin in hemodialysis (HD) patients have been evaluated previously by three groups, resultant dosing recommendations have varied. To address this clinical conundrum, this study combined concentration-time data from these PK evaluations and derived uniform dosing recommendations among patients on HD receiving daptomycin. A two-compartment model with separate HD and non-HD clearance terms was fit to the PK data from these studies by using BigNPAG. Embedded with PK parameters from the population PK analysis, 5,000-subject Monte Carlo simulations (MCS) were performed to identify HD dosing schemes that provided efficacy (cumulative and daily area under the concentration-time curve [AUC] values) and toxicity (trough concentrations of ≥ 24.3 mg/liter) profiles comparable to those from simulations employing the daptomycin PK model derived from the Staphylococcus aureus bacteremia-infective endocarditis (SAB-IE) study. Separate HD dosing schemes were sought for the two weekly interdialytic periods (48 and 72 h). For the 48-h interdialytic period, intra- and post-HD dosing provided the most isometric cumulative and daily AUCs. For the 72-h interdialytic period, all HD dosing schemes provided noncumulative AUC values from 48 to 72 h (AUC(48-72)) that were <50% of the SAB-IE AUC(48-72) values. Increasing the parent dose by 50% intra- or post-HD provided comparable AUC(48-72) values, while maintaining acceptable trough concentration (C(min)) values. When efficacy and toxicity profiles were evaluated for each individual study, higher probabilities for C(min) reaching ≥ 24.3 mg/liter were observed in one of the three studies. Given the high probability of C(min) being ≥ 24.3 mg/liter in one of the three studies, more intensive creatine phosphokinase (CPK) monitoring may be warranted in HD patients receiving daptomycin.
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Wolley MJ, Taylor SL, Hossain F, Abbas SA, Marshall MR. Association between antimicrobial locks for hemodialysis central venous catheters and antibiotic resistance. Hemodial Int 2012; 16 Suppl 1:S2-9. [DOI: 10.1111/j.1542-4758.2012.00740.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Martin J. Wolley
- Department of Renal Medicine; Counties Manukau District Health Board
| | - Susan L. Taylor
- Department of Clinical Microbiology; Middlemore Hospital; Counties Manukau District Health Board
| | - Firoz Hossain
- Department of Renal Medicine; Counties Manukau District Health Board
| | - Saib A. Abbas
- Department of Renal Medicine; Counties Manukau District Health Board
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Kan LP, Lin JC, Chiu SK, Yeh YC, Lin TY, Yang YS, Wang YC, Wang NC, Yeh KM, Chang FY. Methicillin-resistant Staphylococcus aureus bacteremia in hemodialysis and nondialysis patients. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2012; 47:15-22. [PMID: 23040238 DOI: 10.1016/j.jmii.2012.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 07/31/2012] [Accepted: 08/15/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND/PURPOSE Increased mortality has been reported in patients treated with vancomycin for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with high minimum inhibitory concentration (MIC) values within the susceptibility range. However, this finding has not been verified in hemodialysis patients, who have much higher invasive MRSA infection rates than nondialysis patients. We aimed at comparing vancomycin MICs between hemodialysis and nondialysis patients, and identifying predictors of high vancomycin MICs and infection-related mortality in hemodialysis patients with MRSA bacteremia. METHODS Patients with MRSA bacteremia from January 2008 through December 2009 were enrolled. Vancomycin MIC was determined for each first isolate using the Etest method. Clinical characteristics and vancomycin MICs were compared between hemodialysis and nondialysis patients. Factors associated with high vancomycin MIC (2 μg/mL) and infection-related mortality in hemodialysis patients were analyzed. RESULTS A total of 162 MRSA bacteremia episodes were identified. Forty-four (27.0%) isolates were obtained from hemodialysis patients and 118 (73.0%) from nondialysis patients. Diabetes (63.3% vs. 39.8%, p = 0.007) and prior vancomycin exposure in 30 days (31.8% vs. 12.7%, p = 0.005) were more prevalent in hemodialysis group than in nondialysis group. A higher prevalence of vancomycin MIC of 2 μg/mL was observed in hemodialysis group in comparison with nondialysis group (11.4% vs. 1.7%, p = 0.016). In following analyses of hemodialysis group, patients with initial presentation of septic shock had a higher risk of vancomycin MIC of 2 μg/mL than nonseptic shock patients (100.0% vs. 38.5% p = 0.014). Infection-related mortality was associated with age, Acute Physiology and Chronic Health Evaluation II (APACHE-II) score >15, presence of septic shock, receipt of mechanical ventilation, and failure to remove source of bacteremia in univariate analysis. CONCLUSION Hemodialysis patients with MRSA bacteremia are more likely to have a high vancomycin MIC (2 μg/mL) compared with nondialysis patients. Infection-related mortality is associated with the patient's clinical manifestations, including age, APACHE-II score >15, presence of septic shock, receipt of mechanical ventilation, and failure to remove source of bacteremia. Treatment selection should be tailored according to the patient's clinical condition.
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Affiliation(s)
- Li-Ping Kan
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jung-Chung Lin
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Sheng-Kang Chiu
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yen-Cheng Yeh
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Te-Yu Lin
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ya-Sung Yang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yung-Chih Wang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ning-Chi Wang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Kuo-Ming Yeh
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
| | - Feng-Yee Chang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Centers for Disease Control, Department of Health, Taipei, Taiwan
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Sucupira C, Abramczyk ML, de Abreu Carvalhaes JT, de Moraes-Pinto MI. Surveillance system of hemodialysis-associated infections in a pediatric unit. Infect Control Hosp Epidemiol 2012; 33:521-3. [PMID: 22476281 DOI: 10.1086/665312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The bloodstream infection surveillance system proposed by the Centers for Disease Control and Prevention (CDC) was prospectively conducted in a pediatric hemodialysis unit. Thirty patients were included; 73% had a catheter for vascular access at enrollment. Vascular access infection rate was 21.1 per 100 patient-months, well above those observed in adult patient surveys. Staphylococcus aureus was most frequently isolated (23%).
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Affiliation(s)
- Carolina Sucupira
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Universidade Federal de São Paulo, São Paulo-SP, Brazil.
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Patel G, Jenkins SG, Mediavilla JR, Kreiswirth BN, Radbill B, Salgado CD, Calfee DP. Clinical and molecular epidemiology of methicillin-resistant Staphylococcus aureus among patients in an ambulatory hemodialysis center. Infect Control Hosp Epidemiol 2012; 32:881-8. [PMID: 21828968 DOI: 10.1086/661598] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) carriage and transmission in an ambulatory hemodialysis population. DESIGN Prospective cohort study. SETTING Outpatient hemodialysis facility affiliated with a large academic medical center. PARTICIPANTS Of the 170 facility patients, 103 (61%) participated in the study. METHODS Swab specimens of the nares, axillae, and vascular access site were collected from participants weekly for 3 weeks and then monthly for 5 months. Demographic and clinical data were collected monthly for 12 months. Molecular analysis of MRSA isolates was performed. RESULTS The baseline MRSA carriage prevalence was 12%. Factors associated with MRSA carriage included a history of MRSA; failed renal transplantation; hospital admission within 6 months; and receipt of a first-generation cephalosporin, cefepime, or vancomycin. Six subjects acquired MRSA after enrollment (incidence, 1.2 per 100 patient-months at-risk; overall prevalence, 18%). Molecular analysis suggested that transmission occurred within the facility. The incidence of MRSA infection among carriers was 1.76 per 100 patient-months. Community-associated strains (ie, USA300) were isolated from 28% of carriers and at least 25% of infections. CONCLUSIONS The prevalence of MRSA carriage and the incidence of infection among carriers were high among ambulatory hemodialysis patients, and community-associated MRSA was responsible for a large portion of the MRSA burden. A relatively high rate of MRSA acquisition was observed, with indirect evidence of intrafacility transmission. Additional studies are needed to confirm these findings and to identify effective and feasible methods to prevent MRSA transmission and infection among hemodialysis patients.
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Affiliation(s)
- Gopi Patel
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
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Guggenbichler JP, Assadian O, Boeswald M, Kramer A. Incidence and clinical implication of nosocomial infections associated with implantable biomaterials - catheters, ventilator-associated pneumonia, urinary tract infections. GMS KRANKENHAUSHYGIENE INTERDISZIPLINAR 2011; 6:Doc18. [PMID: 22242099 PMCID: PMC3252661 DOI: 10.3205/dgkh000175] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Health care associated infections, the fourth leading cause of disease in industrialised countries, are a major health issue. One part of this condition is based on the increasing insertion and implantation of prosthetic medical devices, since presence of a foreign body significantly reduces the number of bacteria required to produce infection. The most significant hospital-acquired infections, based on frequency and potential severity, are those related to procedures e.g. surgical site infections and medical devices, including urinary tract infection in catheterized patients, pneumonia in patients intubated on a ventilator and bacteraemia related to intravascular catheter use. At least half of all cases of nosocomial infections are associated with medical devices.Modern medical and surgical practices have increasingly utilized implantable medical devices of various kinds. Such devices may be utilized only short-time or intermittently, for months, years or permanently. They improve the therapeutic outcome, save human lives and greatly enhance the quality of life of these patients. However, plastic devices are easily colonized with bacteria and fungi, able to be colonized by microorganisms at a rate of 0.5 cm per hour. A thick biofilm is formed within 24 hours on the entire surface of these plastic devices once inoculated even with a small initial number of bacteria.The aim of the present work is to review the current literature on causes, frequency and preventive measures against infections associated with intravascular devices, catheter-related urinary tract infection, ventilator-associated infection, and infections of other implantable medical devices. Raising awareness for infection associated with implanted medical devices, teaching and training skills of staff, and establishment of surveillance systems monitoring device-related infection seem to be the principal strategies used to achieve reduction and prevention of such infections. The intelligent use of suitable antiseptics in combination with medical devices may further support reduction and prevention of such infections. In addition to reducing the adverse clinical outcomes related with these infections, such reduction may substantially decrease the economic burden caused by device-related infection for health care systems.
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