Cluster-Randomized Trial of Devices to Prevent Catheter-Related Bloodstream Infection

The use of Hub Devices to reduce catheter-related infections in dialysis patients: A narrative review

INTRODUCTION

Catheter-related bloodstream infections are among the most critical issues associated with central venous catheters used for dialysis treatment. To reduce the incidence of this life-threatening complication, various strategies have been developed. Among these, Hub Devices have been introduced in clinical practice to prevent microbial growth at the hub of the catheter.

METHODS

A review was conducted to assess the effectiveness of Hub Devices in reducing bloodstream infections in central venous catheters for dialysis, compared to solid caps. The review analyzed existing literature from three bibliographic databases (PubMed, Embase, and CINAHL) to provide evidence-based recommendations for clinical practice.

RESULTS

After a thorough review of the available data, it was found that out of the 873 records screened, only six trials met the inclusion criteria. Albeit the number of patients observed in these trials was more than 25,000, due to the differences in the mechanism of action of different Hub Devices and the lack of a standardized criterion to identify and measure the outcomes, it is difficult to draw a firm conclusion. It is worth noting, however, that in five out of six trials examined, the Hub Devices exhibited a protective effect when compared to solid caps.

CONCLUSIONS

The use of Hub Devices appears to be associated with a reduction in catheter-related bloodstream infections in the central venous catheter dialysis population. However, the Hub Devices show interesting results that should be investigated with further well-designed prospective studies.

Use of ClearGuard HD caps in pediatric hemodialysis patients

BACKGROUND

Bloodstream infections (BSIs) are a leading cause of hospitalizations and mortality among patients receiving hemodialysis (HD) therapy, especially those with a central venous catheter (CVC) for dialysis access. The use of chlorhexidine impregnated catheter caps (ClearGuard) has been associated with a decrease in the rate of HD catheter-related BSIs (CA-BSIs) in adults; similar data have not been published for children.

METHODS

We compared CA-BSI data from participating centers within the Standardizing Care to Improve Outcomes in Pediatric Endstage Kidney Disease (SCOPE) collaborative based on the center's use of ClearGuard caps for patients with HD catheter access. Centers were characterized as ClearGuard (CG) or non-ClearGuard (NCG) centers, with CA-BSI data pre- and post-CG implementation reviewed. All positive blood cultures in participating centers were reported to the SCOPE collaborative and adjudicated by an infectious disease physician.

RESULTS

Data were available from 1786 SCOPE enrollment forms completed January 2016-January 2022. January 2020 served as the implementation date for analyzing CG versus NCG center data, with this being the time when the last CG center underwent implementation. Post January 2020, there was a greater decrease in the rate of HD CA-BSI in CG centers versus NCG centers, with a decrease from 1.18 to 0.23 and 0.41 episodes per 100 patient months for the CG and NCG centers, respectively (p = 0.002).

CONCLUSIONS

Routine use of ClearGuard caps in pediatric dialysis centers was associated with a reduction of HD CA-BSI rates in pediatric HD patients.

Risk of infections related to endovascular catheters and cardiac implantable devices in hemodialysis patients

Patients requiring dialysis are extremely vulnerable to infectious diseases. The high burden of comorbidities and weakened immune system due to uremia and previous immunosuppressive therapy expose the patient on dialysis to more infectious events than the general population. The infectious risk is further increased by the presence of endovascular catheters and implantable cardiologic devices. The former is generally placed as urgent vascular access for dialysis and in subjects requiring hemodialysis treatments without autogenous arteriovenous fistula. The high frequency of cardiovascular events also increases the likelihood of implanting indwelling implantable cardiac devices (CIED) such as pacemakers (PMs) and defibrillators (ICDs). The simultaneous presence of CVC and CIED yields an increased risk of developing severe prosthetic device-associated bloodstream infections often progressing to septicemia. Although, antibiotic therapy is the mainstay of prosthetic device-related infections, antibiotic resistance of biofilm-residing bacteria reduces the choice of infection eradication. In these cases, the resolution of the infection process relies on the removal of the prosthetic device. Compared to CVC removal, the extraction of leads is a more complex procedure and poses an increased risk of vessel tearing. As a result, the prevention of prosthetic device-related infection is of utmost importance in hemodialysis (HD) patients and relies principally on avoiding CVC as vascular access for HD and placement of a new class of wireless implantable medical devices. When the combination of CVC and CIED is inevitable, prevention of infection, mainly due translocation of skin bacteria, should be a mandatory priority for healthcare workers.

From Home to Wearable Hemodialysis: Barriers, Progress, and Opportunities

Although the past two decades have seen substantial proportional growth of home hemodialysis in the United States, the absolute number of patients treated with home hemodialysis remains small. Currently available stationary hemodialysis devices for use in the home have inherent limitations that represent barriers for more widespread adoption by a larger proportion of individuals with kidney failure. These limitations include device weight and bulk, ergonomics considerations, technical complexity, vascular access challenges, and limited remote patient monitoring. Recent years have witnessed a resurgence in research and development of prototype wearable kidney replacement devices incorporating innovations in miniaturization, new biomaterials, and new methods for toxin clearance and dialysate regeneration. Recent work has built on five decades of incremental innovation in wearable dialysis concepts and prototypes, starting from the work by Kolff in the 1970s. Wearable dialysis devices that successfully overcome key persistent barriers to successful development and adoption of these technologies will radically reshape the landscape of kidney replacement therapies and have the potential to dramatically improve the lives of individuals living with kidney failure.

Renal replacement therapy for acute kidney injury in burn patients, an international survey and a qualitative review of current controversies

BACKGROUND OF THE STUDY

Acute kidney injury (AKI) is a common complication in critically ill burn patients and is associated with a number of serious adverse outcomes. The clinical decision-making process related to the management of AKI in burn patients is complex and has not been sufficiently standardized. The main aim of this study was to explore the diagnostic approach and clinician's attitudes toward the management of AKI and RRT in burn patients around the world.

METHODS

The questionnaire was widely distributed among the members of International Society for Burn Injury (ISBI), who were invited to complete the survey. Data collection and report was compliant with the the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) Web-survey guidelines. The survey form with multiple-choice questions was divided into 3 parts: a. physician and institutional demographics, b. AKI diagnostic information, c. technical aspects of RRT.

RESULTS

A total of 44 respondents worldwide submitted valuable data in the 2-month period. Of all respondents, 43.2% were from Europe, 30% from North America, 7% from South-East Asia 2.3% from Africa and 18.2% from other regions. 93.1% of participants declare that they use specific definitions to detect AKI, while 11.4% declare the use of renal ultrasonography for AKI diagnosis. CRRT appeared to be the most preferred option by 43.2% of participants, followed by intermittent hemodialysis (25%), and prolonged intermittent RRT (6.8%). The expertise to deliver a modality and the availability of resources were considered important factors when selecting the optimal RRT modality by 20.5% and 29.6% of respondents. The use of specific serum biomarkers for AKI diagnosis are stated by 16% of respondents; 25% of specialists refer to the use of biomarkers of AKI as a criterium for discontinuing the RRT. Femoral vena and right jugular vena were the most frequently used location for RRT temporary catheter placement, 54.6% of respondents declared using ultrasound guidance for catheter placement.

CONCLUSIONS

The majority of burn specialists use specific consensus classifications to detect acute kidney injury. Continuous renal replacement therapy appeared to be the most preferred option, while the expertise to deliver a particular modality and resources availability play a significant role in modality selection. The use of ultrasound and specific biomarkers for AKI evaluation is infrequent in routine clinical practice.

Optimising Access Surgery in Senior Haemodialysis Patients (OASIS): study protocol for a multicentre randomised controlled trial

INTRODUCTION

Current evidence on vascular access strategies for haemodialysis patients is based on observational studies that are at high risk of selection bias. For elderly patients, autologous arteriovenous fistulas that are typically created in usual care may not be the best option because a significant proportion of fistulas either fail to mature or remain unused. In addition, long-term complications associated with arteriovenous grafts and central venous catheters may be less relevant when considering the limited life expectancy of these patients. Therefore, we designed the Optimising Access Surgery in Senior Haemodialysis Patients (OASIS) trial to determine the best strategy for vascular access creation in elderly haemodialysis patients.

METHODS AND ANALYSIS

OASIS is a multicentre randomised controlled trial with an equal participant allocation in three treatment arms. Patients aged 70 years or older who are expected to initiate haemodialysis treatment in the next 6 months or who have started haemodialysis urgently with a catheter will be enrolled. To detect and exclude patients with an unusually long life expectancy, we will use a previously published mortality prediction model after external validation. Participants allocated to the usual care arm will be treated according to current guidelines on vascular access creation and will undergo fistula creation. Participants allocated to one of the two intervention arms will undergo graft placement or catheter insertion. The primary outcome is the number of access-related interventions required for each patient-year of haemodialysis treatment. We will enrol 195 patients to have sufficient statistical power to detect an absolute decrease of 0.80 interventions per year.

ETHICS AND DISSEMINATION

Because of clinical equipoise, we believe it is justified to randomly allocate elderly patients to the different vascular access strategies. The study was approved by an accredited medical ethics review committee. The results will be disseminated through peer-reviewed publications and will be implemented in clinical practice guidelines.

TRIAL REGISTRATION NUMBER

NL7933.

PROTOCOL VERSION AND DATE

V.5, 25 February 2021.

Brachial artery transposition versus catheters as tertiary vascular access for maintenance hemodialysis: a single-center retrospective study

Some hemodialysis patients are not suitable for creation of an arteriovenous fistula (AVF) or arteriovenous graft (AVG). However, they can receive a tunneled cuffed central venous catheter (tcCVC), but this carries risks of infection and mortality. We aimed to evaluate the safety and effectiveness of brachial artery transposition (BAT) versus those of tcCVC. This retrospective study evaluated hemodialysis patients who underwent BAT or tcCVC placement because of severe heart failure, hand ischemia, central venous stenosis or occlusion, inadequate vessels for creating standard arteriovenous access, or limited life expectancy. The primary outcome was whole access circuit patency. Thirty-eight patients who underwent BAT and 25 who underwent tcCVC placement were included. One-year patency rates for the whole access circuit were 84.6% and 44.9% in the BAT and tcCVC groups, respectively. The BAT group was more likely to maintain patency (unadjusted hazard ratio: 0.17, 95% confidence interval: 0.05–0.60, p = 0.006). The two groups did not have significantly different overall survival (log-rank p = 0.146), although severe complications were less common in the BAT group (3% vs. 28%, p = 0.005). Relative to tcCVC placement, BAT is safe and effective with acceptable patency in hemodialysis patients not suitable for AVF or AVG creation.

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

Purpose

Central line-associated bloodstream infection (CLABSI) is the second leading cause of death in hemodialysis patients. Patients dialyzed via central venous catheters (CVCs) are more susceptible to vascular access-related bloodstream infection (VRBSI), sepsis, and mortality when compared to patients with other dialysis accesses.

Patients and Methods

A retrospective observational data analysis was conducted from 13 outpatient dialysis clinics in the United States to compare novel chlorhexidine-coated end caps to standard needlefree connectors for differences in CLABSI rates when utilizing CVCs for hemodialysis. There were two periods in this study: in the first study period over a 5-month period (May 2018 to September 2018), data were evaluated from a group of patients undergoing hemodialysis using chlorhexidine end-caps ('chlorhexidine group') as well as a group using standard needlefree connectors ('standard group'). An initial assessment found that a substantial CLABSI rate reduction was seen with use of chlorhexidine-coated end caps; therefore, most patients were switched to chlorhexidine by February 2019 and data continued to be collected till June 2019. The second study period spanned 9 months from October 2018 to June 2019.

Results

Across 13 dialysis centers, anonymized health records of 5934 patients who were dialyzed via CVCs between May 2018 and June 2019 were analyzed. The mean age was 61.3 and 47.1% of all patients were female. Study period one included 967 patients with chlorhexidine and 1044 patients with standard end caps, while there were 3647 chlorhexidine and 276 standard patients in the second period. The combined CLABSI rate in the chlorhexidine group was 0.09/1000 CVC days versus 0.63/1000 CVC days in the standard group (p<0.0001).

Conclusion

Chlorhexidine-coated CVC caps may provide a therapeutic improvement in CVC hemodialysis management.

Nitric Oxide-Releasing Insert for Disinfecting the Hub Region of Tunnel Dialysis Catheters

The use of tunneled dialysis catheters (TDCs) for patients in need of hemodialysis treatments (HDs) causes a significant number of bloodstream infections (BSIs), with very few viable preventative/treatment methods. Use of antibiotics is relatively ineffective due to the development of multidrug-resistant bacterial strains and the inability to penetrate bacterial biofilms. Nitric oxide (NO) is an endogenous gas molecule that has broad-spectrum antimicrobial/antibiofilm activity. In this study, the potential of creating a NO-releasing insert device that is attached onto the hub region cap of TDCs and locally releases NO within the TDC hub is evaluated for its antimicrobial/antibiofilm effectiveness. The NO-releasing insert contains the natural NO donor S-nitrosoglutathione (GSNO), along with zinc oxide (ZnO) nanoparticles to accelerate NO release from the GSNO, within a short silicone tube that is sealed at both ends and attached to the catheter cap. An in vitro 3-d-long antimicrobial study using catheter hubs yielded >6.6 log reductions of both Pseudomonas aeruginosa and Staphylococcus aureus for the NO-releasing insert device compared to controls. Two 14-d-long sheep studies demonstrated that the NO-releasing insert devices are exceptionally potent at preventing bacteria/biofilm growth on the inner lumen walls of TDCs compared to controls that have no preventative treatment devices as well as implanted TDCs that have commercially available chlorhexidine-treated insert devices placed within the hub regions.

Reporting of key methodological and ethical aspects of cluster trials in hemodialysis require improvement: a systematic review

Background

The hemodialysis setting is suitable for trials that use cluster randomization, where intact groups of individuals are randomized. However, cluster randomized trials (CRTs) are complicated in their design, analysis, and reporting and can pose ethical challenges. We reviewed CRTs in the hemodialysis setting with respect to reporting of key methodological and ethical issues.

Methods

We conducted a systematic review of CRTs in the hemodialysis setting, published in English, between 2000 and 2019, and indexed in MEDLINE or Embase. Two reviewers extracted data, and study results were summarized using descriptive statistics.

Results

We identified 26 completed CRTs and five study protocols of CRTs. These studies randomized hemodialysis centers (n = 17, 55%), hemodialysis shifts (n = 12, 39%), healthcare providers (n = 1, 3%), and nephrology units (n = 1, 3%). Trials included a median of 28 clusters with a median cluster size of 20 patients. Justification for using a clustered design was provided by 15 trials (48%). Methods that accounted for clustering were used during sample size calculation in 14 (45%), during analyses in 22 (71%), and during both sample size calculation and analyses in 13 trials (42%). Among all CRTs, 26 (84%) reported receiving research ethics committee approval; patient consent was reported in 22 trials: 10 (32%) reported the method of consent for trial participation and 12 (39%) reported no details about how consent was obtained or its purpose. Four trials (13%) reported receiving waivers of consent, and the remaining 5 (16%) provided no or unclear information about the consent process.

Conclusion

There is an opportunity to improve the conduct and reporting of essential methodological and ethical issues in future CRTs in hemodialysis.

Review Registration

We conducted this systematic review using a pre-specified protocol that was not registered.

REDUcing the burden of dialysis Catheter ComplicaTIOns: a National approach (REDUCCTION) - design and baseline results

Background

Patients with hemodialysis central venous catheters (HD CVCs) are susceptible to health care-associated infections, particularly hemodialysis catheter-related bloodstream infection (HD-CRBSI), which is associated with high mortality and health care costs. There have been few systematic attempts to reduce this burden and clinical practice remains highly variable. This manuscript will summarize the challenges in preventing HD-CRBSI and describe the methodology of the REDUcing the burden of dialysis Catheter ComplicaTIOns: a National approach (REDUCCTION) trial.

Methods

The REDUCCTION trial is a stepped-wedge cluster randomized trial of a suite of clinical interventions aimed at reducing HD-CRBSI across Australia. It clusters the intervention at the renal-service level with implementation randomly timed across three tranches. The primary outcome is the effect of this intervention upon the rate of HD-CRBSI. Patients who receive an HD CVC at a participating renal service are eligible for inclusion. A customized data collection tool allows near-to-real-time reporting of the number of active catheters, total exposure to catheters over time, and rates of HD-CRBSI in each service. The interventions are centered around the insertion, maintenance, and removal of HD CVC, informed by the most current evidence at the time of design (mid-2018).

Results

A total of 37 renal services are participating in the trial. Data collection is ongoing with results expected in the last quarter of 2020. The baseline phase of the study has collected provisional data on 5385 catheters in 3615 participants, representing 603,506 days of HD CVC exposure.

Conclusions

The REDUCCTION trial systematically measures the use of HD CVCs at a national level in Australia, accurately determines the rate of HD-CRBSI, and tests the effect of a multifaceted, evidence-based intervention upon the rate of HD-CRBSI. These results will have global relevance in nephrology and other specialties commonly using CVCs.

Minimising Blood Stream Infection: Developing New Materials for Intravascular Catheters

Catheter related blood stream infection is an ever present hazard for those patients requiring venous access and particularly for those requiring long term medication. The implementation of more rigorous care bundles and greater adherence to aseptic techniques have yielded substantial reductions in infection rates but the latter is still far from acceptable and continues to place a heavy burden on patients and healthcare providers. While advances in engineering design and the arrival of functional materials hold considerable promise for the development of a new generation of catheters, many challenges remain. The aim of this review is to identify the issues that presently impact catheter performance and provide a critical evaluation of the design considerations that are emerging in the pursuit of these new catheter systems.

Novel Approaches to Arteriovenous Access Creation, Maturation, Suitability, and Durability for Dialysis

Since the arteriovenous fistula (AVF) was first conceived over 50 years ago, the goal to create a vascular conduit with predictable and reproducible maturation and durability continues to elude caregivers. Recently, however, advances in the understanding of vascular biology and new technologies now provides us with some optimism; we are moving toward a viable solution. A quickly maturing, sustainable, and durable arteriovenous access may soon be attainable. This review will discuss these advances. There are novel approaches to AVF creation and devices to enhance maturation, advances in arteriovenous graft material(s), and devices to safely prolong the use of tunneled dialysis catheters. Although hemodialysis (HD) access remains a complex problem, these innovations may lead the way to optimizing the care and the quality of life of those patients who have no choice but to proceed with HD.

New Directions in Ensuring Catheter Safety

Tunneled dialysis catheters remain the most common vascular access used to initiate hemodialysis. Unfortunately, their use is associated with higher morbidity and mortality when compared with arteriovenous fistulae or grafts. Different types of catheters with different designs and material properties function differently. Additional devices and medications can be used to decrease the rates of infection and thrombosis. The current available tunneled dialysis catheters remain far from the desired goal and innovation in the field of dialysis vascular access remains in dire need.

KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for hemodialysis vascular access since 1996. Since the last update in 2006, there has been a great accumulation of new evidence and sophistication in the guidelines process. The 2019 update to the KDOQI Clinical Practice Guideline for Vascular Access is a comprehensive document intended to assist multidisciplinary practitioners care for chronic kidney disease patients and their vascular access. New topics include the end-stage kidney disease "Life-Plan" and related concepts, guidance on vascular access choice, new targets for arteriovenous access (fistulas and grafts) and central venous catheters, management of specific complications, and renewed approaches to some older topics. Appraisal of the quality of the evidence was independently conducted by using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, and interpretation and application followed the GRADE Evidence to Decision frameworks. As applicable, each guideline statement is accompanied by rationale/background information, a detailed justification, monitoring and evaluation guidance, implementation considerations, special discussions, and recommendations for future research.

Tunneled hemodialysis catheter care practices and blood stream infection rate in children: results from the SCOPE collaborative

OBJECTIVE

The Standardizing Care to Improve Outcomes in Pediatric End Stage Renal Disease (SCOPE) collaborative seeks to reduce hemodialysis (HD) catheter-associated blood stream infections (CA-BSI) by increasing implementation of standardized HD catheter care bundles. We report HD catheter care practices and HD CA-BSI rates from SCOPE.

METHODS

Catheter care practices and infection events were collected prospectively during the study period, from collaborative implementation in June 2013 through May 2017. For comparative purposes, historical data, including patient demographics and HD CA-BSI events, were collected from the 12 months prior to implementation. Catheter care bundle compliance in 5 care bundle categories was monitored across the post-implementation reporting period at each center via monthly care observation forms. CA-BSI rates were calculated monthly, and reported as number of infections per 100 patient months. Changes in CA-BSI rates were assessed using generalized linear mixed model (GLMM) techniques.

RESULTS

Three hundred twenty-five patients with tunneled HD catheters [median (IQR) age 12 years (6, 16), M 53%, F 47%] at 15 centers were included. A total of 3996 catheter care observations over 4170 patient months were submitted with a median (IQR) 5 (2, 14) observations per patient. Overall bundle compliance was high at 87.6%, with a significant and progressive increase (p < 0.001) in compliance for 4/5 bundle categories over the 48-month study period. The adjusted CA-BSI rate significantly decreased over time from 3.3/100 patient months prior to implementation of the care bundles to 0.8/100 patient months 48 months after care bundle implementation (p < 0.001).

CONCLUSIONS

Using quality improvement methodology, SCOPE has demonstrated a significant increase in compliance with a majority of HD catheter care practices and a significant reduction in the rate of CA-BSI among children maintained on HD.

Prevention of Bloodstream Infections in Patients Undergoing Hemodialysis

Bloodstream infections are an important cause of hospitalizations, morbidity, and mortality in patients receiving hemodialysis. Eliminating bloodstream infections in the hemodialysis setting has been the focus of the Centers for Disease Control and Prevention (CDC) Making Dialysis Safer for Patients Coalition and, more recently, the CDC's partnership with the American Society of Nephrology's Nephrologists Transforming Dialysis Safety Initiative. The majority of vascular access-associated bloodstream infections occur in patients dialyzing with central vein catheters. The CDC's core interventions for bloodstream infection prevention are the gold standard for catheter care in the hemodialysis setting and have been proven to be effective in reducing catheter-associated bloodstream infection. However, in the United States hemodialysis catheter-associated bloodstream infections continue to occur at unacceptable rates, possibly because of lapses in adherence to strict aseptic technique, or additional factors not addressed by the CDC's core interventions. There is a clear need for novel prophylactic therapies. This review highlights the recent advances and includes a discussion about the potential limitations and adverse effects associated with each option.

Drawing blood cultures through intravascular catheters: Controversy and update

Studies published between 1999 and 2011 demonstrated increased blood culture contamination with catheter-drawn cultures compared with percutaneously-drawn cultures. Studies published between 2012 and 2015 reported that use of antiseptic barrier caps on central venous catheter hubs significantly reduces the incidence of catheter-drawn blood culture contamination. Local guidelines regarding sites for blood culture collection should reflect institution-level blood culture contamination rates for percutaneously-drawn and catheter-drawn cultures using currently available technologies that reduce contamination at both sites.

Current Concepts in Hemodialysis Vascular Access Infections

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

Prevention of hemodialysis catheter infections: Ointments, dressings, locks, and catheter hub devices

Tunneled central venous catheters used for the provision of hemodialysis are associated with excess morbidity and mortality. Catheter related exit site and blood stream infections are major risks of their use. Although catheter-avoidance is the best strategy to reduce infections and mortality in the hemodialysis population, the use of catheters remains unacceptably high. In this review, the existing clinical practice guidelines for the prevention of hemodialysis catheter associated infections are outlined, and a comprehensive evidenced-based summary of interventions is provided. This includes details about the use of topical antimicrobial ointments and dressings, intranasal ointment application, prophylactic use of antibiotic and non-antibiotic catheter lock solutions, and catheter hub devices for the prevention of catheter blood stream infections.

Two-Year Observational Study of Bloodstream Infection Rates in Hemodialysis Facility Patients with and without Catheters

BACKGROUND AND OBJECTIVES

Bloodstream infection rates of patients on hemodialysis with catheters are greater than with other vascular accesses and are an important quality measure. Our goal was to compare relative bloodstream infection rates of patients with and without catheters as a quality parameter among the facilities providing hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used CROWNWeb and National Healthcare Safety Network data from all 179 Medicare facilities providing adult outpatient hemodialysis in New England for >6 months throughout 2015-2016 (mean, 12,693 patients per month). There was a median of 60 (interquartile range, 43-93) patients per facility, with 17% having catheters.

RESULTS

Among the five batch-submitting dialysis organizations, the bloodstream infection rate in patients with a catheter in four organizations had adjusted risk ratios of 1.44 (95% confidence interval, 1.07 to 1.93) to 1.91 (95% confidence interval, 1.39 to 2.63) times relative to the reference dialysis provider group (P<0.001). The percentage of catheters did not explain the difference in bloodstream infection rates among dialysis provider organizations. The bloodstream infection rates in patients with a catheter were negatively correlated with the facility's proportion of this patient group. Facilities with <10%, 10%-14.9%, 15%-19.9%, and ≥20% catheter patients had bloodstream infection rates of 4.4, 2.2, 1.9, and 1.5 per 100 patient-months, respectively, in that patient group (adjusted P<0.001). This difference was not seen in patients without catheters. There was no effect of facility patient census or season of the year.

CONCLUSIONS

A study of the adult outpatient hemodialysis facilities in New England in 2015-2016 found that four dialysis provider groups had significantly higher bloodstream infection rates in patients with a catheter than the best-performing dialysis provider group. Hemodialysis facilities with lower proportions of patients with a catheter have significantly higher bloodstream infection rates in this patient group than facilities with >20% catheters, a finding that did not explain the difference among provider organizations.