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Bloodstream Infections in Hemodialysis Patients— Emerging Trends and Preventive Measures

Bloodstream Infections in Hemodialysis Patients— Emerging Trends and Preventive Measures. Source: Patel PR, Kallen AJ, Arduino MJ. Epidemiology, surveillance, and prevention of bloodstream infections in hemodialysis patients. Am J Kidney Dis. 2010:56:566–577.

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Bloodstream Infections in Hemodialysis Patients— Emerging Trends and Preventive Measures

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  1. Bloodstream Infections in Hemodialysis Patients—Emerging Trends and Preventive Measures Source: Patel PR, Kallen AJ, Arduino MJ. Epidemiology, surveillance, and prevention of bloodstream infections in hemodialysis patients. Am J Kidney Dis. 2010:56:566–577.

  2. Infections, particularly bloodstream infections (BSI) are a major cause of significant morbidity and mortality in patients undergoing hemodialysis. • National data from the US Renal Data System (USRDS) indicate that hospitalizations caused by BSI in hemodialysis patients have increased by 34% from 1993 to 2006.

  3. Emerging Trends • BSI can be life-threatening and associated with complications such as endocarditis and osteomyelitis in patients undergoing hemodialysis. • Thus, increase in morbidity due to BSI has led to longer duration of hospital stay and cost. Various studies of BSI in hemodialysis patients have indicated most common organism as Staphylococci and other gram-positive cocci (Table 1). • Emerging infection program by centers for disease control and prevention (CDC) conducted a population-based surveillance, which shows that dialysis patients are 100 times more likely to acquire methicillin-resistant S. aureusinfection than individuals in the general population. • Even, the organism isolated in patients with BSI depends on type of vascular access. • The major risk factor associated with BSI in hemodialysis patients is the type of vascular access. • Findings in a multi-centre study and National Healthcare Safety Network (NHSN) study data indicate increased risk of developing BSI with CVC than other vascular access types (Table 2). • Other risk factors associated with BSI in hemodialysis patients include previous history of BSI, poor patient hygiene, contiguous skin infection, ironoverload, low albumin levels, and history of nasal colonization with S. aureus.

  4. Preventive Interventions • Several measures and actions along with evidence of their use have been suggested to prevent BSI in hemodialysis patients, which are discussed here based on CDC’s and National Kidney Foundation Kidney Disease Outcomes Quality Initiative (KDOQI) recommendations.

  5. Catheter Use • Reducing and avoiding the use of CVC for vascular access is recommended. • Prompt removal of an intravascular catheter that is no longer needed is indicated. • Decreased catheter use has been emphasized based on the national data collected over the past 15 years indicating a increase of BSI risk in catheter patients. • Fistula first as the preferred action should target the decrease in CVC use for both short and long terms (>90 days) thereby, reducing the BSI risk in patients.

  6. Surveillance • Active surveillance involving collection of data, its review, and feedback is an essential part of recommended BSI prevention program. • The NHSN includes a dialysis event module that is available in US hemodialysis centers for BSI surveillance and patient care. • This module is a free internet-based system using standardized validated measures that can share data with other entities such as end-stage renal disease (ESRD) network, health department, other dialysis centers etc. • Some of the other features include multiple analytical options such as analysis of facility data, generation of surveillance reports and track rates of dialysis events.

  7. Surveillance • Outcome and process measures for surveillance of dialysis facilities include: • The BSI rates stratified by vascular access types, pathogens, and antimicrobial susceptibility • Antimicrobial starts and intravenous courses, which • can be individualized to specific antimicrobials • Hospital admissions and duration of hospitalization • Local vascular access site infections • Pyrogenic reactions based on clinical features and • blood culture results • Hand hygiene adherence to dialysis environment • Number and duration of CVC use • Adherence to CVC insertion practices

  8. Catheter Care • CDC and KDOQI recommend educating healthcare personnel on catheter care and aseptic technique. • Hand hygiene should be performed and sterile gloves to be used before accessing the catheter. • The KDOQI recommends wearing surgical mask during catheter connect, disconnect, and dressing change procedures. • Use of chlorhexidine is preferentially recommended for skin antisepsis foe catheter insertion and exit-site care. • Recommended alternative skin antiseptics are 70% alcohol and povidone-iodine. • Catheter-site dressings should be changed when they become loose, wet, or soiled. • Chlorhexidineimpregnated dressings are currently not recommended for routine use by both CDC and KDOQI. • Cleansing catheter hubs and blood tubing connectors with chlorhexidine is recommended by KDOQI. • Caution should be observed when using alcohol-based antiseptics as it may damage polyurethane catheters on prolonged contact.

  9. Antimicrobial Ointments • Application of topical povidone-iodine ointment to the catheter exit site is recommended. • Use of mupirocin ointment for topical application is recommended by KDOQI, but not by CDC as there is a risk of developing resistance. • Topical ointments should be used with caution as some ointments containing polyethylene glycol may not be compatible with certain polyurethane catheters.

  10. Antimicrobial Catheter Lock Solutions • Currently, both CDC and KDOQI do not recommend the prophylactic use of antimicrobial lock solutions.

  11. Antimicrobial-impregnated catheters • KDOQI does not recommend and CDC recommends against the use of catheters impregnated with antimicrobials such as silver sulfadiazine, rifampicin, or minocycline.

  12. Employing Best Practices • Implementation of group interventions such as amending hand-hygiene; use of full barrier precaution during catheter insertion, dressing, and exit; insertion site skin antisepsis with chlorhexidine; optimal catheter site selection; and removal of catheter when not needed, can dramatically reduce catheter related BSI in dialysis patients.

  13. Multiple evidence-based approaches are required to reduce the serious risk of morbidity and mortality from BSI in hemodialysis patients, with the use of CVC and other vascular access types. • Patient safety and quality improvement should be a prior consideration along with concentrated efforts on patient education and training health personnel. • A diverse action plan aimed at improving adherence and practice of currently recommended evidence-based approach can dramatically decrease BSIs and other infections in hemodialysis facilities.

  14. Comprehensive Basketin Anemia Management

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