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Bloodstream Infections in Hemodialysis Patients

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Bloodstream Infections in Hemodialysis Patients Emerging Trends and Preventive Measures Source: Patel PR, Kallen AJ, Arduino MJ. Epidemiology, surveillance, and ... – PowerPoint PPT presentation

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Title: Bloodstream Infections in Hemodialysis Patients


1
Bloodstream Infections in Hemodialysis
PatientsEmerging 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. 201056566577.

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. aureus infection
    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, iron overload, low albumin levels, and
    history of nasal colonization with S. aureus.

4
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5
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 CDCs and National Kidney
    Foundation Kidney Disease Outcomes Quality
    Initiative (KDOQI) recommendations.

6
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 (gt90 days) thereby, reducing the BSI
    risk in patients.

7
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.

8
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

9
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.

10
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.

11
Antimicrobial Catheter Lock Solutions
  • Currently, both CDC and KDOQI do not recommend
    the prophylactic use of antimicrobial lock
    solutions.

12
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.

13
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.

14
  • 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.

15
Comprehensive Basketin Anemia Management
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