Preventing Infections in Patients Undergoing Hemodialysis

Alexander J Kallen; Matthew J Arduino; Priti R Patel

Disclosures

Expert Rev Anti Infect Ther. 2010;8(6):643-655. 

In This Article

Current Infection Control Issues in Hemodialysis

This section highlights a number of current infection control issues facing hemodialysis facilities and discusses recommended practices that target these problems.

Preventing Transmission of Hepatitis B & C

Hepatitis B Preventing transmission of hepatitis B virus (HBV) in dialysis centers has been an important part of infection control in hemodialysis for decades. In 1977, the CDC published infection control recommendations for the control of HBV in hemodialysis facilities, and by 1980 there had been a decline in the incidence of HBV infection both in patients undergoing hemodialysis and among facility staff members.[9,105] In 1982, hepatitis B vaccination was recommended for chronic hemodialysis patients and hemodialysis staff, further reducing the risk for transmission.[10] Following these efforts, the incidence of acute HBV infection in chronic hemodialysis patients has decreased from approximately 6.2% nationally in 1974 to 0.12% in 2002.[3,11]

The cornerstone of preventing HBV infection and its sequelae is vaccination, which is recommended for all patients undergoing chronic hemodialysis and the healthcare providers who care for them. According to data from a CDC survey, in 2002 approximately 56% of chronic hemodialysis patients and approximately 90% of staff members had been vaccinated against hepatitis B.[11] A more recent (2005–2006) study conducted in 776 dialysis facilities from three regions of the USA revealed that 73% of hemodialysis patients had received full or partial vaccination for hepatitis B.[12] Only 62% had received the full hepatitis B vaccine series, which falls substantially below the Healthy People 2010 objective of 90%.[13] Based on claims data, the proportion of all dialysis patients having received at least one dose of hepatitis B vaccine in 2007 was also low at 20%.[2] Both of these data sources suggest unwarranted delays in fully vaccinating at-risk hemodialysis patients.

Before initiating dialysis, patients' full hepatitis B serologic status should be documented and all susceptible patients should be vaccinated. Hemodialysis patients are one of the few groups (along with healthcare personnel [HCP]) that are recommended to undergo post-vaccination testing to assess hepatitis B surface antibody titers, and are the only population recommended to receive booster doses of the vaccine at yearly intervals if their antibody levels have waned.[3] In hemodialysis patients, immunity against hepatitis B cannot be assumed when antibody titers fall below protective levels (typically 10 mIU/ml).

In addition to vaccination, other infection control practices have been used to prevent the transmission of hepatitis B.[3] These techniques are designed to prevent the exposure of susceptible patients to the blood of infected patients and include segregating HBV-infected patients in a separate treatment room, not assigning the same staff members to care for HBV-infected and susceptible patients, and assigning dedicated dialysis equipment and other supplies to infected patients so that these are not used by susceptible patients. In addition, general infection control practices should also be followed, including cleaning and disinfecting nondisposable items between patients, using gloves when patients or hemodialysis equipment are touched, changing gloves between patients, routine cleaning and disinfection of equipment and the environment between patients, adherence to hand hygiene, and adherence to safe injection and medication preparation practices. Surveillance for HBV infection in susceptible patients is also recommended to rapidly identify and appropriately isolate newly infected patients. All patients who fail to respond to the hepatitis B vaccine series or who have not completed the series should be tested monthly for hepatitis B surface antigen.

Hepatitis C The prevalence of antibody to hepatitis C virus (HCV) is higher in hemodialysis patients (7.8%) than in the general population (1.6%)[11,13] and may increase as a function of a patient's time on dialysis.[3] As this virus is primarily transmitted through percutaneous contact with blood, patients undergoing hemodialysis may be at risk for transmission if proper infection control techniques are not followed. The CDC investigated a number of outbreaks of HCV infections in dialysis centers between 1998 and 2006.[14] These outbreaks involved breaches in infection control practices that afforded opportunities for cross-contamination, including the preparation of multidose medications in the dialysis treatment station, use of a mobile medication/supply cart to deliver supplies between patient stations, failure to clean and disinfect the dialysis station or dialysis machine, and/or shared use of single-dose medication vials for more than one patient.

In one study that followed the identification of two HCV seroconversions in a dialysis center, 82 (11%) of 740 sampled environmental surfaces contained hemoglobin and six contained HCV RNA.[15] Samples that contained HCV RNA were obtained from a dialysis machine and a waste cart, while those containing hemoglobin were also found on a removable patient table, in a nursing preparation area, on a patient file cart and on wheelchairs. In addition to the environmental contamination identified, hand hygiene practices and removal of gloves after contact with potentially contaminated surfaces were also suboptimal at this facility.

Infection control techniques to prevent HCV transmission in dialysis centers have been primarily centered on safe injection practices, use of hand hygiene and adequate cleaning of environmental surfaces and equipment between patients. Isolation of patients with HCV infection, as has been done with patients with HBV infection, is not recommended by the CDC or KDOQI. Appropriate infection control practices are covered in detail in the CDC's Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients.[3] In general, recommendations include activities such as reserving items taken into the dialysis station (supplies, medications and equipment) for individual patients and either cleaning and disinfecting them between patients or disposing of them if they cannot be cleaned or disinfected, preparing medications for patients in a clean area away from dialysis stations, not using common medication carts to deliver medications to patients, cleaning and disinfecting stations between patients, and appropriate use of hand hygiene. The CDC also recommends that patients be tested at admission to the unit for the antibody to HCV and then semi-annually thereafter (for patients who remain susceptible) in order to identify potential episodes of transmission. The identification of new HCV infections should prompt an assessment of the possibility of transmission occurring within the facility and evaluation of facility infection control practices. Further recommendations for the prevention of transmission of bloodborne viruses are contained in Box 1.

Preventing Influenza

Individuals with chronic kidney disease, including those receiving hemodialysis, have been identified as a group at higher risk for developing complications of seasonal influenza[16] and therefore the prevention of influenza infection in this group of patients should be a priority in all hemodialysis facilities. Vaccination is an effective way to prevent infection with seasonal influenza. Influenza vaccination has been associated with a decreased risk of hospitalization and death in ESRD patients.[17] Yearly vaccination with inactivated influenza vaccine is recommended for all patients with chronic kidney disease.[16] USRDS reported that 64% of ESRD patients on hemodialysis received influenza vaccination in 2007[2] while Bond et al. found rates of 76% in their study in 776 dialysis facilities in three US regions (2005–2006).[12] Both are below the Healthy People 2010 goal of 90% for influenza vaccination coverage for those with ESRD.[2,106] In addition to influenza vaccine, adult hemodialysis patients should be vaccinated with the pneumococcal polysaccharide vaccine once and then again after 5 years.[18]

Another important and often overlooked aspect of providing protection against influenza for hemodialysis patients is the vaccination of dialysis providers. Data from 2003 suggest that only about 40% of HCP are vaccinated against influenza, despite the fact that vaccination has been shown to decrease staff absenteeism and healthcare facility-acquired influenza.[19–21] In long-term care settings, vaccination of staff members has been associated with improved patient outcomes, including decreased influenza-like illness and decreased overall mortality in residents.[22,23] It is important that dialysis staff members are educated about this important benefit of HCP vaccination for seasonal influenza; HCP in two studies cited self-protection more commonly than patient protection as a reason to be vaccinated for influenza.[24,25] Influenza vaccination rates specifically among dialysis HCP have not been published, but are presumed to be similar to rates in other healthcare settings. In a statewide survey of a random sample of dialysis facilities in North Carolina, USA, only 26% of facilities had a formal written policy regarding annual influenza vaccination of staff members and none mandated staff vaccination.[26] Educational efforts to promote staff influenza vaccination were less frequently employed in dialysis facilities than in any of the other healthcare settings surveyed (i.e., hospitals, home health agencies, assisted living settings and nursing homes). Efforts aimed at improving influenza vaccination of HCP and patients in hemodialysis centers should follow practices that have improved vaccination rates in other settings.[27]

Actions to prevent the transmission of respiratory viruses in general are also important. Hemodialysis centers should be able to identify patients with respiratory symptoms at presentation and ensure their segregation from other patients and staff. Patients should be educated to notify staff when they have a potentially infectious respiratory illness to facilitate this process, including calling the center prior to their arrival. Facilities should also strive to educate patients about respiratory hygiene and cough etiquette and provide supplies such as tissues, trash receptacles, areas for hand hygiene (sinks with soap and water or alcohol-based hand rubs) and surgical masks (which can be worn if tolerated by the patient). Finally, staff members should not be allowed to work while ill with contagious illnesses such as influenza. Facility leave policies should allow staff members to be absent from work when they are ill.

Preventing Bloodstream Infections

Hospitalizations for infection among patients undergoing hemodialysis rose by 26% from 1993 to 2006, according to data gathered by USRDS.[2] The infectious syndrome with one of the highest rates of hospitalization was BSIs, with a rate of 105 admissions per 1000 patient-years for 2005–2007.[2] These infections are associated with high levels of morbidity and mortality; a 19% mortality rate at 12 weeks has been reported for Staphylococcus aureus BSIs among hemodialysis patients.[28]

Rates of BSI in patients undergoing hemodialysis appear to vary depending on the type of vascular access that is present. Patients who have a central venous catheter (CVC) are at a higher risk for BSIs than those with other forms of access. The BSI rate in NHSN for patients with permanent CVCs was approximately 4.2 per 100 patient-months compared with 0.9 and 0.5 per 100 patient-months, respectively, for patients with arteriovenous (AV) grafts and AV fistulas.[29] Other studies have demonstrated similar findings. Dopirak and colleagues reported BSI rates of 41.6 per 100 patient-years for patients with CVCs compared with 1.5 per 100 patient-years for patients with AV grafts or fistulas.[30]

Owing to the influence that the presence of a CVC has on rates of BSI, much of the effort aimed at preventing these infections has targeted minimizing the use of CVCs. The Fistula First Initiative, which was started in 2003 by CMS and ESRD regional quality improvement networks, has a primary goal to increase the use of fistulas to 50% of incident patients and 66% of prevalent hemodialysis patients.[31] However, whether this effort has reduced CVC use is controversial. Nationally, CVC use is approximately 20–25% and the majority of patients (80%) initiate dialysis with a CVC.[107,108]

A number of infection control practices have been recommended in an attempt to decrease BSIs in patients with CVCs. Hand hygiene should always be practiced both by patients and by providers prior to contact with the CVC or the exit site. Optimal insertion practices, including the use of full barrier precautions during CVC placement, skin cleaning with 2% chlorhexidine and performing hand hygiene prior to the procedure, should be used.[6]

Central venous catheter maintenance practices are also important. Dressings for tunneled catheters have been recommended by KDOQI[5] and by the CDC,[6] although the CDC suggests dressings may not be necessary for well-healed tunneled catheters. Two recent systematic reviews failed to show significant differences in BSI rates between transparent film and dry gauze dressings.[32,33] The CDC recommends that dry gauze dressings be used if the patient is diaphoretic or if there is oozing present.[6]

For skin cleansing, chlorhexidine gluconate has been recommended both by the CDC and by KDOQI based on evidence that it is superior to povidone-iodine for the prevention of catheter colonization and catheter-related BSIs.[5,6,34–36] KDOQI specifically recommends that 2% chlorhexidine with 70% alcohol be used preferentially if this preparation is compatible with the catheter being used (prolonged exposure to alcohol may be contraindicated for some polyurethane catheters).[5,37] Aqueous chlorhexidine is recommended as an alternative; however, there have been reports of extrinsic contamination of multi-use alcohol-free chlorhexidine products.[38,39] Povidone-iodine is recommended as a third option. 2% chlorhexidine with 70% alcohol has also been recommended for skin antisepsis prior to accessing AV grafts and fistulas.[5]

Topical antimicrobial ointments applied to the catheter exit site are recommended both by the CDC and by KDOQI as a way to prevent BSI in dialysis patients with CVCs.[5,6] A number of preparations have been shown to be effective at reducing BSIs, including povidone-iodine[40] and 2% topical mupirocin ointment.[41] The use of medical-grade honey (Medihoney™) was shown to result in similar rates of catheter-related BSIs when compared with 2% mupirocin ointment in one study.[42] Polysporin Triple (bacitracin, gramicidin and polymixin B) ointment used at the exit site of cuffed catheters not only showed a decrease in BSIs but also demonstrated a survival advantage.[43] KDOQI has recommended the use of either mupirocin ointment or povidone-iodine ointment at CVC exit sites.[4] The CDC has recommended povidone-iodine and not mupirocin due to concerns about inducing mupirocin resistance.[6] Since there may be compatibility issues between polyurethane CVCs and ointments containing polyethylene glycol (including mupirocin and povidone-iodine), the CVC's manufacturer recommendations should be consulted prior to the use of any topical ointment at the exit site.[37]

Recently, there has been increasing interest in the use of antimicrobial catheter locking solutions as a means of preventing catheter-associated BSIs. Antimicrobial locks have specific appeal for a number of reasons, including the fact that this intervention addresses a different potential mechanism of infection (i.e., intraluminal pathway) than other interventions (i.e., extraluminal). Antimicrobial locks that have been evaluated include those utilizing antibiotics such as gentamicin and nonantibiotic antimicrobials such as citrate. Four recent meta-analyses have summarized the results from these trials and have shown an approximately 60–70% drop in catheter-related BSIs with the use of antibiotic catheter locks.[44–47] Owing to the heterogeneity of studies involving nonantibiotic antimicrobial locks, summary estimates are difficult to interpret.[45] Although studies involving antimicrobial locks are promising, most of these evaluations have been subject to several problems. First, many of the studies were carried out with a control group that had a higher rate of infection than has been observed in reporting systems such as NHSN, raising the question of what the additive effect of locks might be in centers with lower catheter BSI rates. Second, it has not been clear in some of the studies whether or not standard infection control recommendations were instituted in addition to the antimicrobial lock. Therefore, it is not known whether antimicrobial locks offer an advantage over recommended best practices. Third, most of these studies have not adequately assessed other negative consequences of the use of antimicrobial locks, such as the development of antimicrobial resistance. A recent observational study did describe an increase in gentamicin resistance of coagulase-negative staphylococci following the introduction of gentamicin locks.[48] Although antimicrobial locks appear to be promising, the CDC does not currently recommend them for routine use in hemodialysis catheters, and no specific recommendation has been made by KDOQI.[5,6]

Environmental Cleaning

Blood contamination of equipment, of frequently touched surfaces and of the patient station in the dialysis unit is common. Studies have shown that the presence of bloodborne pathogens (e.g., HBV and HCV) can be detected on various surfaces within the dialysis unit.[49–52] The hemodialysis machine and its components can also be vehicles for patient-to-patient transmission of bloodborne viruses and pathogenic bacteria.[53–55] The external surfaces of the machine are the most likely sources for contamination. These include not only frequently touched surfaces (e.g., the control panel), but also attached waste containers used during the priming of the dialyzers, blood tubing draped or clipped to waste containers, and items placed on tops of machines for convenience (e.g., dialyzer caps, clamps and medication vials).[14]

Since environmental contamination with blood and other fluids (e.g., processed water and dialysate) in this setting is common, the correct use of detergents and disinfectants to inactivate and remove potential pathogens is an essential component of infection control in this setting. The types of products that are used are listed in Table 1. Antiseptics are typically used topically and should not be used to disinfect equipment or surfaces. For most surfaces and shared devices (e.g., blood pressure cuffs, hemostats, clamps and so on) one would use a low-level (hospital-grade) disinfectant to intermediate-level (tuberculocidal-grade) disinfectant (Table 2). Disinfectants and their sale, distribution and use are regulated under the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) by the US Environmental Protection Agency (EPA). Products used in the dialysis setting should have public health label claims and instructions for preparation and use to achieve the appropriate level of microbial inactivation. For lists of EPA-registered products with various public health label claims, see the EPA's web site.[109] When using disinfectants, one should always follow the product label for intended use. The first step in any disinfectant process is to preclean the surface or item, since the presence of organic soil (e.g., dirt and blood) will interfere with the action of the disinfectants and may actually cause the product to fail.[51,56] Cleaning with a detergent or detergent–disinfectant not only removes soil but can also physically reduce the bioburden, thus enhancing the disinfection process. When applying the disinfectant, it is essential to use the appropriate wet contact time, which allows the disinfectant to act against microbes present on the surface. In dialysis facilities, rapid turnover of patient stations to accommodate multiple patient treatments has the potential to interfere with appropriate application of disinfectant and observance of contact time. For disinfection of various instruments and medical devices, the manufacturer's instructions for cleaning and disinfection should be followed.

Injection Safety

Between 1998 and 2006, the CDC and other public health authorities investigated six outbreaks of HCV transmission in dialysis centers in the USA.[14,57] These investigations identified 40 patients who likely acquired HCV infection in hemodialysis centers due to breaches in infection control, including unsafe injection practices. Syringe reuse, which has been implicated in many outbreaks of HBV or HCV in other healthcare settings, has not been recognized as a major contributor to transmission in dialysis settings. Instead, improper handling of shared medication vials in a manner that could facilitate contamination has been more prevalent. Some of the unsafe injection practices linked to bloodborne pathogen outbreaks include preparation of parenteral medications for multiple patients in patient treatment areas and reuse of single-dose medications for multiple patients.[57] In 2001, investigators documented an outbreak of Serratia liquefaciens BSI in hemodialysis patients, which resulted from multiple entry into and pooling of medication from single-dose medication vials.[58] Although pooling of medications was explicitly prohibited by the CMS following the outbreak, reuse of single-dose medications for multiple patients has remained a common practice in dialysis centers until fairly recently.[59]

Currently, the major challenges to injection safety in this setting are protecting parenteral medications from areas where contaminants are likely to be present and can be easily introduced, and ensuring that medications are handled in an aseptic manner by qualified personnel. In a survey conducted by the CDC in 2002, only 53% of responding facilities prepared medications from multidose vials in a dedicated medication room or an area that was separate from the patient treatment area.[11] In many states, dialysis patient care technicians are allowed to prepare and administer certain parenteral medications. Unlike nurses, technicians might not receive formal training in aseptic technique or medication- and infusion-handling practices.

In order to minimize the risk for pathogen transmission from contaminated medications, the CDC recommends that medications for individual patients from multidose vials be prepared in a separate medication room or in another area that is separate from patient treatment areas.[3] Medication carts should not be used to deliver medications to multiple patients, and supplies such as vials, alcohol swabs and syringes should not be stored in the pockets of HCP. Single-use vials should be entered only once. Multidose vials should not be brought into patient treatment areas and should be entered with a new sterile needle and syringe for each injection given.[110] Detailed recommendations for safe injection practices are described in the CDC's Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients and in the 2007 Guidelines for Isolation Precautions.[3,110] Additional injection safety recommendations are described in Box 1.

Preventing Transmission of Multidrug-resistant Organisms

Multidrug-resistant organisms (MDROs) are organisms that are not susceptible to one or more classes of antimicrobial agents. Most of these organisms are bacteria, and their nonsusceptibility to multiple commonly prescribed antimicrobials makes treatment of these organisms a challenge. Although a number of bacteria or groups of bacteria meet this broad definition, the organisms often listed in this category include vancomycin-resistant enterococci (VRE), vancomycin-resistant and methicillin-resistant S. aureus (VRSA and MRSA) and multidrug-resistant Gram-negative bacilli; Clostridium difficile is intrinsically resistant to most antimicrobials and is also frequently included in this group.

Risk factors for many of these organisms have historically included exposure to healthcare settings. Approximately 86% of invasive MRSA infections have their onset in healthcare facilities or occur in the community among people with healthcare exposures.[60] For C. difficile, approximately 67% of infections in one study were in people who were hospitalized or had been hospitalized within 12 weeks.[61] For many organisms, the proportions that are multidrug-resistant continue to increase in the USA. Approximately 7% of Klebsiella pneumoniae isolated from the bloodstream and reported to the SENTRY Antimicrobial Surveillance Program were resistant to broad spectrum third-generation cephalosporins in 1997;[62] in NHSN in 2006 and 2007, the proportion resistant to these antimicrobials had increased to approximately 27%.[63]

Patients undergoing hemodialysis are generally thought to be at higher risk for infections caused by MDROs. In an analysis of data from a CDC-funded surveillance system for invasive MRSA infections, Lucero and colleagues found that the risk for invasive MRSA infections was more than 100-times higher for patients on dialysis than for the general population.[64] In addition, three of the eleven patients with VRSA in the USA were on hemodialysis.[65,66] Recent studies have also suggested high rates of colonization with MDROs in hemodialysis patients. Hadley and colleagues found an MRSA carriage rate of 5.6% in hemodialysis patients, which is higher than the rates seen in the general population (1.5% around that time).[67,68] In one evaluation of a cohort of outpatient hemodialysis patients in Massachusetts, USA, colonization with VRE or MRSA was found in 13 and 5% of patients, respectively; however, more patients in that cohort (16%) were found to be colonized with multidrug-resistant Gram-negative bacilli.[69]

In light of the risk for carriage of these MDROs, concern has been raised about how best to manage these patients in the outpatient hemodialysis setting. Aggressive measures, such as active surveillance testing, contact precautions and decolonization, which are used in the acute inpatient setting, may be challenging to implement in these situations. In addition, there are still large gaps in the understanding of the transmission of these organisms in outpatient dialysis. Regardless, some measures should be applied to patients with MDROs in any setting. These include aggressive use of hand hygiene by providers after contact with the patient or their environment and promoting the judicious use of antimicrobial agents.[103]

In dialysis facilities, the use of contact precautions is generally not recommended by the CDC for patients colonized with MDROs.[3,110] Transmission of MDROs in outpatient dialysis settings has not been demonstrated and it is currently believed that if appropriately followed, infection control practices recommended for all dialysis patients should be an effective means to limit transmission of these MDROs between hemodialysis patients. However, some groups of patients may warrant additional infection control precautions, including those with draining infected wounds that cannot be adequately covered and patients with uncontrolled diarrhea or fecal incontinence.[3] For these patients, providers should use an additional gown over their usual clothing, which can be removed when the provider has finished caring for the patient. In addition, these patients should be dialyzed at a station that has as few adjacent stations as possible.

Decolonization

Colonization with S. aureus is a recognized risk factor for subsequent S. aureus infections in patients on hemodialysis.[70] Along with coagulase-negative staphylococcus, S. aureus is one of the most common causes of BSIs in patients on hemodialysis, accounting for approximately 22% of these infections.[29] In addition, S. aureus infections, particularly BSIs, have been associated with high rates of morbidity and mortality. S. aureus BSIs in hemodialysis patients have also been associated with the development of complications, including endocarditis and osteomyelitis.[71,72]

Owing to the severe consequences of S. aureus infections, particularly bacteremia, and the fact that colonization is thought to preceed infection, there has been interest since the 1980s in S. aureus decolonization as a means of preventing these infections in patients undergoing hemodialysis. This interest has in part been driven by studies that have shown some benefit of decolonization in other subgroups of patients, particularly patients undergoing surgical procedures.[73,74] However, to date, decolonization in hemodialysis patients remains controversial. Although most studies of hemodialysis patients have shown decreases in S. aureus infections in patients undergoing decolonization, the effect of decolonization on overall infections is less clear.[75–77] In addition, since patients may be colonized at multiple body sites and may become recolonized over time after successful decolonization, the best regimens to use for decolonization (decolonizing agent used, site where applied and frequency of treatment) remain to be determined.

In the 1980s, Yu et al. found that oral rifampin twice a day for 5 days and intranasal bacitracin four times a day for 7 days, each repeated every 3 months, led to significant reductions in S. aureus infections among colonized patients.[70] Boelaert et al. conducted a randomized trial among hemodialysis patients who were S. aureus carriers of intranasal 2% mupirocin ointment applied three times a day for 2 weeks and then at the end of each dialysis session for 9 months. They found significantly fewer S. aureus infections in the mupirocin group, although the one patient in the study who developed a S. aureus BSI was in the mupirocin group.[76] In a subsequent observational trial from the same group, intranasal mupirocin decolonization therapy applied to S. aureus carriers was associated with a fourfold decrease in S. aureus BSIs, although the incidence of all BSIs did not significantly change.[77] Kluytmans et al. found similar decreases in S. aureus BSIs in another observational trial of hemodialysis patients but they did not evaluate all BSIs.[75] In that trial, patients were screened monthly and were treated with intranasal mupirocin twice a day for 1 week and then once a week. In a meta-analysis of four studies of mupirocin, used in hemodialysis patients either intranasally or at catheter exit sites, there was an overall 78% reduction in S. aureus BSIs.[78]

The effect of routine decolonization on subsequent rates of antimicrobial resistance is a significant concern. Yu et al. found rifampin-resistant isolates in four of the 22 rifampin-treated patients in their study.[70] Studies of the limited use of intranasal mupriocin for S. aureus decolonization for peri-operative patients have generally not identified high rates of resistance to mupirocin.[79] However, high prevalence of mupirocin resistance has been identified, including in a recent report from a surgical intensive care unit in a tertiary care medical center that does not routinely use mupirocin for decolonization (13% resistance).[80] More research is needed to determine whether limited use of mupirocin will affect resistance rates of S. aureus.

Routine decolonization has not been endorsed by the CDC or KDOQI as a means of preventing infections in patients undergoing hemodialysis.[4,5,6,103] Further work is needed to understand the potential benefit of this intervention on overall infection, particularly BSI, rates. Regardless, if decolonization is used, it should be used only on patients known to be colonized with S. aureus in an effort to minimize the development of resistance to decolonizing agents.

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