Dialysis: Guidelines May Reduce Bloodstream Infections

Joe Barber Jr, PhD

May 14, 2013

Patients undergoing hemodialysis had significantly lower rates of bloodstream infection (BSI) after dialysis facilities implemented targeted prevention guidelines, according to the findings of a quality improvement project.

Priti R. Patel, MD, PhD, from the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia, and colleagues published their findings in an article published online May 13 in the American Journal of Kidney Disease.

The authors note that patients receiving hemodialysis are particularly susceptible to BSIs. "The rate of hospitalizations for bacteremia or septicemia among maintenance hemodialysis patients was 116 events per 1,000 patient-years in 2010 and has increased 51% since 1993," the authors write. "Hemodialysis patients are particularly susceptible to BSIs because of their need for vascular access, typically through arteriovenous (AV) fistulas or grafts or central venous catheters (CVCs)."

In the study, the researchers monitored BSI rates at 17 participating hemodialysis centers before and after implementation of the CDC prevention guidelines. The quality improvement plan included chlorhexidine use for skin antisepsis, patient education/engagement, and staff education and competency.

Before the plan was implemented, the mean overall BSI (defined as a positive blood culture collected from a patient within 1 day of admission) and access-related BSI (vascular access was suspected as the infection source) rates were 1.09 and 0.73 events per 100 patient-months, respectively. The authors excluded positive blood cultures that were collected within 21 days of a prior positive result from the analysis. The quarterly crude rates of overall and access-related BSIs were higher for patients with CVCs than for those with AV fistulas.

During the 15-month intervention period, the mean and access-related BSI rates decreased to 0.89 and 0.42 events per 100 patient-months, respectively. The investigators estimated the mean overall BSI rate decreased by 32% (95% confidence interval [CI], 8% - 50%; P = .01) and the mean access-related BSI rate decreased by 54% (95% CI, 38% - 67%; P < .001), based on generalized linear mixed models using segmented regression analysis.

In addition, in the models, the overall and access-related BSI rates decreased within 1 month of implementation of the quality improvement plan, and these decreases were maintained throughout the observation period. The limitations of the study included the lack of a control group and a lack of representativeness among the participating hospitals.

"We believe this initiative has helped define what is achievable through focused efforts among dialysis facility staff to improve adherence to CDC-recommended practices for BSI prevention," the authors write. "An important next step is to reproduce the results in other dialysis facilities to expand the impact and further prevent these devastating patient infections."

The study was supported by the Centers for Disease Control and Prevention. The authors have disclosed no relevant financial relationships.

Am J Kidney Dis. Published online May 13, 2013. Abstract


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