HD Catheters Linked With Highest Rate of Bloodstream Infections
Nearly 70% of access-related bloodstream infections occurred in hemodialysis patients with central venous catheters.
Use of central venous catheters is associated with the highest rates of bloodstream infections compared with other forms of vascular access, a new study confirms.
In an analysis of 2014 data from the vast majority of dialysis centers in the United States, Duc B. Nguyen, MD, of the Centers for Disease Control and Prevention (CDC) in Atlanta, and colleagues found that catheters (tunneled and non-tunneled combined) were associated with 63% of bloodstream infections and 69.8% of access-related bloodstream infections. The rate of bloodstream infections was 2.16 per 100 patient-months with central venous catheters, compared with just 0.26 and 0.39 per 100 patient-months for arteriovenous fistulas and arteriovenous grafts, respectively. More patients using catheters also were hospitalized for these infections and other dialysis-related events.
“Catheters are a portal of entry for infection and might be used in patients with higher acuity of illness,” Dr Nguyen and colleagues explained in the Clinical Journal of the American Society of Nephrology. The investigators affirmed efforts to limit catheter use and acknowledged declining rates of related infections in recent years.
Staphylococcus aureus was the most common bloodstream pathogen (30.6%). However, 39.5% of S. aureus isolates tested were resistant to methicillin. The investigators also pointed out other drug-resistant pathogens, including Escherichia coli resistant to cephalosporins (17.8% of isolates tested), Klebsiella resistant to cephalosporins (14.6%), Enterococcus resistant to vancomycin (11.4%), and Enterobacter resistant to carbapenems (4.8%).
While infection rates have declined, antibiotic starts have not fallen to the same degree. Vancomycin was the most commonly used antimicrobial in 76% of intravenous antibiotic starts. The investigators suggested that some dialysis facilities may not routinely obtain blood cultures before using antibiotics.
“We now have a clearer picture of the rates and types of infections hemodialysis patients in the United States are experiencing — nearly all US outpatient hemodialysis facilities are participating in CDC's National Healthcare Safety Network (NHSN) Dialysis Event surveillance,” Dr Nguyen commented in a press release. “Our findings emphasize the need for hemodialysis facilities to improve infection prevention and vascular access care practices.” CDC resources on infection prevention can be found here https://www.cdc.gov/dialysis/prevention-tools/index.html
In an accompanying editorial, Dana Miskulin, MD, of Tufts University School of Medicine in Boston, and Ambreen Gul, MD, of Dialysis Clinic Inc., of Albuquerque, New Mexico, highlighted the problem of underreporting. “In closing, we make a plea to the dialysis community to ‘clean up' the data, so that the Quality Improvement Project is fairer for all and to enable the full potential of these data, both for improving care now and for generating new evidence to provide future opportunities to improve care and outcomes to be realized,” they wrote.
For this study, 6005 outpatient hemodialysis facilities reported dialysis event data for 2014 to the CDC's NHSN. Centers reported 160,971 dialysis events, including 29,516 bloodstream infections, 149,722 intravenous antimicrobial starts, and 38,310 pus, redness, or increased swelling at the HD vascular access site events. Of these, 22,576 (76.5%) bloodstream infections related to vascular access.
Duc B. Nguyen, Alicia Shugart, Christi Lines, et al. National Healthcare Safety Network (NHSN) Dialysis Event Surveillance Report for 2014. Clin J Am Soc Nephrol doi: 10.2215/CJN.11411116 [Epub ahead of print]
Catheters Linked to Most Bloodstream Infections in Dialysis Patients. American Society of Nephrology; June 29, 2017 (news release)
Miskulin DC and Gul A. Infection Monitoring in Dialysis Units: A Plea for “Cleaner” Data. Clin J Am Soc Nephrol. doi:10.2215/CJN.05220517