| Abstract|| |
Infection is the second most common cause of mortality in patients with end stage renal disease (ESRD). Following strict aseptic precautions during a hemodialysis (HD) session could reduce dialysis-related infection, thereby reducing mortality and morbidity rates. This retrospective study was undertaken to identify the prevalence of dialysis-related bacteremia, sepsis, and catheter infections during HD at Bahrain Specialist Hospital, Bahrain, after following rigid infection control procedures. All HD sessions performed between January 2004 and December 2007 were included. Strict aseptic precautions were observed for every patient in our dialysis unit. The patients' demographic characteristics as well as presence of hypertension (HTN), diabetes mellitus (DM) and use of immunosuppressive drugs were recorded. Results of culture of dialysis catheter tip were collected for all catheters removed or changed during the study period. Catheter surface culture yielding more than 15 colonies and catheter lumen culture yielding more than 1000 CFU/mL were considered positive. All episodes of rigors, chills, bacteremia, and sepsis were recorded. Overall, a total of 1084 HD sessions performed on 46 patients were studied. The mean age of the study patients was 55.2 years (SE 2.5). Fifty four percent were male, 50% had DM, 85% had HTN and 11% were immunosuppressed. With implementation of strict aseptic precautions no catheter-related infection, bacteremia or sepsis was found. Culture of 50 dialysis catheters showed Diptheroid in three patients, MRSE in two patients and MSSE, Enterobacter, and Klebsiella in one patient each. None of the study patients had signs or symptoms of infection or bacteremia. Our study further indicates that following strict aseptic precautions during HD sessions can reduce, if not eliminate, infection as a major cause of mortality and morbidity.
|How to cite this article:|
Al-Said J, Pagaduan AC. Infection-free hemodialysis: Can it be achieved?. Saudi J Kidney Dis Transpl 2009;20:677-80
| Introduction|| |
Infection is one of the major causes of mortality and morbidity in patients on hemodialysis (HD). It is considered the second most common cause of mortality in these patients.  A common picture to HD health care workers is patients shivering or developing fever during or after the dialysis session. In extreme cases, bacteremia and septicemia can develop. The episodes of infection contribute to increased morbidity and mortality in these patients.
While discussing this important subject of reducing dialysis-related infections, a question arises: are we as nephrologists, doing a proper job in following the recommended guidelines and preventing dialysis-related infections? We could get the answer during our rounds in the dialysis units. It is not uncommon to see and perhaps ignore, dialysis nurses connecting/disconnecting patients while at the same time they are manipulating the dialysis machine knobs with sterile gloves.
In order to answer these queries, we decided to test the effect of following strict infection control guidelines in reducing the incidence of HDrelated infection, which is defined as any episode of fever or chills during a HD session, with or without positive blood or catheter tip culture.
| Methodology|| |
This is a retrospective study, which analyzed data taken from HD sessions performed in our unit from January 2004 to December 2007. The details recorded included: patients' age, gender, type of vascular access, whether they have acute renal failure or ESRD, presence of diabetes mellitus (DM), hypertension (HTN), and if patients were on immunosuppressive medications. The following rules were strictly implemented for every dialysis patient in our unit:
Clinical signs of infection including fever, chills, redness and discharge at the vascular access exitsite were monitored and registered. Blood, catheter, and skin swab cultures were collected, when required. Positive dialysis catheter cultures were considered according to the WHO guidelines. Quantitative lumen culture with growth of more than 1000 colony forming units (CFU) /mL was considered significant. Cultures from the catheter surface growing > 15 CFU/mL were considered significant. 
- Two nurses were involved in connecting and disconnecting patients to the dialysis machines. One would control the machine and the other nurse would handle the access using sterile precautions.
- Proper hand washing was ensured before and after connecting patients to the machine.
- Disposable gowns, face masks, head caps, and eye shields for patients, nurses and doctors were mandatory during the handling of any vascular access.
- Using Betadine (10% povidone iodine) solution and allowing adequate time for it to dry, without wiping, before starting any connection, was ensured.
- The external part of the catheter was cleaned with Betadine before every HD session.
- Mupirocin cream was used at the skin catheter exit-site.
- 0.2 mL of heparin, (5000 IU /mL) was added to the dead space volume and the total volume was injected into every catheter port after each HD session.
- Dressing for dialysis accesses was changed by only the dialysis team.
- No visitors were allowed to stay in the dialysis unit.
- Each patient's medicines were kept in a separate box.
- Routine culture was performed for all dialysis catheter tips after their removal.
- Careful monitoring was undertaken for any signs or symptoms of infection. Cultures were sent from the skin or blood when needed.
- Regular cultures of dialysis water were performed every three months and after completion of any maintenance work on the dialysis water circuit.
- Monthly sterilization with chlorox, for the dialysis unit as a whole, including water tanks, sinks, tables, couches, chairs, floor, and drain was performed.
- Regular screening was undertaken of all medical staff and patients, for MRSA, every six months.
| Results|| |
Hemodialysis service was initiated in our hospital in January 2004. The total number of HD sessions included in this study was 1084 giving an average of 35 sessions per month. Patients' demographic features are shown in [Table 1]. The types of the vascular access used are shown in [Table 2].
As a protocol, all HD catheters removed were cultured. The results of these tests are shown in [Table 3] and [Table 4]. Positive cultures from this site were not associated with local exit site infection or clinical sepsis or bacteremia. We did not encounter any episode of fever, chills or shivering in our studied patients. Similarly, no cases of bacteremia or sepsis were encountered.
| Discussion|| |
The reported annual mortality rate among HD patients is around 23%. It is found that during the first year of HD, the mortality rate is about 40.5 per 1000 patient-years.  Infection is considered the second most common cause of mortality in HD patients accounting for 12-22%. Cardiovascular disease remains the most common cause of death.  ,
Part of the infection is related to the HD procedure itself because of breaching of the normal skin defensive mechanism. The other part is due to low patient immunity secondary to the effect of uremic toxins. The risk of infection related death reportedly increases 2-3 folds among patients with vascular catheters as compared to those with fistulas or grafts.  , The annual episodes of catheter related bacteremia in the United States is reported to be 67500-150000. Of these patients, 10% will require hospitalization because of either severe sepsis or metastatic infection.  The total risk of catheter-related bacteremia is 1.78/100 patient-months, while it is 0.25 for fistulas, 0.53 for grafts, 4.84 for cuffed tunneled catheters and 8.73 for non-cuffed catheters. The reported risk of vascular access infection varies in different HD centers, between 0.31 to 3.9/ 100 patient-months.  Although the majority of the dialysis sessions in our unit were performed with either cuffed tunneled catheters or vascath, we did not notice any episode of dialysisrelated infection.
Culture of the catheter lumen was positive in six patients (12%). Two additional patients had positive culture of the outer surface of the catheter, showing Diphtheroids. We routinely culture all catheter tips as a quality control exercise, on implementation of proper aseptic technique in dealing with HD vascular access. None of the patients had any signs or symptoms of exit-site or systemic infection. The cause of catheter removal was either malfunction or duration longer than six months for cuffed tunneled catheter or, two weeks for internal jugular catheter.
Most of the patients included in this study were either those with acute renal failure or patients with ESRD who were recently initiated on HD. The patients are transferred afterwards to community or governmental HD units for long-term care. This could explain the high incidence of catheter use, whether cuffed tunneled or vascath, among the study patients.
It would have been ideal if we could test a control group in whom implementation of the above guidelines was not followed. However, this would pose an ethical question especially after noticing the effectiveness of these precautions.
When discussing the subject of infection and its prevention in HD patients, one argument that always comes up against implementing the required guidelines, is staff shortage or patient non-compliance. In addition to these two reasons, it is also possible that we, as nephrologists, are not implementing and/or training our staff to follow the guidelines properly. Better supervision, tight infection control and effective training to dialysis staff could help in reducing the need for hospitalization for access revision, antibiotic therapy or possibly, management of sepsis. It is useful to provide the staff with updated protocols for aseptic precautions in HD units. It is also very crucial to spend quality time in training and supervising the implementation of the sterile techniques to prevent dialysis related infection.
The additional expenses in providing adequate staff required to implement these guidelines will be compensated in the long term, since reducing HD-related infection can reduce the over all cost of treatment for ESRD patients.
| Conclusion|| |
Implementing tight infection control guidelines is achievable and it would reduce, if not eliminate, the incidence of dialysis-related infection. We have been training all our new nursing staff to follow these procedures rigidly. We consider staff shortage or limited resources unacceptable excuses against the strict implementation of all these guidelines.
| Acknowledgement|| |
The authors would like to thank Ms. Rema B. Pachoco, Ms. Rekha Basnet and Ms. Soni Rajesh Murdeshwar for their assistance in the preparation of this manuscript.
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|3.||Infection and Immunity. Management of the Maintenance Hemodialysis Patients. Chapter 59: The kidney. Brenner and Rector′s. WB. Saun-ders 7 th edition, 2004. |
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Bahrain Specialist Hospital, Manama
[Table 1], [Table 2], [Table 3], [Table 4]