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Saudi Journal of Kidney Diseases and Transplantation
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BRIEF COMMUNICATION  
Year : 2013  |  Volume : 24  |  Issue : 6  |  Page : 1228-1232
Successful elimination of hemodialysis-related bacteremia and vascular access infection


1 Department of Internal Medicine; Department of Nephrology, Bahrain Specialist Hospital, Manama, Bahrain
2 Department of Nephrology, Bahrain Specialist Hospital, Manama, Bahrain
3 Bacteriology Division, Laboratory Department, Bahrain Specialist Hospital, Manama, Bahrain

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Date of Web Publication13-Nov-2013
 

   Abstract 

Hemodialysis (HD) related bacteremia and dialysis induced infection constitute major risk factors for mortality and morbidity among patients with end stage renal disease. In this retrospective study, we attempted to assess the impact of the infection control protocol introduced in our center on the prevalence of HD related bacteremia and vascular access infection. All the HD sessions performed over 8 years, from January 2004 till the end of December 2011, were included in this study. Over 108 months of the study period, 6161 HD sessions were performed on 118 patients. Demographic data of all the study patients were collected. The type of vascular access as well as the presence of diabetes and hypertension were recorded. During the study period, 15 episodes of dialysis related bacteremia were noted in nine patients. Three of them required hospitalization for administration of parenteral antibiotics. Blood cultures in 93% of the infection episodes (14/15) grew Sphingomonas paucilomobilis. One patient had methicillin resistant Staphylococcus aureus grown on blood culture. The prevalence of HD related bacteremia and vascular access infection in our unit were lower than international published data. The infection control protocol used seems to have been successful in reducing HD related bacteremia and eliminating vascular access infection.

How to cite this article:
Al-Said J, Pagaduan A, Murdeshwar S. Successful elimination of hemodialysis-related bacteremia and vascular access infection. Saudi J Kidney Dis Transpl 2013;24:1228-32

How to cite this URL:
Al-Said J, Pagaduan A, Murdeshwar S. Successful elimination of hemodialysis-related bacteremia and vascular access infection. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2014 Dec 29];24:1228-32. Available from: http://www.sjkdt.org/text.asp?2013/24/6/1228/121313

   Introduction Top


The aim of this study was to identify the following: (a) the outcome of the infection control protocol introduced in our unit on the prevalence of hemodialysis (HD)-related bacteremia and vascular access infection, (b) the types of bacteria that caused the infection and (c) the prevalence of hospitalization and final outcome of these patients.

The infection control protocol followed in our unit

The infection control protocol included multiple procedures followed for physicians, nursing staff, reverse osmosis (RO), water treatment, dialysis unit facility, dialysis machines and finally the patients. The implementation of each part of the protocol, explained below, was periodically monitored by the physicians and the nursing team. The details are clarified as below:

Physicians and nursing staff:

  1. Education and training of new physicians.
  2. Hand washing.
  3. Universal and fluid spill precautions.
  4. Screening for hepatitis B virus (HBV) and hepatitis C virus (HCV) serology. Vaccination with booster was administered as required and updated annually.
  5. Biannual screening for methicillin-resistant Staphylococcus aureus (MRSA) and treating when positive, with daily antiseptic soap baths and Meprocilin (Bactroban) nasal cream.
  6. Maintaining a nurse to patient ratio of 2:1 during connection and disconnection. While during regular monitoring, the ratio is reversed to 1:2.
  7. Active involvement in supervising the delivery of dialysis by the nursing team.
  8. Patient rounds with new dialysis ordersduring each session.
  9. Continuous monitoring of the patients and full pre- and post-dialysis physical assessments.
  10. Patient education and supervision.
  11. Ensuring that the patient is escorted till his/her transportation vehicle after the HD session.
  12. Evaluation of performance and review of outcome with adjustments implemented as needed.
Patients:

  1. Initial screening for MRSA, HBV, HCV and human immunodeficiency virus (HIV) serology for all patients coming for dialysis.
  2. HBV and HCV serology check on an annual basis.
  3. Vaccination against HBV for antibody-negative patients at either 0, 1, 6 or 0, 1, 2 months depending on the clinical situation
  4. Annual vaccination against flu for all patients.
  5. Administration of pneumococcal vaccine every 5 years.
  6. Practicing isolation during dialysis for HBV and MRSA infected patients.
  7. MRSA screening biannually. Treating positive patients with daily antiseptic soap bath and Meprocilin (Bactroban) local cream.
  8. Culture of any dialysis catheter exit-site discharge.
  9. Culture all HD catheter tips after removal.
  10. Performing blood cultures for patients having unexplained fever or rigors.
  11. Cleaning the skin over the arterio-venous (AV) fistula or graft and the catheter exit-site with Betadine and allowing it to dry before use.
  12. Routine application of Meprocilin (Bactroban) cream to the exit-site of the catheter
  13. Filling the catheter dead space with unfractionated Heparin 5000 units/mL solution with additional 0.2 mL
  14. Using Opsite and gauze to cover the catheter completely with an elastic adhesive bandage.
  15. Separating each patient's medications trays.
Dialysis unit:

  1. Performing dialysis in closed unit areas with electrical doors without allowing any visitors.
  2. Using air-tight air conditioned filtered air and cleaning the air filter every 3 months.
  3. Using curtain dividers between the patients during connection and disconnection
  4. Having red line zones with the area beyond requiring practice of universal precautions for all personnel during connection and disconnection.
  5. Monthly cleaning of the whole unit, including the floor and the sinks, with Clorox.
  6. Culture of unit surfaces every 3 months.
  7. Cleaning beds and tables with Clorox once a week.
  8. Cleaning the bathrooms with Dettol and Clorox after each shift.
  9. Collection of waste and garbage after each session.
  10. Separate closets to keep patients' belongings.
  11. Using an isolation room for MRSA and HBV positive patients.
  12. Cleaning the beds after use by MRSA-positive patients.
Dialysis water treatment and reverse osmosis machine:

  1. Maintaining a separate water supply and closed water circuit to the dialysis unit.
  2. Maintaining filtration of the water before entering and after exiting the reservoir tanks.
  3. Maintaining filtration of the water before and after the RO.
  4. Attaching the machines to a sealed wall drainage system.
  5. Ensuring to change all filters every 3 months.
  6. Sterilization of the RO using Puristeril every 3 months or after any maintenance or repair work.
  7. Flushing of the water pipes automatically every 8 h during weekends and after working hours.
  8. Performing water culture every 3 months or after any maintenance work. Any positive results mandated inspection and resterilization of that compartment. Cultures are repeated till negative results are confirmed.
  9. Cleaning the water tanks manually every 6 months.
  10. Chemical analysis of the water every 3 months.
Dialysis machines:

  1. Separate designated machines for HBV positive patients.
  2. Double heat disinfection after dialyzing HCV and HIV positive patients.
  3. Pre- and post-dialysis heat disinfection and hot rinse.
  4. Cleaning the external surface of the machine with 90% alcohol after each session.
  5. Cleaning the surface of all dialysis machines once per week using Clorox.
  6. Changing the filters of all dialysis machines every 3 months or after every 100 sessions.
  7. Changing the inlet filters every 6 months.
  8. Regular pre- and post-dialysis culture of the water every 3 months, and repeated if positive (more than 100 CFU/mL) after sterilization.
  9. Cleaning the exhaust filter once per week.
  10. Heat disinfection with Diasteril and hot rinse before and after each dialysis session and after any maintenance work.
  11. Culture swab of the machine surface every month.
  12. Single use of dialysis filters and tubing.

   Results Top


The total number of patients involved in the study was 118 and the duration of the study was 8 years, during which 6161 dialysis sessions were performed. The demographics of the study patients are shown in [Table 1]. Over the 8-year study period, we saw only 15 HD-related bacteremic infection episodes in nine patients. Three of them required hospitalization for treatment. In 14 of the episodes, Sphingomonas paucilomobilis was grown on blood culture. One of the patients grew MRSA. All the patients recovered after treatment with oral Levofloxacin 250 mg daily for 14 days with an initial intravenous dose. None of the patients died. We did not encounter any case of dialysis catheter-induced infection nor did we see any case of vascular access infection. Because of the unusual organism obtained on blood culture, [7] and because all episodes occurred over a 2 month period, we performed further inspection and additional cultures of the dialysis water from all the reservoirs, pipes and machines. Finally we identified the source of Sphingomonas paucimobilis to be the water in the tanks and the water that stagnates overnight in the hose behind the dialysis machine. This hose connects the RO circuit to the individual dialysis machines. We performed manual cleaning and sterilization of the entire water circuit from the reservoir tanks to the dialysis machines.
Table 1: Demographic characteristics of the study patients.

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We revised and updated our infection control protocol by adding a heat disinfection session early in the morning before starting the first session in addition to the one performed after finishing dialysis the night before. For the past 2 years, we have not had any episodes of infection. The overall rates of infection are shown in [Table 2].
Table 2: Prevalence of infection and hospitalization rates in our unit as compared with the United States Renal Data System 2012 data.

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The types of the dialysis vascular access are presented in [Figure 1].
Figure 1: The types of vascular access in the study patients.

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   Discussion Top


We found that by following a tight infection control protocol, HD related bacteremia and vascular access infection were substantially reduced. The 15 cases identified were mainly due to Sphingomonas paucilomobilis. The primary source was the water in the pipes and tank. After inspection of the dialysis water circuit and flow in the unit, we found that the pipes connecting the dialysis machines to the RO water circuit retained water, and this remained stagnant overnight. It was a major source for bacterial contamination.

After cleaning the water reservoir, changing all the filters and modifying our dialysis disinfection protocol, we eliminated bacteremia from our HD unit completely. Adding a heat disinfection cycle before the first morning HD session in addition to the one after the last session the night before was effective in cleaning the stagnant pipe water behind the HD machines.

In spite of having cuffed tunneled catheters as the more common HD vascular access [Figure 1], and with most of our patients being in the first few months of HD, the prevalence rate of HD bacteremia and hospital admission in our study patients was substantially low as compared with the international data [Table 2].

We did not randomize a group of patients for assessment of each of the infection control protocol steps because we considered that it would be unethical to reduce standards for the control group. We understand that following this protocol would require additional efforts and cost, but these could be justified. As an example, the high nurse to patient ratio of 2:1 during connection and disconnection could be implemented by overlapping the nursing working shifts. In fact, if we estimate the additional cost of the recommended frequent filter changes, unit cleaning and staff infection screening, it would still be lower than the cost of treating patients with HD related bacteremia and access infection, not to mention the reduced mortality rates. [3],[8]

We believe that our protocol was successful in decreasing the HD-related infection by changing handling of vascular access rather than changing the type of access. [4],[5],[6] These results raise the possibility that improper handling of the HD access could be the major cause of a high infection prevalence, which could be even more important than the type of vascular access. [9] Further studies are needed to find the answers.

In conclusion, the infection control protocol that we follow has eliminated infection in our HD unit, and we believe that it would make a difference in other HD units too if it were to be implemented.

Conflict of Interest: None

 
   References Top

1.United States Renal Data system annual report 2012. Available from: http://www. usrds.org. [Last accessed on May 1, 2013].  Back to cited text no. 1
    
2.Reducing blood stream infection. http:// www.cdc.gov/nhsn/ psc-da-de.html. [Last accessed on May 1, 2013].  Back to cited text no. 2
    
3.Patel P, Kallen A, Arduino M. Epide-miology, surveillance and prevention of bloodstream infection in hemodialysis patients. Am J Kidney Dis 2010;56:566-77.  Back to cited text no. 3
    
4.Bagdasarian N, Heung M, Malani PN. Infectious complications of dialysis access devices. Infect Dis Clin North Am 2012; 26:127-41.  Back to cited text no. 4
    
5.Tal MG, Selecting optimal hemodialysis catheters: Material, advanced features, and preferences. Tech Vasc Interv Radiol 2008; 11:186-91.  Back to cited text no. 5
    
6.Abbas SA, Haloob IA, Taylor SL, et al. Effect of antimicrobial locks for the tunneled hemodialysis catheters on bloodstream infection and bacterial resistance: A quality improvement report. Am J Kidney Dis 2009;53:492-502.  Back to cited text no. 6
    
7.Fitzgibbons LN, Pulse DL, Mackay K, Forrest GN. Management of gram positive coccal bacteremia and hemodialysis. Am J Kidney Dis 2011;57:624-40.  Back to cited text no. 7
    
8.Weber DJ, Rutala WA. Bloodstreem infections: Prevention and Management. Infect Dis Clin North Am 2011;25:77-102.  Back to cited text no. 8
    
9.Tokars JI, Light P, Anderson J, et al. A prospective study of vascular access infection at seven outpatient hemodialysis centers. Am J Kidney Dis 2001;37:1232-40.  Back to cited text no. 9
    

Top
Correspondence Address:
Jafar Al-Said
Departments of Internal Medicine and Nephrology, Bahrain Specialist Hospital, Manama
Bahrain
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PMID: 24231491

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