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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2009  |  Volume : 20  |  Issue : 4  |  Page : 677-680
Infection-free hemodialysis: Can it be achieved?

Bahrain Specialist Hospital, Manama, Bahrain

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Date of Web Publication8-Jul-2009


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

How to cite this URL:
Al-Said J, Pagaduan AC. Infection-free hemodialysis: Can it be achieved?. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2021 Jan 17];20:677-80. Available from: https://www.sjkdt.org/text.asp?2009/20/4/677/53304

   Introduction Top

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. [1] 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 Top

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:

  1. 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.
  2. Proper hand washing was ensured before and after connecting patients to the machine.
  3. Disposable gowns, face masks, head caps, and eye shields for patients, nurses and doc­tors were mandatory during the handling of any vascular access.
  4. Using Betadine (10% povidone iodine) so­lution and allowing adequate time for it to dry, without wiping, before starting any con­nection, was ensured.
  5. The external part of the catheter was cleaned with Betadine before every HD session.
  6. Mupirocin cream was used at the skin ca­theter exit-site.
  7. 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.
  8. Dressing for dialysis accesses was changed by only the dialysis team.
  9. No visitors were allowed to stay in the dia­lysis unit.
  10. Each patient's medicines were kept in a se­parate box.
  11. Routine culture was performed for all dia­lysis catheter tips after their removal.
  12. Careful monitoring was undertaken for any signs or symptoms of infection. Cultures were sent from the skin or blood when needed.
  13. Regular cultures of dialysis water were per­formed every three months and after com­pletion of any maintenance work on the dia­lysis water circuit.
  14. Monthly sterilization with chlorox, for the dialysis unit as a whole, including water tanks, sinks, tables, couches, chairs, floor, and drain was performed.
  15. Regular screening was undertaken of all medical staff and patients, for MRSA, every six months.
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. [2]

   Results Top

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 Top

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. [1] 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. [1] ,[3]

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. [4] ,[5] 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. [6] 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. [7] 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 Top

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 Top

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.

   References Top

1.Morbidity and mortality. USRD 2007. www.usrds.org www.usrds.org>.  Back to cited text no. 1    
2.Kumari S. WHO guidelines on prevention and control of hospital associated infections. Regional office for South East Asia Jan 2002.  Back to cited text no. 2    
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.  Back to cited text no. 3    
4.Pastan S, Soucie M, McClellan WM. Vascular access and increased risk of death among hemodialysis patients. Kidney Int 2002;62:620-6  Back to cited text no. 4    
5.Allon M, Depner TA, Radeva M, et al. Impact of dialysis dose and membrane on infection-related hospitalization and death: Result of the HEMO Study. J Am Soc Nephrol 2003;14: 1863-70.  Back to cited text no. 5    
6.Allon M. Dialysis catheter-related bacteremia: treatment and prophylaxis. Am J Kidney Dis 2004;44(5):779-91.  Back to cited text no. 6    
7.Tokaris J, Miller E, Stein G. New national surveillance system for hemodialysis associated infection. Am J Infect Control 2002;30(5):288-95  Back to cited text no. 7    

Correspondence Address:
Jafar Al-Said
Bahrain Specialist Hospital, Manama
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PMID: 19587520

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  [Table 1], [Table 2], [Table 3], [Table 4]


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