American Journal of Infection Control 42 (2014) 182-4
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Incidence of nosocomial hemodialysis-associated bloodstream infections at a county teaching hospital Matías Gnass MD, Caren Gielish LVN, Silvia Acosta-Gnass MSc * Infection Prevention and Control Department, Riverside County Regional Medical Center, Riverside, CA
Key Words: Dialysis vascular access HbA1c MRSA
Background: Infections are an important cause of morbidity and mortality in patients undergoing hemodialysis. Limited information is to be found regarding nosocomial hemodialysis-associated bloodstream infections (HABSI). Methods: We sought to determine the rate of nosocomial HABSI and its associated risk factors at Riverside County Regional Medical Center. Inpatients who received hemodialysis during 2011 and 2012 were included, and outcomes were recorded along with risk factors. Data was analyzed with SPSS Inc software. Results: A total of 619 patients was included. Fourteen HABSI were detected, with a rate of 3.33/1,000 hemodialysis sessions and 1.03/1,000 patient-days. An association was detected between HABSI and vascular access type (highest risk with nontunneled catheters), length of hospital stay, number of hemodialysis sessions, and hemoglobin A1c level. A correlation was also noted between HABSI because of MRSA and colonization of nares with MRSA. A predominance of staphylococci infections was detected. Conclusion: The rate of HABSI observed at Riverside County Regional Medical Center was lower than similar studies (2.5 per 1,000 patient-days and 3.95 per 1,000 hemodialysis sessions). The most important risk factors were determined to be nontunneled catheters, hemoglobin A1c greater than 7%, and nares colonization for HABSI because of MRSA. Infection prevention efforts in the inpatient hemodialysis population should focus on control of hyperglycemia and decolonization of nares from MRSA. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
In the United States, in 2010, there were over 100,000 new patients diagnosed with end-stage renal disease, the majority of which began therapy with hemodialysis, and more than 376,000 end-stage renal disease patients received hemodialysis that year. Hospitalization is a common occurrence in this population. The average admission rate in 2010 was 1.87 per patient-year, with a length of stay of 12.1 days per admission.1 These patients are at an increased risk for infection because of the immunocompromised state they are in, caused by uremia, the hemodialysis procedure itself, chronic renal failure complications and comorbid conditions.2,3 In addition, the constant access to the vascular system for hemodialysis contributes to the development of hemodialysis-associated bloodstream infections (HABSI).4-6 Nosocomial infections continue to be an important cause of mortality and increased length of hospital stay.7,8 There have not been many studies that have focused on the inpatient hemodialysis
population and the infections they present. Therefore, to develop effective prevention strategies, this research was carried out to study the epidemiologic characteristics of HABSI in the inpatient population of Riverside County Regional Medical Center (RCRMC). METHODS Patient population Riverside County Regional Medical Center (Moreno Valley, CA) is a 394-bed teaching hospital. All patients who were hospitalized and underwent hemodialysis during January 2011 to December 2012 were included in the study. Demographic and clinical data were obtained by reviewing medical records and laboratory reports. Definitions
* Address correspondence to Silvia Acosta-Gnass, MSc, 6275 Barranca Drive, Riverside, CA 92506. E-mail address: [email protected] (S. Acosta-Gnass). Conflicts of interest: None to report.
The CDC definitions were used to classify each event: positive blood culture, access-related bacteremia, secondary bacteremia, wound infection, pneumonia, and urinary tract infection.9
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.08.014
M. Gnass et al. / American Journal of Infection Control 42 (2014) 182-4
183
Fig 2. Frequency of Staphylococcus species isolated from hemodialysis-associated bloodstream infections at Riverside County Regional Medical Center during 2011-2012. Fig 1. Frequency of microorganisms isolated from hemodialysis-associated bloodstream infections at Riverside County Regional Medical Center during 2011-2012.
Review of microbiology laboratory records was the main method for detecting cases. Analysis of clinical data by the researchers determined whether criteria for HABSI were met. The total number patients receiving hemodialysis, along with number of hemodialysis sessions and length of hospital stay, were recorded as denominators. MRSA active surveillance culture Nasal cultures for MRSA are collected from both anterior nares, including septum, using a culturette swab and sent to the laboratory. This procedure is performed on admission of every patient who will receive dialysis treatment at RCRMC. Hemoglobin A1c measurement At RCRMC, following the American Diabetes Association Clinical Practice guidelines, hemoglobin A1c (HbA1c) measurement is performed at least 2 times a year in patients who are meeting treatment goals and who have stable glycemic control and performed quarterly in patients whose therapy has changed or who are not meeting glycemic goals. For those patients who do not have recent A1c measurement, the test is performed on admission. Statistical analysis Categorical variables were compared using c2 or Fischer exact test, and continuous variables were studied using logistic regression, to estimate the odds ratio (OR) of potential risk factors for developing nosocomial hemodialysis-associated infections. A P value of .05 or less was considered statistically significant. Data was gathered on Microsoft Excel (Microsoft Corp, Redmond, WA) spreadsheets and analyzed with IBM SPSS statistics (SPSS Inc, Chicago, IL). Rates were calculated based on events per 1,000 patient-days of hospitalization and events per 1,000 hemodialysis sessions. RESULTS During January 2011 to December 2012, a total of 619 patients received hemodialysis at RCRMC. The average age for this population was 57 15 years old; 54% were male, and 48% had diabetes. There were 1,024 admissions recorded during the 24-month period (giving an average 1.65 admissions per patient) with a mean length of stay of 13.2 days per admission. A total of 4,204 hemodialysis sessions was recorded, averaging 4.1 sessions per admission.
Vascular access distribution showed 383 fistulas (37.4%), 58 grafts (5.7%), 338 tunneled catheters (33%), and 245 nontunneled catheters (23.9%). On admission, patients underwent a nasal swab for detection of MRSA, of which 74 were positive. There were 300 diabetic patients (48%). HbA1c measurements revealed a mean of 6.5% with a standard deviation of 1.6. Fourteen hemodialysisassociated infections were detected during this period, with a rate of 3.33 per 1,000 hemodialysis sessions and 1.03 per 1,000 patient-days of hospitalization. Rates of infection per type of vascular access were as follows: for fistulas, 0.9 per 1,000 hemodialysis sessions and 0.33 per 1,000 patient-days of hospitalization (OR, 0.13; 95% confidence interval [CI]: 0.02-0.97, P ¼ .16); for grafts, 13.51 per 1,000 hemodialysis sessions and 5.28 per 1,000 patient-days of hospitalization (OR, 2.84; 95% CI: 0.62-12.9, P ¼ .72); for tunneled catheters, 2.39 per 1,000 hemodialysis sessions and 0.79 per 1,000 patient-days of hospitalization (OR, 0.81; 95% CI: 0.25-2.6, P < .05); and, for nontunneled catheters, 5.5 per 1,000 hemodialysis sessions and 1.36 per 1,000 patient-days of hospitalization (OR, 3.24; 95% CI: 1.139.34, P < .05). A positive correlation was detected between HABSI and length of hospital stay (r ¼ 0.82; 95% CI: 0.79-0.83, P < .05) and number of hemodialysis sessions (r ¼ 0.56; 95% CI: 0.52-0.61, P < .05). For patients with diabetes, a positive correlation was detected between HABSI and HbA1c level (r ¼ 0.49; 95% CI: 0.42-0.55, P < .05). Risk for a hemodialysis-associated event significantly increased with HbA1c levels greater than 7% (OR, 3.62; 95% CI: 1.15-11.4, P < .05). An association was also noted between HABSI because of MRSA and colonization of nares with MRSA (OR, 21.7; 95% CI: 5.3-88.8, P < .05). Of the total 14 isolated microorganisms, 9 (64%) were grampositive cocci with a predominance of 8 staphylococcal infections (57%). Within this group of staphylococci, Staphylococcus aureus was the main microorganism isolated (63%) (see Figs 1 and 2). DISCUSSION Much information is available regarding hemodialysisassociated infections in the outpatient hemodialysis centers.10-17 However, there are few published reports that have studied this subject in the inpatient hemodialysis population. The present study is a 24-month retrospective research performed at the RCRMC to describe the epidemiologic characteristics of HABSI. The results of this study showed that the rates of HABSI at RCRMC were lower than the rates detected by similar studies, eg, D’Agata et al (2.5 per 1,000 patient-days of hospitalization)18 and Saeed et al (3.95 per 1,000 hemodialysis sessions).19 A statistically significant association was detected between HABSI and several of the risk factors that were studied. The use of nontunneled catheters was related to an increased risk of an
184
M. Gnass et al. / American Journal of Infection Control 42 (2014) 182-4
infectious event. The same was true for increasing values of HbA1c above the level of 7%.20-22 Colonization of nares with MRSA was seen to be associated with an increased risk of developing a HABSI because of MRSA, as had been previously observed by other authors.23,24 The current literature identifies coagulase-negative Staphylococcus, S aureus, and Escherichia coli as the major pathogens implicated in hemodialysis-associated infections.25 This study also identified Staphylococcus as the main pathogen implicated in nosocomial hemodialysis-associated infections. Infection prevention efforts in the inpatient hemodialysis population should focus on 2 major risk factors: first, strict control of hyperglycemia; and, second, decolonization of nares from MRSA. In addition, as has been extensively studied and recommended by the National Kidney Foundation, use of fistulas for vascular access should be preferred over catheters.26
References 1. US Renal Data System. USRDS 2012 annual data report: atlas of end-stage renal disease in the United States. Bethesda [MD]: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2012. 2. Eleftheriadis T, Antoniadi G, Liakopoulos V, Kartsios C, Stefanidis I. Disturbances of acquired immunity on hemodialysis patients. Semin Dial 2007;20:440-51. 3. Eleftheriadis T, Liakopoulos V, Leivaditis K, Antoniadi G, Stefanidis I. Infections in hemodialysis: a concise review, part 1: bacteremia and respiratory infections. Hippokratia 2011;15:12-7. 4. Betjes MG. Prevention of catheter-related bloodstream infection in patients on hemodialysis. Nat Rev Nephrol 2011;7:257-65. 5. Bonomo RA, Rice D, Whalen C, Linn D, Eckstein E, Shlaes DM. Risk factors associated with permanent access-site infections in chronic hemodialysis patients. Infect Control Hosp Epidemiol 1997;18:757-61. 6. Gulati S, Sahu KM, Avula S, Sharma RK, Ayyagiri A, Pandey CM. Role of vascular access as a risk factor for infections in hemodialysis. Ren Fail 2003;25:967-73. 7. Allon M, Radeva M, Bailey J, Beddhu S, Butterly D, Coyne DW, et al. The spectrum of infection-related morbidity in hospitalized haemodialysis patients. Nephrol Dial Transplant 2005;20:1180-6. 8. Centers for Disease Control and Prevention. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR 2001; 50:1-43. 9. Centers for Disease Control and Prevention. Dialysis event protocol. In: Centers for Disease Control and Prevention, editor. National Healthcare Safety Network manual: patient safety component manual. Atlanta [GA]: Division of Healthcare Quality Promotion; 2011. p. 1-3.
10. Hoen B, Paul-Dauphin A, Hestin D, Kessler M. EPIBACDIAL: a multicenter prospective study of risk factors for bacteremia in chronic hemodialysis patients. J Am Soc Nephrol 1998;9:869-76. 11. Jean G, Charra B, Chazot C, Vanel T, Terrat JC, Hurot JM, et al. Risk factor analysis for long-term tunneled dialysis catheter-related bacteremias. Nephron 2002; 91:399-405. 12. Johnston BL, Conly JM. Central venous catheter-associated bloodstream infections in hemodialysis patients: another patient safety bundle? Can J Infect Dis Med Microbiol 2006;17:99-102. 13. Patel PR, Yi SH, Booth S, Bren V, Downham G, Hess S, et al. Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report. Am J Kidney Dis 2013;62:322-30. 14. Ponce P, Cruz J, Ferreira A, Oliveira C, Vinhas J, Silva G, et al. A prospective study on incidence of bacterial infections in portuguese dialysis units. Nephron Clin Pract 2007;107:133-8. 15. Stevenson KB, Adcox MJ, Mallea MC, Narasimhan N, Wagnild JP. Standardized surveillance of hemodialysis vascular access infections: 18-month experience at an outpatient, multifacility hemodialysis center. Infect Control Hosp Epidemiol 2000;21:200-3. 16. Taylor G, Gravel D, Johnston L, Embil J, Holton D, Paton S. Incidence of bloodstream infection in multicenter inception cohorts of hemodialysis patients. Am J Infect Control 2004;32:155-60. 17. Tokars JI, Light P, Anderson J, Miller ER, Parrish J, Armistead N, et al. A prospective study of vascular access infections at seven outpatient hemodialysis centers. Am J Kidney Dis 2001;37:1232-40. 18. D’Agata EM, Mount DB, Thayer V, Schaffner W. Hospital-acquired infections among chronic hemodialysis patients. Am J Kidney Dis 2000;35:1083-8. 19. Saeed Abdulrahman I, Al-Mueilo SH, Bokhary HA, Ladipo GO, Al-Rubaish A. A prospective study of hemodialysis access-related bacterial infections. J Infect Chemother 2002;8:242-6. 20. Morioka T, Emoto M, Tabata T, Shoji T, Tahara H, Kishimoto H, et al. Glycemic control is a predictor of survival for diabetic patients on hemodialysis. Diabetes Care 2001;24:909-13. 21. Ricks J, Molnar MZ, Kovesdy CP, Shah A, Nissenson AR, Williams M, et al. Glycemic control and cardiovascular mortality in hemodialysis patients with diabetes: a 6-year cohort study. Diabetes 2012;61:708-15. 22. Shurraw S, Hemmelgarn B, Lin M, Majumdar SR, Klarenbach S, Manns B, et al. Association between glycemic control and adverse outcomes in people with diabetes mellitus and chronic kidney disease: a population-based cohort study. Arch Intern Med 2011;171:1920-7. 23. Centers for Disease Control and Prevention. Invasive methicillin-resistant Staphylococcus aureus infections among dialysis patients. MMWR 2007;56:197-9. 24. Grünewald T, Lindner M, Weiß S, Ruf I, Treutler T, Ruf B, et al. Staphylococcus colonization, mortality and morbidity in hemodialysis patients: 10 years of observation. Int J Hyg Environ Health 2013;216:751-4. 25. D’Amato-Palumbo S, Kaplan AA, Feinn RS, Lalla RV. Retrospective study of microorganisms associated with vascular access infection in hemodialysis patients. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:56-61. 26. National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 updates: Hemodialysis adequacy, peritoneal dialysis adequacy and vascular access. Am J Kidney Dis 2006;48:S1-322.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Incidence of nosocomial hemodialysis-associated bloodstream infections at a county teaching hospital Matías Gnass MD, Caren Gielish LVN, Silvia Acosta-Gnass MSc * Infection Prevention and Control Department, Riverside County Regional Medical Center, Riverside, CA
Key Words: Dialysis vascular access HbA1c MRSA
Background: Infections are an important cause of morbidity and mortality in patients undergoing hemodialysis. Limited information is to be found regarding nosocomial hemodialysis-associated bloodstream infections (HABSI). Methods: We sought to determine the rate of nosocomial HABSI and its associated risk factors at Riverside County Regional Medical Center. Inpatients who received hemodialysis during 2011 and 2012 were included, and outcomes were recorded along with risk factors. Data was analyzed with SPSS Inc software. Results: A total of 619 patients was included. Fourteen HABSI were detected, with a rate of 3.33/1,000 hemodialysis sessions and 1.03/1,000 patient-days. An association was detected between HABSI and vascular access type (highest risk with nontunneled catheters), length of hospital stay, number of hemodialysis sessions, and hemoglobin A1c level. A correlation was also noted between HABSI because of MRSA and colonization of nares with MRSA. A predominance of staphylococci infections was detected. Conclusion: The rate of HABSI observed at Riverside County Regional Medical Center was lower than similar studies (2.5 per 1,000 patient-days and 3.95 per 1,000 hemodialysis sessions). The most important risk factors were determined to be nontunneled catheters, hemoglobin A1c greater than 7%, and nares colonization for HABSI because of MRSA. Infection prevention efforts in the inpatient hemodialysis population should focus on control of hyperglycemia and decolonization of nares from MRSA. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
In the United States, in 2010, there were over 100,000 new patients diagnosed with end-stage renal disease, the majority of which began therapy with hemodialysis, and more than 376,000 end-stage renal disease patients received hemodialysis that year. Hospitalization is a common occurrence in this population. The average admission rate in 2010 was 1.87 per patient-year, with a length of stay of 12.1 days per admission.1 These patients are at an increased risk for infection because of the immunocompromised state they are in, caused by uremia, the hemodialysis procedure itself, chronic renal failure complications and comorbid conditions.2,3 In addition, the constant access to the vascular system for hemodialysis contributes to the development of hemodialysis-associated bloodstream infections (HABSI).4-6 Nosocomial infections continue to be an important cause of mortality and increased length of hospital stay.7,8 There have not been many studies that have focused on the inpatient hemodialysis
population and the infections they present. Therefore, to develop effective prevention strategies, this research was carried out to study the epidemiologic characteristics of HABSI in the inpatient population of Riverside County Regional Medical Center (RCRMC). METHODS Patient population Riverside County Regional Medical Center (Moreno Valley, CA) is a 394-bed teaching hospital. All patients who were hospitalized and underwent hemodialysis during January 2011 to December 2012 were included in the study. Demographic and clinical data were obtained by reviewing medical records and laboratory reports. Definitions
* Address correspondence to Silvia Acosta-Gnass, MSc, 6275 Barranca Drive, Riverside, CA 92506. E-mail address: [email protected] (S. Acosta-Gnass). Conflicts of interest: None to report.
The CDC definitions were used to classify each event: positive blood culture, access-related bacteremia, secondary bacteremia, wound infection, pneumonia, and urinary tract infection.9
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.08.014
M. Gnass et al. / American Journal of Infection Control 42 (2014) 182-4
183
Fig 2. Frequency of Staphylococcus species isolated from hemodialysis-associated bloodstream infections at Riverside County Regional Medical Center during 2011-2012. Fig 1. Frequency of microorganisms isolated from hemodialysis-associated bloodstream infections at Riverside County Regional Medical Center during 2011-2012.
Review of microbiology laboratory records was the main method for detecting cases. Analysis of clinical data by the researchers determined whether criteria for HABSI were met. The total number patients receiving hemodialysis, along with number of hemodialysis sessions and length of hospital stay, were recorded as denominators. MRSA active surveillance culture Nasal cultures for MRSA are collected from both anterior nares, including septum, using a culturette swab and sent to the laboratory. This procedure is performed on admission of every patient who will receive dialysis treatment at RCRMC. Hemoglobin A1c measurement At RCRMC, following the American Diabetes Association Clinical Practice guidelines, hemoglobin A1c (HbA1c) measurement is performed at least 2 times a year in patients who are meeting treatment goals and who have stable glycemic control and performed quarterly in patients whose therapy has changed or who are not meeting glycemic goals. For those patients who do not have recent A1c measurement, the test is performed on admission. Statistical analysis Categorical variables were compared using c2 or Fischer exact test, and continuous variables were studied using logistic regression, to estimate the odds ratio (OR) of potential risk factors for developing nosocomial hemodialysis-associated infections. A P value of .05 or less was considered statistically significant. Data was gathered on Microsoft Excel (Microsoft Corp, Redmond, WA) spreadsheets and analyzed with IBM SPSS statistics (SPSS Inc, Chicago, IL). Rates were calculated based on events per 1,000 patient-days of hospitalization and events per 1,000 hemodialysis sessions. RESULTS During January 2011 to December 2012, a total of 619 patients received hemodialysis at RCRMC. The average age for this population was 57 15 years old; 54% were male, and 48% had diabetes. There were 1,024 admissions recorded during the 24-month period (giving an average 1.65 admissions per patient) with a mean length of stay of 13.2 days per admission. A total of 4,204 hemodialysis sessions was recorded, averaging 4.1 sessions per admission.
Vascular access distribution showed 383 fistulas (37.4%), 58 grafts (5.7%), 338 tunneled catheters (33%), and 245 nontunneled catheters (23.9%). On admission, patients underwent a nasal swab for detection of MRSA, of which 74 were positive. There were 300 diabetic patients (48%). HbA1c measurements revealed a mean of 6.5% with a standard deviation of 1.6. Fourteen hemodialysisassociated infections were detected during this period, with a rate of 3.33 per 1,000 hemodialysis sessions and 1.03 per 1,000 patient-days of hospitalization. Rates of infection per type of vascular access were as follows: for fistulas, 0.9 per 1,000 hemodialysis sessions and 0.33 per 1,000 patient-days of hospitalization (OR, 0.13; 95% confidence interval [CI]: 0.02-0.97, P ¼ .16); for grafts, 13.51 per 1,000 hemodialysis sessions and 5.28 per 1,000 patient-days of hospitalization (OR, 2.84; 95% CI: 0.62-12.9, P ¼ .72); for tunneled catheters, 2.39 per 1,000 hemodialysis sessions and 0.79 per 1,000 patient-days of hospitalization (OR, 0.81; 95% CI: 0.25-2.6, P < .05); and, for nontunneled catheters, 5.5 per 1,000 hemodialysis sessions and 1.36 per 1,000 patient-days of hospitalization (OR, 3.24; 95% CI: 1.139.34, P < .05). A positive correlation was detected between HABSI and length of hospital stay (r ¼ 0.82; 95% CI: 0.79-0.83, P < .05) and number of hemodialysis sessions (r ¼ 0.56; 95% CI: 0.52-0.61, P < .05). For patients with diabetes, a positive correlation was detected between HABSI and HbA1c level (r ¼ 0.49; 95% CI: 0.42-0.55, P < .05). Risk for a hemodialysis-associated event significantly increased with HbA1c levels greater than 7% (OR, 3.62; 95% CI: 1.15-11.4, P < .05). An association was also noted between HABSI because of MRSA and colonization of nares with MRSA (OR, 21.7; 95% CI: 5.3-88.8, P < .05). Of the total 14 isolated microorganisms, 9 (64%) were grampositive cocci with a predominance of 8 staphylococcal infections (57%). Within this group of staphylococci, Staphylococcus aureus was the main microorganism isolated (63%) (see Figs 1 and 2). DISCUSSION Much information is available regarding hemodialysisassociated infections in the outpatient hemodialysis centers.10-17 However, there are few published reports that have studied this subject in the inpatient hemodialysis population. The present study is a 24-month retrospective research performed at the RCRMC to describe the epidemiologic characteristics of HABSI. The results of this study showed that the rates of HABSI at RCRMC were lower than the rates detected by similar studies, eg, D’Agata et al (2.5 per 1,000 patient-days of hospitalization)18 and Saeed et al (3.95 per 1,000 hemodialysis sessions).19 A statistically significant association was detected between HABSI and several of the risk factors that were studied. The use of nontunneled catheters was related to an increased risk of an
184
M. Gnass et al. / American Journal of Infection Control 42 (2014) 182-4
infectious event. The same was true for increasing values of HbA1c above the level of 7%.20-22 Colonization of nares with MRSA was seen to be associated with an increased risk of developing a HABSI because of MRSA, as had been previously observed by other authors.23,24 The current literature identifies coagulase-negative Staphylococcus, S aureus, and Escherichia coli as the major pathogens implicated in hemodialysis-associated infections.25 This study also identified Staphylococcus as the main pathogen implicated in nosocomial hemodialysis-associated infections. Infection prevention efforts in the inpatient hemodialysis population should focus on 2 major risk factors: first, strict control of hyperglycemia; and, second, decolonization of nares from MRSA. In addition, as has been extensively studied and recommended by the National Kidney Foundation, use of fistulas for vascular access should be preferred over catheters.26
References 1. US Renal Data System. USRDS 2012 annual data report: atlas of end-stage renal disease in the United States. Bethesda [MD]: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2012. 2. Eleftheriadis T, Antoniadi G, Liakopoulos V, Kartsios C, Stefanidis I. Disturbances of acquired immunity on hemodialysis patients. Semin Dial 2007;20:440-51. 3. Eleftheriadis T, Liakopoulos V, Leivaditis K, Antoniadi G, Stefanidis I. Infections in hemodialysis: a concise review, part 1: bacteremia and respiratory infections. Hippokratia 2011;15:12-7. 4. Betjes MG. Prevention of catheter-related bloodstream infection in patients on hemodialysis. Nat Rev Nephrol 2011;7:257-65. 5. Bonomo RA, Rice D, Whalen C, Linn D, Eckstein E, Shlaes DM. Risk factors associated with permanent access-site infections in chronic hemodialysis patients. Infect Control Hosp Epidemiol 1997;18:757-61. 6. Gulati S, Sahu KM, Avula S, Sharma RK, Ayyagiri A, Pandey CM. Role of vascular access as a risk factor for infections in hemodialysis. Ren Fail 2003;25:967-73. 7. Allon M, Radeva M, Bailey J, Beddhu S, Butterly D, Coyne DW, et al. The spectrum of infection-related morbidity in hospitalized haemodialysis patients. Nephrol Dial Transplant 2005;20:1180-6. 8. Centers for Disease Control and Prevention. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR 2001; 50:1-43. 9. Centers for Disease Control and Prevention. Dialysis event protocol. In: Centers for Disease Control and Prevention, editor. National Healthcare Safety Network manual: patient safety component manual. Atlanta [GA]: Division of Healthcare Quality Promotion; 2011. p. 1-3.
10. Hoen B, Paul-Dauphin A, Hestin D, Kessler M. EPIBACDIAL: a multicenter prospective study of risk factors for bacteremia in chronic hemodialysis patients. J Am Soc Nephrol 1998;9:869-76. 11. Jean G, Charra B, Chazot C, Vanel T, Terrat JC, Hurot JM, et al. Risk factor analysis for long-term tunneled dialysis catheter-related bacteremias. Nephron 2002; 91:399-405. 12. Johnston BL, Conly JM. Central venous catheter-associated bloodstream infections in hemodialysis patients: another patient safety bundle? Can J Infect Dis Med Microbiol 2006;17:99-102. 13. Patel PR, Yi SH, Booth S, Bren V, Downham G, Hess S, et al. Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report. Am J Kidney Dis 2013;62:322-30. 14. Ponce P, Cruz J, Ferreira A, Oliveira C, Vinhas J, Silva G, et al. A prospective study on incidence of bacterial infections in portuguese dialysis units. Nephron Clin Pract 2007;107:133-8. 15. Stevenson KB, Adcox MJ, Mallea MC, Narasimhan N, Wagnild JP. Standardized surveillance of hemodialysis vascular access infections: 18-month experience at an outpatient, multifacility hemodialysis center. Infect Control Hosp Epidemiol 2000;21:200-3. 16. Taylor G, Gravel D, Johnston L, Embil J, Holton D, Paton S. Incidence of bloodstream infection in multicenter inception cohorts of hemodialysis patients. Am J Infect Control 2004;32:155-60. 17. Tokars JI, Light P, Anderson J, Miller ER, Parrish J, Armistead N, et al. A prospective study of vascular access infections at seven outpatient hemodialysis centers. Am J Kidney Dis 2001;37:1232-40. 18. D’Agata EM, Mount DB, Thayer V, Schaffner W. Hospital-acquired infections among chronic hemodialysis patients. Am J Kidney Dis 2000;35:1083-8. 19. Saeed Abdulrahman I, Al-Mueilo SH, Bokhary HA, Ladipo GO, Al-Rubaish A. A prospective study of hemodialysis access-related bacterial infections. J Infect Chemother 2002;8:242-6. 20. Morioka T, Emoto M, Tabata T, Shoji T, Tahara H, Kishimoto H, et al. Glycemic control is a predictor of survival for diabetic patients on hemodialysis. Diabetes Care 2001;24:909-13. 21. Ricks J, Molnar MZ, Kovesdy CP, Shah A, Nissenson AR, Williams M, et al. Glycemic control and cardiovascular mortality in hemodialysis patients with diabetes: a 6-year cohort study. Diabetes 2012;61:708-15. 22. Shurraw S, Hemmelgarn B, Lin M, Majumdar SR, Klarenbach S, Manns B, et al. Association between glycemic control and adverse outcomes in people with diabetes mellitus and chronic kidney disease: a population-based cohort study. Arch Intern Med 2011;171:1920-7. 23. Centers for Disease Control and Prevention. Invasive methicillin-resistant Staphylococcus aureus infections among dialysis patients. MMWR 2007;56:197-9. 24. Grünewald T, Lindner M, Weiß S, Ruf I, Treutler T, Ruf B, et al. Staphylococcus colonization, mortality and morbidity in hemodialysis patients: 10 years of observation. Int J Hyg Environ Health 2013;216:751-4. 25. D’Amato-Palumbo S, Kaplan AA, Feinn RS, Lalla RV. Retrospective study of microorganisms associated with vascular access infection in hemodialysis patients. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:56-61. 26. National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 updates: Hemodialysis adequacy, peritoneal dialysis adequacy and vascular access. Am J Kidney Dis 2006;48:S1-322.
