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Catheters connected to most bloodstream infections in patients on dialysis

Patients on dialysis where a catheter was used were at greater risk for bloodstream infections, according to an analysis published in Clinical Journal of the American Society of Nephrology.

The data used in this analysis is also being utilized by CMS for the first time to determine dialysis facilities’ performance on the end stage renal disease Quality Improvement Program’s bloodstream infections measure, according to researchers.

Duc Bui Nguyen, MD of the CDC’s Division of Healthcare Quality Promotion, and colleagues reviewed data from 6,005 outpatient hemodialysis facilities — nearly all dialysis facilities in the U.S. — and 160,971 dialysis events from 2014.

Researchers found that of the 29,516 events involved bloodstream infections:

•77% were related to accessing patients' blood;

•70% of access-related bloodstream infections and 63% of the bloodstream infections occurred in patients with a central venous catheter;

•45.9% occurred in patients known to have a fever;

•34.4% occurred in patients known to have chills;

•3.5% occurred in patients known to have a drop in BP; and

•Staphylococcus aureus was the most commonly isolated bloodstream infection pathogen (31%), and 40% of S. aureus isolates tested were resistant to methicillin.

In addition, Nguyen and colleagues found that hospitalizations occurred in 48% of bloodstream infections and that death occurred in 2% of bloodstream infections. Researchers also noted that other dialysis events, including IV antimicrobial starts (n = 149,722) and increased swelling at the hemodialysis access site, pus, or redness (n = 38,310), were more likely among patients with central venous catheters.

“We now have a clearer picture of the rates and types of infections hemodialysis patients in the United States are experiencing,” Nguyen said in a press release. “Our findings emphasize the need for hemodialysis facilities to improve infection prevention and vascular access care practices.”

In an accompanying editorial, Dana Miskulin, MD, Tufts University School of Medicine, and Ambreen Gul, MD, Dialysis Clinic Inc., wrote that dialysis-related events may be underreported.

“The major problem is that event reporting to the [National Health Safety Network] is based on an honors system — dialysis units report their own data. There is no cross validation, audit, or other reconciliation process to ensure events are reported accurately... There is also a financial disincentive with identifying bloodstream infections. We suspect that there are ‘less innocent’ reasons for missing data and that some dialysis units may have gone so far as to implement policies and procedures to reduce the likelihood of diagnosing a bacteremia in the unit.

“We make a plea to the dialysis community to ‘clean up’ the data,” Miskulin and Gul concluded, “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 generating evidence to provide future opportunities to improve care and outcomes, to be realized.”

Healio has reported on the CDC's catheter-related bloodstream infections guidelines, which emphasized maximal sterile barrier precautions when inserting catheters, cleaning the skin with chlorhexidine, and avoiding routine replacement of certain catheters.

Disclosure: Nguyen reports no relevant financial disclosures. Healio Family Medicine was unable to determine Miskulin and Gul’s relevant financial disclosures prior to publication.