Article

Bloodstream Infection Prevention in ESRD: Forging a Pathway for Success

Centers for Disease Control and Prevention, Atlanta, Georgia
American Journal of Kidney Diseases (Impact Factor: 5.76). 02/2014; 63(2):180-2. DOI: 10.1053/j.ajkd.2013.11.003
Source: PubMed
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    ABSTRACT: Sepsis is the second leading cause of death in patients with end stage renal disease (ESRD) on hemodialysis (HD). The average cost to the healthcare system for catheter-related infections (CRI) ranges from $4000 to $80,235 for each occurrence. CRI is a significant health problem leading to increased hospitalizations, morbidity, mortality, and a financial burden to the healthcare system. The purpose of this study was to evaluate the clinical and cost effectiveness of implementing published guidelines that pertain to patients on HD. Adult patients receiving long-term HD through a tunneled and cuffed HD catheter in an outpatient dialysis setting were studied. One-hundred and eighty-seven patients on HD were instituted on published guidelines (chlorhexidine to clean the exit site and HD catheters/hubs, hand washing, aseptic technique with site/dressing changes/placing patients on HD, setting up an infrastructure to support monitoring CRI) and prospectively followed from May 2009 to April 2010. Comparison was made to a retrospective cohort of 198 patients on HD from May 2008 to April 2009 in the same unit using standard care (sodium hypochlorite to clean the exit site; povidone iodine to clean the HD catheter hubs). A t-test analysis compared the two groups for differences. The number of infections decreased from 1.7 to 0.2 per 1000 catheter days during a 12-month period (p = 0.005). The number needed to prevent one adverse outcome of a CRI was 22 patients, with a relative risk of 0.11 and relative risk reduction of 89% in the treated group. The return on investment for implementing the program was 169% in one year, and the break-even point occurred within the first quarter. The projected annual savings in one dialysis unit was $141,606 using the project hospital's data and $179,010 using national data. CRI in patients on HD are preventable. The analysis revealed a significant reduction in CRI by implementing published guidelines with a significant cost savings to the healthcare system.
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    ABSTRACT: An increasing proportion of central line-associated bloodstream infections (CLABSIs) are seen in outpatient settings. Many of such infections are due to hemodialysis catheters (HD-CLABSIs). Such infections are associated with substantial morbidity, mortality, and excess healthcare costs. Patients who receive dialysis through a catheter are 2-3 times more likely to be hospitalized for infection and to die of septic complications than dialysis patients with grafts or fistulas. Prevention measures include minimizing the use of hemodialysis catheters, use of CLABSI prevention bundles for line insertion and maintenance, and application of antimicrobial ointment to the catheter exit site. Instillation into dialysis catheters of antimicrobial solutions that remain in the catheter lumen between dialyses (antimicrobial lock solutions) has been studied, but it is not yet standard practice in some dialysis units. At least 34 studies have evaluated the impact of antimicrobial lock solutions on HD-CLABSI rates. Thirty-two (94%) of the 34 studies demonstrated reductions in HD-CLABSI rates among patients treated with antimicrobial lock solutions. Recent multicenter randomized controlled trials demonstrated that the use of such solutions resulted in significantly lower HD-CLABSI rates, even though such rates were low in control groups. The available evidence supports more routine use of antimicrobial lock solutions as an HD-CLABSI prevention measure in hemodialysis units.
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