Bloodstream infections were more common among patients who received central venous catheters during hemodialysis than among patients who received other vascular access types, according to recent findings published in the Clinical Journal of the American Society of Nephrology.
Duc Bui Nguyen, MD, of CDC’s Division of Healthcare Quality Promotion, National Center for Emerging Infectious Diseases, and colleagues said the findings underscore the need to continue efforts limiting the use of central venous catheters (CVCs).
The researchers examined data submitted to the National Healthcare Safety Network (NHSN) in 2014 — the first year that the CMS also used the data to assess the performance of dialysis facilities. The analysis included patients who had an arteriovenous fistula (AVF), arteriovenous graft (AVG) or CVC during hemodialysis. According to a press release, experts typically recommend the use of an AVF during hemodialysis, which is formed by connecting a patient’s vein and artery to create a site through which blood can be accessed. An alternative method to access blood is through the use of an AVG, which is a plastic channel between a vein and an artery. Few patients receive a CVC instead for various reasons, such as to avoid surgery, the release said.
More than 6,000 outpatient hemodialysis facilities reported event data for 2014. This represented approximately 94% of all Medicare-certified dialysis facilities in the U.S. According to the researchers, AVFs represented 62.8% of patient-months, CVCs represented 18.8% of patient-months, and AVGs represented 11.8% of patient-months.
Overall, 160,971 dialysis events were reported, including 29,561 bloodstream infections (BSIs); 149,722 IV antimicrobial starts; and 38,310 episodes of pus, redness or increased swelling at the hemodialysis access site. Of the BSIs, 76.5% were related to accessing patients’ blood.
Although only a minority of patients appeared to have had a CVC, the researchers found that they accounted for 63% of BSIs and 69.8% of access-related BSIs. They estimated that the rate of BSIs per 100 patient-months was 0.26 for AVF, 0.39 for AVG and 2.16 for CVC. Patients who received a CVC also had the highest rate of other dialysis events, including IV antimicrobial starts (7.91 for CVC vs. 2.07 for AVF and 2.63 for AVG).
In other results, the most common pathogen isolated from patients with BSIs was Staphylococcus aureus (30.6%). Nearly 40% of S. aureus isolates that were tested were resistant to methicillin.
“We now have a clearer picture of the rates of types of infections hemodialysis patients in the United States are experiencing — nearly all U.S. outpatient hemodialysis facilities are participating in CDC’s NHSN Dialysis Event surveillance,” Nguyen said in a press release. “Our findings emphasize the need for hemodialysis facilities to improve infection prevention and vascular access care practices.”
Nguyen and colleagues acknowledged several limitations to the study, including the likelihood of underreporting of BSIs. In a related editorial, Dana Miskulin, MD, of Tufts University School of Medicine, and Ambreen Gul, MD, of the Dialysis Clinic Inc., noted that NHSN reporting is based on an honors system and there are no processes or policies in place to ensure that events are accurately reported.
“We make a plea to the dialysis community to ‘clean up’ the data, 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,” they wrote. – by Stephanie Viguers
Disclosure: The researchers report no relevant financial disclosures.