Bloodstream Infection in Hemodialysis Outpatients

Infection is the second leading cause of death among dialysis patients (Mokrzycki, et. al, 2021) (Millson et al., 2019), with most patients who develop a bloodstream infection undergoing hemodialysis (HD) with a central venous catheter (Fisher et al., 2019) (Mokrzycki et al., 2021) (Patel et al., 2013).  The U.S. Department of Health and Human Services published The United States Renal Data System 2023 Annual Data Report which reported that the percentage of individuals initiating HD with a catheter, with or without a maturing permanent access, increased by 4.6% from 2018 to 2021, reaching 85.4% (2023). Additionally, the report showed that the percentage of patients initiating HD with a catheter only, which reached a nadir of 60.3% in 2013, grew to 74.0% in 2021 and from 2013 to 2021, the percentage initiating HD with an AV fistula fell from 17.0% to 12.2%, and the percentage starting with catheter and a maturing fistula fell from 18.0% to 10.2%.  Patients who undergo HD with a catheter are at significantly increased risk of developing an infection than patients who have an arteriovenous fistulae or graft (Soi, et al., 2016).  Measure #1460 Bloodstream Infection (BSI) in Hemodialysis Outpatients allows facilities to track the types of vascular access present in patients who develop a (BSI), so that they can work to improve the type of access a patient has prior to initiating chronic outpatient HD and thereby reduce infection risk.

Multiple studies provide strong empirical support for the association between the reduction of bloodstream infections (BSI) in HD outpatients and BSI prevention practices. Specifically, chlorhexidine
use for catheter exit-site care, staff training and competency assessments focused on access care and aseptic technique, hand hygiene and vascular access care audits, and feedback of infection and adherence rates to staff have shown to reduce the rates of BSI in outpatient HD patients. Michigan Medicine conducted a recent study in pediatric patients receiving outpatient HD through a central venous catheter (CVC) to determine if BSI rates would decrease with the use of a closed system using needleless connectors and staff audits of dialysis prevention measures.  The study began in 2020 and included pediatric patients receiving HD through a central venous catheter (CVC) who had a needless connector added to the end of the atrial and venous blood lines.  Monthly surveillance was completed.  After one year, the CVC BSI rate decreased from 16.95 per 100 patient-months in 2019 to 5.5 per 100 patient-months in 2020. Hospital admissions associated with BSIs decreased from 14 in 2019 to 5 in 2020 (Yee & Ricchiuti, 2023). The number of BSIs with a loss of vascular access outcome decreased from 5 in 2019 to 3 in 2020 (Yee & Ricchiuti, 2023). The study found that the use of needleless connectors and staff auditing the use of best practices led to a substantial reduction of BSI in pediatric outpatient HD patients.   
In 2009, CDC began to work with hemodialysis centers to determine if BSI rates in outpatient hemodialysis centers could be reduced through improved adherence to recommended infection prevention practices.  Participants worked with CDC to develop the “Core Interventions for BSI Prevention”, which included bundled prevention activities to decrease BSI rates. The bundle included hand hygiene, reducing the use of catheters and maximizing the use of arteriovenous fistulas and grafts, specific catheter maintenance care practices, staff education and competency assessments, and patient education. Seventeen outpatient hemodialysis centers implemented these bundled interventions and showed a 32% overall reduction of access-related BSI incidence and a 54% reduction in the central venous catheter population following implementation (Patel, et al., 2013).  Four years after the interventions were initiated, the facilities continued to see reductions in their access-related BSI incidence rates (Yi, et al., 2016).  
In a study published in 2014, a CVC care plan, incorporating use of chlorhexidine with alcohol pads to “scrub the hubs” (consistent w/ CDC recommendations) was implemented in 211 facilities. BSI rates in these facilities were compared to matched facilities practicing usual catheter care. Findings showed that BSI and IVABS rates declined by 20% in facilities that adopted the new catheter care procedure. Further, these declines were sustained over time, and were associated with a lower rate of hospitalizations (Rosenblum et al., 2014). 
Another study launched in late 2017 studied safety culture and BSI prevention practices in a large outpatient dialysis program in upstate New York.  The study implemented BSI prevention practices including: hand hygiene, station cleaning, fistula/graft and catheter access and access care, exit site care and patient engagement.  The programs standardized infection ratio (SIR) decreased from 1.960 in 2017 to 0.985 in 2018 (Millson, et. al., 2019). In addition, the study found that there was a decrease in organisms identified from blood cultures that are associated with poor aseptic technique.  The program also observed a decrease their MRSA-related BSI rates by 80% (Millson, et. al., 2019).  
This evidence supports a link between BSI prevention practices, such as hand hygiene, appropriate catheter use, aseptic technique for catheter access and maintenance, surveillance, staff education and training, and the reduction of BSIs.  

•    Fisher M, Golestaneh L, Allon M, Abreo K, Mokrzycki MH. Prevention of Bloodstream Infections in Patients Undergoing Hemodialysis. Clin J Am Soc Nephrol. 2020 Jan 7;15(1):132-151. doi: 10.2215/CJN.06820619. Epub 2019 Dec 5. Erratum in: Clin J Am Soc Nephrol. 2022 Apr;17(4):568-569. PMID: 31806658; PMCID: PMC6946076.
•    Millson T, Hackbarth D, Bernard HL. A demonstration project on the impact of safety culture on infection control practices in hemodialysis. Am J Infect Control. 2019 Sep;47(9):1122-1129. 
•    Mokrzycki MH, Leigh KA, Kliger AS, Niyyar VD, Bren Asp V, Golestaneh L, Taylor Q, Novosad SA. Implementation of an Electronic Catheter Checklist in Outpatient Hemodialysis Facilities: Results of a Pilot Quality Improvement Project. Kidney360. 2021 Feb 9;2(4):684-694. 
•    Patel PR, Yi SH, Booth S, Bren V, Downham G, Hess S, Kelley K, Lincoln M, Morrissette K, Lindberg C, Jernigan JA, Kallen AJ. Bloodstream infection rates in outpatient hemodialysis facilities participating in a collaborative prevention effort: a quality improvement report. Am J Kidney Dis. 2013 Aug;62(2):322-30. 
•    Rosenblum A, Wang W, Ball L, Latham C, Maddux F, Lacson F. Hemodialysis catheter care strategies: a cluster-randomized quality improvement initiative. Am J Kidney Dis. 2014; 63(2):259-267. 
•    Soi V, Moore CL, Kumbar L, Yee J. Prevention of catheter-related bloodstream infections in patients on hemodialysis: challenges and management strategies. Int J Nephrol Renovasc Dis. 2016 Apr 18;9:95-103. 
•    United States Renal Data System. 2023 USRDS Annual Data Report: Epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2023. https://usrds-adr.niddk.nih.gov/2023/introduction. Accessed November 15, 2023. 
•    Yee, M. & Ricchiuti, S. Preventing Pediatric Outpatient Hemodialysis Morbidity: Implementing the Use of Needleless Connectors and Prevention Process Measures Audits to Reduce Bloodstream Infections. American Journal of Infection Control, Volume 51, Issue 7, Supplement, 2023, Page S35. 
•    Yi SH, Kallen AJ, Hess S, Bren VR, Lincoln ME, Downham G, Kelley K, Booth SL, Weirich H, Shugart A, Lines C, Melville A, Jernigan JA, Kleinbaum DG, Patel PR. Sustained Infection Reduction in Outpatient Hemodialysis Centers Participating in a Collaborative Bloodstream Infection Prevention Effort. Infect Control Hosp Epidemiol. 2016 Jul;37(7):863-6. 

In addition to the studies cited above, the following section describes evidence based-Guidelines for the Prevention of Intravascular Catheter-related Infections 2011.

The following guideline supports the measure and is evidence based-Guidelines for the Prevention of Intravascular Catheter-related Infections 2011.

The guideline recommendations include specific interventions and practices for healthcare personnel who insert intravascular catheters and for persons responsible for surveillance and control of infections in hospital, outpatient, and home healthcare settings to prevent intravascular catheter-related infections. Evidence supports a link between these practices and the reduction of BSIs among outpatient hemodialysis patients, including intravascular catheter-related infection prevention practices, such as aseptic technique for catheter access and maintenance, hand hygiene, and surveillance of implemented bundled prevention strategies and infections to ensure compliance.  

•    Source: O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, Lipsett PA, Masur H, Mermel LA, Pearson ML, Raad II, Randolph AG, Rupp ME, Saint S; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011 May;52(9):e162-93.

The system for categorizing recommendations in this guideline is as follows:
Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence.
Category IC. Required by state or federal regulations, rules, or standards.
Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.
Unresolved issue. Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists.

Strategies for Prevention of Catheter-Related Infections in Adult and Pediatric Patients 
Education, Training and Staffing
Recommendations
1. Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections. Category IA
2. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters. Category IA
3. Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters. Category IA

Central Venous Catheters Recommendations
1. Weigh the risks and benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism, and catheter misplacement). Category IA
2. Avoid using the femoral vein for central venous access in adult patients. Category 1A
3. Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled CVC placement. Category IB
5. Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein stenosis. Category IA
6. Use a fistula or graft in patients with chronic renal failure instead of a CVC for permanent access for dialysis. Category 1A
8. Use a CVC with the minimum number of ports or lumens essential for the management of the patient. Category IB

Hand Hygiene and Aseptic Technique
Recommendations
1. Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR). Hand hygiene should be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained. Category IB
2. Maintain aseptic technique for the insertion and care of intravascular catheters. Category IB
4. Sterile gloves should be worn for the insertion of arterial, central, and midline catheters. Category IA
5. Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. Category II
6. Wear either clean or sterile gloves when changing the dressing on intravascular catheters. Category IC

Maximal Sterile Barrier Precautions
Recommendations
1.    Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile
gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guidewire exchange. Category IB
Skin Preparation
Recommendations
2. Prepare clean skin with a.0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives. Category IA
5. Antiseptics should be allowed to dry according to the manufacturer’s recommendation prior to placing the catheter. Category IB

Catheter Site Dressing Regimens
Recommendations
1. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site. Category IA
2. If the patient is diaphoretic or if the site is bleeding or oozing, use gauze dressing until this is resolved. 
Category II
3. Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled. Category IB
4. Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance. Category IB
5. Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower). Category IB
8. Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed. Category II
9. No recommendation can be made regarding the necessity for any dressing on well-healed exit sites of longterm cuffed and tunneled CVCs. Unresolved issue
14. Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site. Category IB
15. Encourage patients to report any changes in their catheter site or any new discomfort to their provider. Category II
 

Catheter Securement Devices
Recommendation
Use a sutureless securement device to reduce the risk of infection for intravascular catheters. Category II

Antimicrobial/Antiseptic Impregnated Catheters and Cuffs
Recommendation
Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin -impregnated CVC in patients whose catheter is expected to remain in place >5 days if, after successful implementation of a comprehensive strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing. The comprehensive strategy should include at least the following three components: educating persons who insert and maintain catheters, use of maximal sterile barrier precautions, and a .0.5% chlorhexidine preparation with alcohol for skin antisepsis during CVC insertion. Category IA

Systemic Antibiotic Prophylaxis
Recommendation
Do not administer systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter colonization or CRBSI. 
Category IB
 

Antibiotic/Antiseptic Ointments
Recommendation
Use povidone iodine antiseptic ointment or bacitracin/gramicidin/polymyxin B ointment at the hemodialysis catheter exit site after catheter insertion and at the end of each dialysis session only if this ointment does not interact with the material of the hemodialysis catheter per manufacturer’s recommendation. Category IB

Antibiotic Lock Prophylaxis, Antimicrobial Catheter Flush and Catheter Lock Prophylaxis
Recommendation
Use prophylactic antimicrobial lock solution in patients with long term catheters who have a history of multiple CRBSI despite optimal maximal adherence to aseptic technique. Category II

Replacement of CVCs, Including PICCs and Hemodialysis Catheters
Recommendations
1. Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter related infections. Category IB
2. Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is suspected. Category II

Performance Improvement
Recommendation
Use hospital-specific or collaborative-based performance improvement initiatives in which multifaceted strategies are ‘‘bundled’’ together to improve compliance with evidence-based recommended practices. Category IB