Comp Clin Pathol DOI 10.1007/s00580-014-1890-1
ORIGINAL ARTICLE
Incidence and risk factors of bloodstream catheter-related infections in hemodialysis patients Simin Samani & Mahsa Saffari & Malihe Charkhchian & Arash Khaki
Received: 7 January 2014 / Accepted: 21 January 2014 # Springer-Verlag London 2014
Abstract Bloodstream catheter-related infections (BCRIs) are the most common complications of temporary catheters in hemodialysis (HD) patients. This study was designed to evaluate the incidence and risk factors of bloodstream catheter-related infections in hemodialysis patients. Also, we aimed to identify the microorganisms isolated from the bloodstream and catheter of patients. From March 2012 to April 2013, this cross-sectional descriptive study was performed. A questionnaire that included demographic and medical data was completed for each case. Also, laboratory data, including catheter and blood cultures, were collected for each case. The collected data were analyzed using SPSS software. A P value <0.05 was considered significant. A total of 236 temporary hemodialysis catheters were inserted in 220 patients. A total of 44 BCRIs were found during the study period. Staphylococcus aureus was a common pathogenic organism in BCRIs. BCRIs rate was 11.4/1,000 catheter-days and 15.1/1,000 dialysis sessions. Our analysis indicated that poor patient hygiene and poor hygiene of the medical staff, duration of catheterization, and high number of catheter manipulation were associated with BCRIs. The most effective method of prevention seems to be the promotion of the infection control precautions
S. Samani Department of Pathology, Qazvin University of Medical Science, Qazvin, Iran M. Saffari (*) Department of Microbiology, Islamic Azad University, Zanjan, Iran e-mail:
[email protected] M. Charkhchian Department of Nephrology, Qazvin University of Medical Science, Qazvin, Iran A. Khaki Department of Pathology, Tabriz University of Medical Sciences, Tabriz, Iran
that should be emphasized by educating and training the health providers. We still need to adopt measures to minimize the use of temporary vascular accesses by creation of fistulas in a timely fashion. Keywords Bloodstream catheter-related infections . Hemodialysis . Staphylococcus aureus
Introduction Patients with end-stage renal disease need to receive regular hemodialysis (HD) through an effective vascular access until renal replacement therapy. There are three main types of permanent vascular access used in HD patients including arteriovenous fistula, synthetic arteriovenous graft, and central venous catheter. In patients who do not have permanent access for HD, temporary vascular access can be established by the percutaneous insertion of a catheter into a large central vein. However, approximately 25 % of patients use temporary catheters for HD for a variety of reasons. Bloodstream catheter-related infections (BCRIs) are the most significant complication of hemodialysis catheters, occurring in 3.4– 18.2 episodes/1,000 catheter-days (Kairaitis and Gottlieb 1999; Beathard 1999; Chatzinikolaou et al. 2003; Contreras et al. 2003; Saad 1999). Moreover, these patients are at highest risk of infection, which can manifest as life-threatening events such as endocarditis, osteomyelitis, epidural abscess, septic arthritis, and even death (Marr et al. 1997). Consequently, these complications result in a considerable increase in health-care costs, morbidity, mortality, and microbial resistance (Saxena and Panbotra 2005; Gonçalves et al. 2004). In a study, mortality from catheter infection was estimated between 12 and 25 %, and the estimated cost to the health-care system was US$25,000 per episode (Band 2013).
Comp Clin Pathol
The main risk factors for catheter infection include underlying disease, poor patient hygiene and poor hygiene of the medical staff, inexperienced medical attendant inserting the catheter, insertion site and method of catheter insertion, duration of catheterization, cumulative number of catheter manipulation, high number of hemodialysis runs, and serum albumin level (Nassar and Ayus 2001; O’Grady et al. 2002; Pearson 1996; Polderman and Girbes 2002). Determining risk factors of catheter-associated infections may aid in its prevention and subsequently lower therapeutic health-care costs and improve patient’s quality of life. There were no data about the incidence of catheter-related infections in our nephrology service. The present study was designed to evaluate the prevalence of risk factors for bloodstream infection among patients with temporary catheter for hemodialysis and to identify the microorganisms isolated from the bloodstream and catheter of patients. Also, in this study, we aimed to determine predisposing factors contributing to these infections at our center.
Methods From March 2012 to April 2013, this cross-sectional descriptive study was performed on HD patients that were hospitalized on the HD section at the Bouali-Sina University Hospital, Qazvin, Iran. Temporary hemodialysis catheters were inserted into the acute or chronic renal disease patients. The patients were followed for the duration of their stay in place, and data about the signs of inflammation on the catheter sites were obtained daily and surveyed for bloodstream infections. Catheter-related bacteremia was suspected when a patient experienced fever, chills, purulent discharge from the catheter site, erythema, tenderness over exit site, and signs of bacteremia in the absence of any focus of infection on clinical and laboratory examinations. The patients with clinical or laboratory evidence of another focus of infection or negative blood culture were excluded from study. A questionnaire that included demographic and medical data such as age, sex, underlying disease, dates of hospital admission and discharge, date and site of catheter insertion, hand hygiene and use of maximal sterile barriers for insertion and maintenance, patient hygiene, duration of catheterization, number of catheter manipulations (high number of catheter manipulation ≥3/day), number of hemodialysis runs, administration of antibiotics at the time of catheterization, occurrence of complications, and date of removal of the catheter was completed for each case. Also, laboratory data, including complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and catheter and blood cultures were collected for each case. BCRIs were defined as to Centers for Disease Control and Prevention (CDC) criteria (O’Grady et al. 2002). Blood
samples of 3 to 7 ml drawn simultaneously from central venous catheter and peripheral veins were cultured and then the differential positivity times of cultures were evaluated. After aseptic catheter removal, a 4-cm segment from the tip section of each catheter was cultured using the sonication technique. Cultures yielding 103 cfu or more colonies were recorded as positive (Sherertz et al. 1990). Identification of the causative microorganisms was performed using the automated Scepter system (Becton, Dickinson, USA) and classical methods. Immediately, after sending blood samples for culture, empiric antibiotic therapy for BCRIs with appropriate coverage against Staphylococcus aureus, coagulase-negative Staphylococci, and gram-negative bacteria that included vancomycin and ceftazidime was initiated (O’Grady et al. 2002). Statistical analysis The collected data were analyzed using SPSS software (version 16.0; SPSS Inc., Chicago, IL, USA). Fisher’s exact chi-square test and Student’s t test were used to assess statistical relationships between variables of groups. Demographic characteristics, medical data, and laboratory test data were subjected to a multivariate analysis. Logistic regression analysis was used to assess whether risk factors for the development of BCRIs were independent. Continuous data are presented as mean±standard deviation. Results of the analysis were presented as P values, odds ratio (OR), and 95 % confidence interval (95 % CI). A P value <0.05 was considered significant. Ethical approval The study was approved by the ethics committee of the university before its initiation, and the protocols used conformed to the ethical guidelines of the 1975 Helsinki Declaration. All parents were informed about the study protocol, and the written consent was obtained from all parents.
Table 1 Frequency of pathogenic organisms in BCRIs Organism
Frequency and percentage
S. aureus Multiple-resistant S. aureus (MRSA) E. coli Coagulase-negative Staphylococci Enterococci Streptococcus D Pseudomonas aeruginosa Klebsiella pneumoniae Acinetobacter Total
14 (32 %) 8 (18 %) 6 (14 %) 4 (9 %) 4 (9 %) 3 (7 %) 3 (7 %) 1 (2 %) 1 (2 %) 44 (100 %)
Comp Clin Pathol Table 2 Comparison between demographic and laboratory data of the infected and noninfected patients Parameters
Positive BCRIs (n=44)
Negative BCRIs (n=176)
P value
Gender (m/f) Age (mean±SD) (years) No. of patients with history of previous catheter placement No. of patients with a positive history of catheter-associated infections Mean duration of catheter placement (days) No. of patients with positive diabetes mellitus White blood cell count (gm/dL) Hemoglobin (gm/dL) Platelet ESR (mm/h) CRP
23/21 53.5±15.4 6 3 34±13 18 12.2±5.1 10.0±1.2 275.2±115.1 69.4±2.2 14.2±5.2
97/79 48.6±13.2 16 9 20±17 84 9.9±4.5 9.8±2.3 246.9±105.1 49.2±5.3 9.7±3.5
NS NS NS NS 0.04 NS 0.04 NS NS 0.02 NS
Results
The comparison of demographic parameters in this study showed that mean duration of catheter placement was significantly higher in infected patients. On the other hand, leukocytosis and ESR were significant differences between the patients with and without BCRIs. On the other hand, age, gender, number of patients with history of previous catheter placement, number of patients with positive history of catheter-associated infections, number of patients with positive diabetes mellitus, and other laboratory parameters do not have significant differences between two groups. Table 2 summarized the comparison between demographic and laboratory data of the infected and noninfected patients. In analysis, risk factors of BCRI multivariate logistic regression do not show any significant correlation between diabetes mellitus and insertion site with BCRIs. Although this analysis indicated that poor patient hygiene and poor hygiene of the medical staff, duration of catheterization, and high number of catheter manipulation were associated with BCRIs (Table 3). Bacterial resistance to vancomycin and ceftazidime was observed in 6 and 5 % of the cases, respectively. Escherichia
Overall, 220 cases received a temporary catheter for HD in this study. Of these patients, 120 (54.5 %) were male and 100 (45.5 %) were female. Mean age was of 58.5±12 years (range 13–95.6 years). Of all patients, 75 (34 %) cases were older than 65 years, 102 (46.3 %) were diabetic, 22 (10 %) cases had history of previous catheter placement, and 12 (5.4 %) cases had a history of previous catheter-associated infections. A total of 236 temporary hemodialysis catheters were inserted in 220 patients and remained in situ for a cumulative total of 3,840 catheter-days. There were 2,930 dialysis sessions. A total of 44 BCRIs were found during the study period. BCRI rate was 11.4/1,000 catheter-days and 15.1/1,000 dialysis sessions. Forty-four microorganisms were isolated as etiologic agent for the BCRIs in all patients (one microorganisms for each patient). S. aureus was a common pathogenic organism in BCRIs. The frequency of the causative microorganisms is detailed in Table 1.
Table 3 Multivariate logistic regression analysis risk factors of BCRIs
Parameters
Odd ratio (95 % confidence interval)
P value
Diabetes mellitus Poor patient hygiene
2.143 (1.562–3.324) 1.399 (1.184–2.008)
NS 0.024
Poor hygiene of the medical staff Insertion site Right jugular Left jugular Subclavian Femoral Prolonged duration of catheterization High number of catheter manipulation
1.125 (0.773–2.676)
0.014
2.037 (1.110–2.836) 1.544 (0.811–1.545) 1.636 (1.619–2.834) 1.855 (1.170–1.965) 2.345 (1.887–3.946) 2.011 (0.558–3.001)
NS NS NS NS 0.001 0.012
Comp Clin Pathol
coli and Klebsiella pneumoniae were the most common resistant organisms.
Discussion The main factors limiting the long-term use of hemodialysis catheters are poor flow and catheter infection. Temporary catheters in hemodialysis patients are the most common and significant cause of blood stream infections (Eggimann and Pittet 2002). In our study, BCRI rate was 11.4/1,000 catheterdays. This rate of BCRIs obtained during our study is similar BCRI rates (3.4 to 18.2 in 1,000 catheter-days) in the previous literature (Beathard 1999; Saad 1999). A variable common pathogenic organism in catheter infection has been reported in previous literature. In a prospective trial, S. aureus was the cause of infection in 33–80 % of cases (Gray et al. 1984; Band 2013). In other studies, coagulase-negative Staphylococci, Staphylococcus haemolyticus, and S. aureus were the most common causative organisms (Nabi et al. 2009). In our study, S. aureus was the most frequently isolated pathogen, followed by multiple-resistant S. aureus (MRSA), and E. coli, causing infection often associated with bacteremia. Some studies demonstrated increased carriage rates of S. aureus in patients receiving hemodialysis than in the general population. The vestibulum nasi is regarded as the major site of S. aureus carriage from where the organism can spread to other parts of the body (Von Eiff et al. 2001). Von Eiff et al. reported that S. aureus isolated from blood samples of septicemic patients were clonally identical to those obtained from nasal specimens in 82.2 % patients, signifying that the organisms in the bloodstream originated from the individual’s own nasal flora (Von Eiff et al. 2001). Poor patient hygiene and poor hygiene of medical staff are two important risk factors for increased BCRIs (Nassar and Ayus 2001). Likewise, our multivariate logistic analysis showed that poor hygiene of the patient and medical staff was two important factors on the rate of BCRIs. Attention paid to hygiene and using aseptic techniques during the insertion and care and manipulation of intravascular catheters are known to be effective precautions against BCRIs (Yilmaz et al. 2007). It is possible to obtain hand hygiene with water-free alcohol-based products or antibacterial soap (Bischoff et al. 2000). Our results demonstrate that the incidence of BCRIs was increased by inadequate hand hygiene before catheter manipulations (OR=1.125, 95 % CI= 0.773–2.676; P=0.014). One important finding of our study concerning the frequent manipulation of catheters is that frequent catheter manipulation led to an increase in the BCRI rate (OR=2.011, 95 % CI=0.558–3.001; P=0.012). Moreover, prolonged duration of catheter usage have been described as major risk factors related to infection in HD patients associated with a high risk of developing sepsis or
colonization of the catheter (Pisoni et al. 2002). The cumulative hazard of catheter-related bacteremia was significantly magnified 3 weeks after insertion (Saxena and Panbotra 2005). These reported findings are in accordance with the results found in the present study, namely the mean duration of catheter placement was 34±13 days. This result showed a significantly high duration of catheter placement among patients who developed BCRIs (OR=2.345, 95 % CI=1.887– 3.946). Fortunately, in our study, bacterial resistance to antibiotic therapy was low, especially to vancomycin and ceftazidime. Enterococci and E. coli were the most common resistant organisms. In a study on intensive care patients, 26 % of isolated Enterococci were resistant to vancomycin (CDC. National Nosocomial Infections (NNIS) system report, data summary from January 1990). In this study, MRSA has a higher rate in comparison to other studies. This rate may be justified with using of antibiotics in developing country like ours.
Conclusion We conclude that the rate of BCRI and the causative organisms found in our study is comparable to previous reports. The most effective method of prevention seems to be the promotion of the infection control precautions that should be emphasized by educating and training the health providers. We still need to adopt measures to minimize the use of temporary vascular accesses by creation of fistulas in a timely fashion.
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