Infection is the second leading cause of hospitalization and mortality in hemodialysis patients. Compared to patients on peritoneal dialysis, patients undergoing hemodialysis are twice likely to be hospitalized due to infection. In addition, about one in four deaths among hemodialysis patients are associated to infections. Notably, infections are associated with excessive financial burden for patients and healthcare facilities.
Although hemodialysis patients are continually exposed to a variety of infections, catheter-related bloodstream (CRB) infections are particularly more severe and can even possibly result in fatal outcomes. Around 37,000 patients with central catheters develop bloodstream infection each year, with an estimated cost of $23,000 per hospitalization.
Incidence of CRB Infections
Two of the most common causes of catheter-related infection are Staphylococcus aureus and Staphylococcal epidermidis. These microorganisms can lead to considerable morbidity, even possible death. The catheter insertion site serves as the portal of entry for these bacteria. Bacteria migrate to the insertion site from the skin and follow through the outer surface of the catheter. Repeated use of catheter lumen during hemodialysis sessions increases the risk of contamination.
CRB infections are rarely caused by infusion of contaminated solutions. Studies show that the duration of catheterization increases the risk of infection. Moreover, the infection rate is higher with non-tunneled catheters compared to tunneled catheters. Incidence of infection among patients with non-tunneled catheters is between 3.8 to 12.8 events per 1,000 catheter days and 2.9 per 1,000 catheter days for tunneled catheters. The possibility of adverse outcome steadily increases over time. The risk of infection for nontunneled catheters in the IJ location is five times higher than the tunneled catheters, and seven times for femoral catheters in the femoral site.
Preventing CRB Infections
While the incidence of infections is high, it is considered a preventable complication. Dialysis nurses and dialysis technicians are at the forefront in the prevention of CRB infections.
Dialysis nurses must alert the nephrologist of any evidence of exit-site infection, even if there are no systemic symptoms present. Usually, exit site infection preludes bacteremia thus prompt catheter removal is often recommended. Bacteria are thought to migrate much faster along the outer surface and tunnel of the catheter due to the absence of a cuff.
Dialysis nurses and dialysis technicians must strictly follow infection prevention protocols. Below are preventive measures:
• Use of 2% aqueous chlorhexidine for skin disinfection before insetion
• Proper insertion technique
• Practice aseptic technique during access handling
• Thorough skin disinfection using povidone-iodine solution at every HD session
• Application of mupirocin ointment or povidone-iodine ointment at insertion site every change of dressing
• Use of dry gauze dressing
• Use of surgical mask and face shield by healthcare providers and patients during cannulation and de-cannulation procedures
• Shortened/limited duration of catheters
Many healthcare facilities now use 2% aqueous chlorhexidine for skin disinfection prior to insertion. Chlorhexidine is more preferred over isopropyl alcohol and povidone-iodine. During catheter insertion or guidewire exchange, maximal sterile barrier precautions must be carefully followed.
Dialysis nurses and all other healthcare providers must be aware that hemodialysis access, especially central lines, should not be used to draw blood samples or used for infusions. After each HD session, disinfect the surrounding skin using povidone-iodine or chlorhexidine solution. Apply antimicrobial ointment (such as polysporin or mupirocin) to the catheter exit site, then, apply dry gauze (not occlusive dressing) over the exit site. Make sure the exit site is secured with plaster.
In 2009, the Centers for Disease Control and Prevention (CDC) has established 9 core interventions in the prevention of bloodstream infections among the dialysis community. Among others, hand hygiene has been pointed out as among the most important procedures that can help reduce infections associated to hemodialysis. The CDC noted a poor adherence with aseptic techniques in both acute and chronic hemodialysis facilities. Other core interventions recommended by CDC include: surveillance and feedback, catheter/vascular access care observations, continuous staff training and education, patient education, catheter reduction, catheter hub disinfection, use of chlorhexidine for skin disinfection, and use of antimicrobial ointment. Participants in the study have shown a decrease in the incidence of bloodstream infection.
Finally, realizing the burden and fatality of bloodstream infections, healthcare providers including doctors, dialysis nurses, and dialysis technicians must understand their pivotal role in preventing infection. Each facility has its own infection prevention and tracking protocols, which every healthcare provider is expected to know and practice.
Do you know your facilities infection prevention protocols? Do you practice them? As healthcare practitioners, let us show our care to our patients by diligently practicing recommended infection control interventions.