Getting to Zero: Outpatient Hemodialysis Catheter-Associated Bloodstream Infections

Background: A hemodialysis catheter is the major risk factor for bactermemia for dialysis patients. Relative risk for bacteremia for patients with permanent (cuffed) hemodialysis catheters is about sevenfold the risk for patients with arteriovenous fistulas. By 2008, 72% of 103 hemodialysis patients at our facility had a catheter, exceeding regional and national percentages. In 2007, 11 bloodstream infections (BSIs) were noted at a rate of 1.7 per 100 patient months; this increased to a rate of 2.4 BSIs per 100 patient months during the first 4 months of 2008. Of concern is mulitply drug resistant organism (MDRO) colonization, which had risen from 8% in 2005 to over 35% in 2007, increasing risk of exposure and infection. Noncompliance with the CDC's 2001 recommendations for prevention of infection in hemodialysis was observed. For example, hand hygiene was omitted between touching machines or when performing non-invasive procedures. Supplies were stored adjacent to the patients' chairs, and a few surfaces were not cleaned between patients. Catheter manipulations were performed without hub disinfection, and patients were not required to wash their hands prior to a procedure.

Objective: To reduce hemodialysis catheter-associated bloodstream infections

Methods: A bundle of best practices were applied simultaneously:

• Catheter hub disinfection prior to each accession with chlorhexidine gluconate 3.15% w/v in 70% isopropyl alcohol
• Performing hand hygiene plus gloving prior to contacting patients or machines
• Assisting patients to perform hand hygiene pre-dialysis
• Relocating supplies, from near the patient to a central area
• Strengthening environmental cleaning practices
• Utilizing chlorhexidine gluconate impregnated sponge dressings on exit sites of those catheters  deemed high risk, i.e. a previous infection, a femoral site, or patients with limited access alternatives 
• Further implementation and strengthening of a comprehensive fistula placement program

Results: Catheter associated BSI rate dropped from 2.4 per 100 patient months to 0, which was sustained for 15 months. 24 BSIs were prevented during that period with an estimated $480,000 in cost savings. Fistula utilization reached 41% by 2009. The MDRO colonization rate remained stable.

Conclusions: A bundle of best practices was effective in reducing and sustaining central line associated BSIs; however, there was no change in MDRO prevalence.Targeting chlorhexidine impregnated sponge dressings for high risk catheters preserved resources. Optimal hand hand hygiene and  gloving in an outpatient hemodialysis unit is extremely challenging. Interpretation of best practices for dialysis catehter care was challenging because guidelines are somewhat inconsistent. Finally, sustaining the infection rate at zero is directly related to reduced utilization of catheter accesses.