Bacteremia in hemodialysis patients

Table 1 Causative organisms of bacteremia in hemodialysis patients

	Hemodialysis patients	Hemodialysis vascular access-associated		Hemodialysis catheter-related bacteremia	General population
Ref.	Danese et al[19], 2006	Loo et al[20], 2015	D’Amato-Palumbo et al[21], 2013	Aslam et al[22], 2014	Biedenbach et al[23], 2004			Alfandari et al[24], 2016
Region	United States	Singapore	United States	Meta-analysis	North America	Latin America	Europe	France
n	15618	144	112	1386	42857	11743	26613	519
Gram positive		73.6%	73.2%					39.7%
Staphylococcus aureus	38.4%	47.2%	50.9%	25.9%	26.0%	21.6%	19.5%	15.4%
(MRSA)		13.9%	23.2%					2.9%
(MRSA/SA)		29.4%	45.6%					18.8%
Other staphylococcus	15.4%	20.1%	10.7%	23.4%	11.5%	13.3%	14.6%	8.3%
Streptococcus	11.9%		2.7%		9.5%	6.8%	6.5%	12.5%
Enterococcus			8.9%		10.2%	3.3%	7.2%	3.5%
Gram negative		26.4%	23.2%	22.0%				55.3%
Escherichia coli	6.5%		4.5%		17.7%	18.2%	22.4%	34.5%
Pseudomonas spp.	3.6%	9.0%	9.8%		4.3%	6.5%	6.1%	1.5%
Enterobacter spp.		4.9%			3.7%	5.5%	4.2%	3.7%
Klebsiella spp.			5.4%		7.6%	10.1%	7.3%	7.1%
Proteus mirabilis								2.3%
Candida spp.		1.2%	3.6%					6.2%

MRSA: Methicillin-resistant Staphylococcus aureus.

Table 2 Antibiotic concentrations applied in locks[31]

	Dosage (mg/mL)	Heparin or saline, IU/mL
Vancomycin	2.5	2500 or 5000
Vancomycin	2.0	10
Vancomycin	5.0	0 or 5000
Ceftazidime	0.5	100
Cefazolin	5.0	2500 or 5000
Ciprofloxacin	0.2	5000
Gentamicin	1.0	2500
Ampicillin	10.0	10 or 5000
70% ethanol		0

Table 3 Antibiotic dosing for patients who are undergoing hemodialysis[31]

Empirical dosing pending culture results

Vancomycin plus empirical gram-negative rod coverage based on local antibiogram data

Or

Vancomycin plus gentamicin (Cefazolin may be used in place of vancomycin in units with a low prevalence of methicillin-resistant staphylococci)

Vancomycin: 20 mg/kg loading dose infused during the last hour of the dialysis session, and then 500 mg during the last 30 min of each subsequent dialysis session

Gentamicin (or tobramycin): 1 mg/kg, not to exceed 100 mg after each dialysis session

Ceftazidime: 1 g iv after each dialysis session

Cefazolin: 20 mg/kg iv after each dialysis session

For Candida infection

An echinocandin (caspofungin 70 mg iv loading dose followed by 50 mg iv daily; intravenous micafungin 100 mg iv daily; or anidulafungin 200 mg iv loading dose, followed by 100 mg iv daily); fluconazole (200 mg orally daily); or amphotericin-B

iv: Intravenous.

Table 4 Core interventions of dialysis blood stream infections prevention in collaboration with the Centers for Disease Control and Prevention

Surveillance and feedback using NHSN

Conduct monthly surveillance for BSIs and other dialysis events using NHSN-Dialysis Surveillance. Calculate facility rates and compare to rates in other NHSN facilities. Actively share results with front-line clinical staff. See Data Reports on this website (available from: URL: http://www.cdc.gov/dialysis/reports-news/data-reports.html)

Hand hygiene observations

Perform observations of hand hygiene opportunities monthly and share results with clinical staff. See observation protocols for hand hygiene and glove use on this website (available from: URL: http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis-Hand-Hygiene-Observations.pdf)

Catheter/vascular access care observations

Perform observations of vascular access care and catheter accessing quarterly. Assess staff adherence to aseptic technique when connecting and disconnecting catheters and during dressing changes. Share results with clinical staff

Staff education and competency

Train staff on infection control topics, including access care and aseptic technique. Perform competency evaluation for skills such as catheter care and accessing every 6-12 mo and upon hire. See staff education on this website (available from: URL: http://www.cdc.gov/dialysis/clinician/index.html)

Patient education/engagement

Provide standardized education to all patients on infection prevention topics including vascular access care, hand hygiene, risks related to catheter use, recognizing signs of infection, and instructions for access management when away from the dialysis unit. See patient education on this website (available from: URL: http://www.cdc.gov/dialysis/clinician/index.html)

Catheter reduction

Incorporate efforts (e.g., through patient education, vascular access coordinator) to reduce catheters by identifying and addressing barriers to permanent vascular access placement and catheter removal

Chlorhexidine for skin antisepsis

Use an alcohol-based chlorhexidine (> 0.5%) solution as the first line skin antiseptic agent for central line insertion and during dressing changes. Povidone-iodine (preferably with alcohol) or 70% alcohol are alternatives for patients with chlorhexidine intolerance

Catheter hub disinfection

Scrub catheter hubs with an appropriate antiseptic after cap is removed and before accessing. Perform every time catheter is accessed or disconnected. If closed needleless connector device is used, disinfect connector device per manufacturer’s instructions

Antimicrobial ointment

Apply antibiotic ointment or povidone-iodine ointment to catheter exit sites during dressing change. See information on selecting an antimicrobial ointment for hemodialysis catheter exit sites (selecting an antimicrobial ointment). Use of chlorhexidine-impregnated sponge dressing might be an alternative

NHSN: National Healthcare Safety Network; BSIs: Blood stream infections.