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Abstract: TH-PO274

Catheter-Related Bloodstream Infections in Dialyzed Patients: Improvement Project in Hemodialysis Centre in Prince Mansour Military Hospital, Taif Region, Kingdom of Saudi Arabia

Session Information

Category: Dialysis

  • 703 Dialysis: Vascular Access


  • AlMalki, Najlaa, Al Hada Military Hospital, Taif, Makkah, Saudi Arabia
  • Abidi, Hichem, Al Hada Military Hospital, Taif, Makkah, Saudi Arabia

Group or Team Name

  • Al Hada Armed Forces Hospital Nephrology Department

Prevention of catheter-related bloodstream infections (CRBSIs) - a leading cause of morbidity and mortality in hemodialysis- is a multifaceted approach, mainly based on well-designed and implemented infection control and water quality programs. An extensive outbreak (attack rate of 35%) of CRBSIs with Xanthomonas occurred in PMMH HD Centre in 2019. A regional multidisciplinary team was invested with the mission of building on the investigation findings throughout the outbreak period, to set strategies to avoid similar situations in the future. We report the results of the improvement project that was built on the root cause analysis of this Xanthomonas outbreak.


The multidisciplinary team proceeded with an in-depth investigation including literature, system change, Reverse Osmosis/ raw water systems, and infection control practices reviews; incorporating findings and actions taken by the local team. A root cause analysis was conducted based on collected data. Recommendations from the committee were formulated as an improvement project.


The outbreak was officially declared over by the end of the intervention period (March 2020). During the post-intervention period (April 2020 to April 2022), a single case of Xanthomonas CRBSI occurred. An estimated overall 85% of the project recommendations were implemented.


Outbreaks of healthcare-associated infections are extremely stressful and challenging. Yet, lessons learned when investigating and mitigating such events could set sound foundations for quality improvement initiatives. The goals of the presented project were achieved successfully, mainly by instituting a new leadership system for the hemodialysis center- with a physically present most responsible nephrologist, and a full-time infection control professional- which set the stage for further quality improvement initiatives.

Improvement project main interventions
+ Point prevalence study for all patients with catheters
- Draw Central and peripheral blood cultures from all patients with CVCs
+ Emphasize department’s program of ‘fistula first’ for patients likely to be dialysed in a foreseeable future.
- Adopt % of patients first dialysed through fistula as a quality indicator.
- Adopt the % of patients with exclusive CVC > 90 days as a quality indicator.
+ Infection control job-specific training and monitoring of practices for HD staff
- Assign a full-time infection control professional to oversee IPC related activities.
- Update competency checklists for nurses and retrain. Assess competency regularly.
- Daily observations of procedures and practices
+ Housekeeping staff training and monitoring
- Assign specific HK staff for HD units to be trained about the specificities of HD setting
- Regular monitoring of HK practices with feedback
- Use triple-bucket system to avoid contamination
+ Ensure permanent senior medical supervision of activities
- Appoint a consultant nephrologist to be responsible (and physically present) for HD centre activities
+ Main raw (non-RO) water treatment and distribution systems
- Empty all tanks urgently, clean and disinfect internal surfaces before refilling with water.
- Cleaning and then disinfection of the whole piping system either by superheating, hyper chlorination or both is urgently needed. Contracting with a specialized company is warranted.
- Draw a new pipeline from the water treatment plant to directly feed the HD building (both RO and non-RO systems).
- Provide tools for water sampling and necessary containers and chemicals (e.g. sodium thiosulfate).
- Hand hygiene faucets and sinks need to be changed as design is not conform to standards. Add HH sinks missing in several areas of the HD units.
- Set a water management program for the facility supervised by a water management committee.
+ Implement surveillance of all positive blood cultures from haemodialysis patients
- Calculate rates of CRBSIs and follow trends over time
+ Antimicrobial stewardship activities
- Review appropriateness of empirical antibiotics according to local microbiology
- Update policy for clinical management of CRBSIs according to latest international guidelines
- Consult with ID specialist
+ Ensure Infection control/vascular access care supplies availability
- Secure continuously a minimum stock of supplies for at least 3 months (PPE, Skin disinfectant, surface disinfectant, Biopatch, transparent dressing…)
+ Staffing level (nurse to patient ratio)
- Nurses are working at approximately 60% of the recommended nurse to patient ratio. Urgent recruiting of new staff is needed.
+ Change Ice-making machines
- Install new machines with automatic dispensing (no direct contact with ice for dispensing).
- A schedule for cleaning and disinfection according to manufacturer’s instructions should be implemented.
- Microbiological quality of water to be checked regularly
+ RO water system
- Change the two raw water tanks in the RO room to be conforming with recommended design and easy to clean
- Urgently follow up with the RO Company to fix the problem of low return water temperature. Closely monitor thereafter to make sure the problem is solved.
- A written policy for water sampling techniques from RO system should be in place.
- Install a water chiller after the raw water tanks in the RO room.
- Change the malfunctioning pumps to avoid critical situation of loss of pressure.
- Recruit or train a water technician for PMMH.