Abstract: TH-PO273
Reducing Staphylococcus epidermidis Catheter-Related Bloodstream Infections in Dialyzed Patients: Experience From the Hemodialysis Centre in Prince Mansour Military Hospital, Kingdom of Saudi Arabia
Session Information
- Vascular Access: From Biology to Managing Complications
November 03, 2022 | Location: Exhibit Hall, Orange County Convention Center‚ West Building
Abstract Time: 10:00 AM - 12:00 PM
Category: Dialysis
- 703 Dialysis: Vascular Access
Authors
- AlMalki, Najlaa, Al Hada Military Hospital, Taif, Makkah, Saudi Arabia
- Abidi, Hichem, Al Hada Military Hospital, Taif, Makkah, Saudi Arabia
Background
Catheter-related bloodstream infections (CRBSIs) are a major cause of morbidity and mortality in hemodialysis. Although Methicillin- resistant Staphylococcus epidermidis (MRSE) is a leading causative agent, little literature deals with the mitigation of related CRBSIs, particularly in hemodialysis settings. A flare of MRSE CRBSIs occurred in PMMH HD center starting from August 2019, unveiled when instituting dialysis events surveillance (in March 2020) and studying historical data. A specific improvement project was designed to tackle this flare.
Methods
Fifteen percent of the patients had MRSE colonized catheters and were thought to represent a reservoir for the spread of the microorganism in the center. In the absence of specific international guidelines and the paucity of specific literature, mitigation actions were built on general infection control principles and analogy with Staphylococcus aureus, in consultation between nephrologists, infection control physician, infectious disease specialist, and nurses. An aggressive strategy of “seek and eliminate” against MRSE was adopted.
Results
Results were exceptional. MRSE CRBSI rates were significantly lowered towards the pre-flare period rates during the intervention period (April 2020 to August 2020), and post-intervention rates were maintained even lower to date (April 2022).
Conclusion
Assignment of a dedicated infection control professional to the hemodialysis center and implementation of the dialysis events surveillance with study of historical CRBSI data, allowed for the detection of the reported flare. Despite the lack of specific guidelines and literature, mitigation actions decided collectively allowed for a prompt and sustained control of MRSE CRBSIs.
Main interventions
| + Targeted Active surveillance cultures: - Newly accepted patients - Patients resuming dialysis in the centre after hospitalization or dialysis in other centres (for three sessions or more) | - Detect patients with colonized CVCs that represent a potential reservoir for future CRBSIs. |
| + Removal/exchange of CVC: - Surveillance: Patients found to have paired central and peripheral positive blood cultures will have their CVC removed/exchanged and treated as per clinical CRBSI guidelines. - CVC lumen colonization: Patients with isolated positive central line cultures (clinical or surveillance BC) will be treated by antibiotic lock. If colonization is still present after lock therapy, CVC will be removed/exchanged. - Clinical CRBSIs: - Immediate removal for: -- Clinically and hemodynamically unstable patient. -- Persistent fever 48 to 72 after initiation of systemic antibiotics -- Metastatic complications, including suppurative thrombophlebitis, endocarditis -- Presence of a tunnel-site infection -- Infections due to S aureus, Pseudomonas aeruginosa, fungi, or mycobacteria. Due to local high prevalence and incidence, CRBSI with Methicillin-resistant S. Epidermidis. - Delayed removal for persistent bacteraemia 7 days after initiating antibiotics in stable asymptomatic patients. | - Promptly remove/exchange colonized CVCs. - Decolonize CVC. If colonization persists, remove/exchange CVC to avoid future CRBSI and possible transmission to other patients. - Optimize treatment of CRBSI by immediately removing source of infection in clinically severe cases and or epidemiologically significant organisms. - Persistent bacteraemia after 7 days is considered a proxy for treatment failure. |
| + Prophylactic lock therapy - All cases where CVC removal/exchange is indicated (clinical or surveillance) but not done should receive long-term prophylactic lock therapy (weekly TPA) - This includes patients at higher risk for CRBSI | - When removal/exchange of CVC is not feasible or declined by the patient, long-term prophylactic lock therapy will help decrease the risk of future CRBSIs. |
| + Extra interventions for MRSE: - Decolonization protocol for patients with MRSE CVC colonization, present or recurrent MRSE CRBSI. - Contact precautions for MRSE CVC colonization or active MRSE CRBSI - Extra emphasis on hand hygiene and disinfection (skin and surfaces) practices. | - Minimize burden of MRSE body carriage (main source for CVC lumen colonization) - Avoid spread of MRSE between patients |