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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 14  |  Issue : 4  |  Page : 179-183

The rate of catheter-related bloodstream infection in renal dialysis patients using central venous catheters: A retrospective study


1 Department of Internal Medicine, Tawam Hospital, Al Ain, UAE
2 University of Sharjah, Sharjah, UAE
3 Dialysis Unit, SEHA Dialysis Services, Al Ain, UAE
4 Department of Internal Medicine, Tawam Hospital; Division of Infectious Diseases, Tawam Hospital, Al Ain, UAE
5 Department of Internal Medicine, Tawam Hospital; Division of Nephrology, Tawam Hospital, Al Ain, UAE

Date of Submission03-May-2021
Date of Decision28-May-2021
Date of Acceptance10-Jun-2021
Date of Web Publication11-Jan-2022

Correspondence Address:
Khaled Karkout
Department of Internal Medicine, Tawam Hospital, Al Ain
UAE
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_22_21

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  Abstract 


Background: Globally, haemodialysis patients using central venous catheters remain at a huge risk for blood stream infections. Most of these infections are caused by skin dormant organisms. Patients suffering from blood stream infections have the risk of seeding the infection into distant organs leading to multiple organ failure, fulminant shock and death. Objectives: our primary objective is to calculate the rate of catheter related blood stream infections (CRBSI) in patients inevitably using central venous catheters (CVC) while waiting for their arteriovenous fistula (AVF) maturation, and compare it to the international benchmark. Our secondary objective is to compare the morbidity and mortality outcomes between patients using central venous catheters vs. patients with arteriovenous fistula. Methods: A retrospective single centre study on Tawam hospital outpatient dialysis patients, who underwent dialysis at the SEHA dialysis service (SDS) centre. Data were obtained from 1st January 2015 till 30th Dec 2015. We only included patients needed to temporarily use CVC while waiting for their AV maturation. Data were obtained from Electronic Medical Records, and analysed using SPSS. Results: The total study population was 219 patients, of them; 175 patients of them were using a CVC for their first haemodialysis session. Out of patients using CVC, 53 (30.3%) patients were admitted at least once for an episode of infection during the first year of initiation of dialysis. The number of overall admission days were higher in the CVC group (2172 days) when compared to patients who started their haemodialysis with AVF directly without using CVC initially (588 days). The rate of CRBSI in our patients using CVC temporarily appeared to be 5.2 episodes per 1000 catheter-days. The number of interventional radiology procedures needed were significantly higher in the patients using CVC. There were 16 mortality cases, of which 15 (93.8%) were in the group using CVC. Conclusion: Dialysis through central venous catheter showed to have an increase in the number of admission days (overall and related to CRBSI), morbidity and mortality when compared to arteriovenous fistula. In the light of these findings, the decision of either waiting for fistula maturation or using CVC temporarily should be carefully tailored on case by case basis. Quality improvement projects are needed to address this important problem hospital wide. Decreasing hospitalization decreases the burden and the stretch on health care services and allows to provide better patient centred care.

Keywords: Arteriovenous fistula, catheter, chronic, dialysis, kidney failure, sepsis


How to cite this article:
Karkout K, Ibrahim AA, Khoudeir A, Karkout R, Delgado AL, Saleem A, Chabaan A. The rate of catheter-related bloodstream infection in renal dialysis patients using central venous catheters: A retrospective study. Hamdan Med J 2021;14:179-83

How to cite this URL:
Karkout K, Ibrahim AA, Khoudeir A, Karkout R, Delgado AL, Saleem A, Chabaan A. The rate of catheter-related bloodstream infection in renal dialysis patients using central venous catheters: A retrospective study. Hamdan Med J [serial online] 2021 [cited 2022 Jan 20];14:179-83. Available from: http://www.hamdanjournal.org/text.asp?2021/14/4/179/335376




  Introduction Top


The decision of which type of vascular access to be used for a haemodialysis patient is challenging. It is affected by multiple factors, including and not limited to the timing of initiation of dialysis and its urgency, patient demographics and the centre's practice (the level of comfort of the nephrologist, surgeon and dialysis nurses).[1] Established guidelines have promoted the use of arteriovenous fistulas (AVFs) as the preferred type of vascular access because of lower risk of related infections but cited low evidence in the literature to support this recommendation.[2] Catheter-related bloodstream infection (CRBSI) is bacteraemia associated with the insertion of catheters, and is considered one of the most costly, lethal and avoidable infections. The true incident of CRBSI is probably not precisely known, due to the variations in its definition amongst different dialysis centres. Tawam Hospital is a tertiary and a referral centre to which a large number of patients in need of haemodialysis are referred annually. As a big centre, we decided to reflect on our practice and assess our performance to be able to compare it to similar dialysis centres regionally and internationally. We aimed in this study to measure the rate of CRBSI amongst patients using central venous catheter (CVC) temporarily, and to compare it to the international benchmark. We then aimed to compare morbidity and mortality outcomes in those patients to others who started their dialysis using AVF. In our practice, we accept both of the definitions outlined by the Infectious Diseases Society of America and the Kidney Disease Outcomes Quality Initiative, as definitions of CRBSI [Table 1].
Table 1: Definitions of catheter-related bloodstream infections in literature[3]

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  Materials and Methods Top


Population and study design

This was a retrospective single-centre study on Tawam Hospital dialysis patients. Data were obtained for patients needing their first haemodialysis session (whether due to acute or chronic kidney diseases) for the entire year of 2015 (1 January to 30 December). We collected the data in 2015 and completed the study during the rest of the years to date. This created a good gap in time, for if we to recreate the study in the future, we'd have an idea on our progress. Data were obtained from electronic medical records. Our variants of the study included patients demographics with protection of patient privacy, the date of dialysis initiation, the date of AVF formation, type of vascular access used in the first session of dialysis, the date at which the formed fistula was cannulised and number of fistula- or catheter-related interventional radiology procedures done during the next 12 months, number of episodes of infections and admission days (overall and related to infections).

Inclusion criteria

All patients who started planning for dialysis as of 1 January 2015 till 30 December 2015, who were started on haemodialysis via a CVC before continuing the dialysis via AVF and those who waited and used AVF for the first session immediately.

Exclusion criteria

  • Patients who are exclusively dialysing using CVC and have not had AVF at any point
  • Patients who had AVF but had not been cannulated yet.


Consent and ethical considerations

Ethical approval for this study was obtained from the Research Ethics Committee of Tawam Hospital. The study design was carefully explained to all participants along with the aim and purpose of this study, and privacy was assured.

Data analysis

Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) software version 25 (SPSS 25, IBM, Armonk, NY, United States of America). Descriptive statistics were used to describe the mean scores and proportions. To examine the correlation between demographics and selected characteristics of patients, Pearson's Chi-square (χ2) test and analysis of variance were used. All analyses were performed using two-tailed hypothesis testing with the level of significance set at 0.05 (P value). Results obtained were compared with other articles to evaluate and conclude.


  Results Top


Demographics and basic information

A total of 296 new patients presented to the SDS centre in 2015, who met the inclusion criteria. A small number of patients changed their course of treatment or lost follow-up, which led us to exclude their charts from the review, making the final study population equal to 219 patients [Figure 1]. The study sample compromised of 137 (62.6%) male and 82 (37.4%) female patients. The mean age (standard deviation) of the study population was 55.4 (16.0) years. About 60 (27.4%) of the total study sample were UAE nationals, while the vast majority were expats, counting 159 (72.6%). Demographics are shown in [Table 2].
Figure 1: Flow chart indicating final sample size in the study

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Table 2: Demographics and certain aspects of our study population

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Patients using central venous catheter group

The patients who used CVC for their first haemodialysis session were compromising of 79.9% of our study population (n = 175) [Figure 2]. Those patients who had CVC while waiting for their AVF maturation had more interventional radiology procedures done (a cumulative of 67 procedures in the overall group) [Figure 3]. Out of patients using CVC, 53 (30.3%) patients were admitted at least once for an episode of infection during the 1st year of initiation of dialysis. The longest period of one admission lasted for 40 days for a patient in this group. The sum (min-max) of days as inpatient in this group was 2172 (1–110) days, of them 428 (1–40) days exclusively treating infections.
Figure 2: Percentage of patients who used CVC versus AVF for the first haemodialysis session. CVC: Central venous catheter, AVF: Arteriovenous fistula

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Figure 3: The cumulative number of IR procedures and number of patients who needed admissions for suspected catheter-related bloodstream infection in each group of the study. IR: Interventional radiology

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To calculate the rate of CRBSI in this group, we divided the number of CRBSI episodes (which is 82 episodes in total in this group) by the number of line days, and multiplied by 1000.[4] The number of line days was calculated by multiplying number of months needed till maturation of AVF by 30 (525 × 30 = 15,750 days). Therefore, the rate of CRBSI in our patients using CVC temporarily appeared to be 5.2 episodes per 1000 catheter-days.

The central venous catheter group compared to arteriovenous fistula group

Patients who started their dialysis using AVF were 44 patients (20.1%). This group had less IR procedures done and had less patients who had infection-related episodes of admission in comparison to the group using CVC [Figure 3]. In the AVF group, only 11 (25%) patients were admitted at least once for an episode of infection during the 1st year of initiation of dialysis, the longest period of admission being 21 days. The sum (min-max) of days as inpatient in this group was 588 (1–153) days, of them 62 (1–21) days exclusively treating infections. The length of admission (whether overall, or for treating infections) was higher in the CVC group (analysis done using independent t-test), but results are not statistically significant. Most of the patients who had their AVF ready to use in the 1st year of dialysis had it ready in 3 months (53 out of 111 patients, i.e. 53.4%) [Figure 4]. There were 16 mortality cases, 15 of them (93.8%) were in the group using CVC [Figure 5].
Figure 4: Timeframe needed for patients' arteriovenous fistula maturation

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Figure 5: Mortality cases according to their vascular access type in the first 12 months

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The number of interventional radiology procedures was higher in patients using CVC (38.9% of them needed at least 1 procedure vs. 9.1% of the AVF group), in a statistically significant Chi-square test (P ≤ 0.001). Patients who used CVC for haemodialysis had more episodes of admissions treating infections (30.3% in this group vs. 25% in the AVF group), and more number of mortality cases [Figure 5], but the results are statistically insignificant.


  Discussion Top


There are multiple advantages of CVCs in patients needing haemodialysis, including the availability of multiple insertion sites, immediate readiness to use, less cardiovascular complications and many others. With that being said, CVCs have been associated with certain complications too. These include access failure, breakage, dysfunction, infection and thrombosis.[5]

Infection of the CVC line is a leading risk factor contributing to morbidity and mortality in haemodialysis patients. CRBSIs from CVC use occur at rates of 1.1–6.1 episodes per 1000 catheter-days in international reports.[6],[7] Our centre stands within the range reported internationally. We are also comparable to our neighbour in Saudi Arabia, where Albadawi et al. report their centre's CRBSI rate to be 5.2, prior to their quality improvement project which reduced it to 3.9 then to zero.[8] It is indeed advocated for the rate to be zero, which does not seem to be unachievable.[9] In addition, our time of fistula maturation (which was 53% within the first 3 months) is close to the United States registry data (the United States Renal Data System) which is reported to be 55%–60%.

The potential risk factors that could lead to CRBSI include the comorbidities of the patient, method of catheter insertion, site of catheter insertion and duration of catheterisation. Coagulase-negative staphylococci seem to be a major causative organism of CRBSI, being responsible for about 37% of the overall causative organisms in some reports.[10] These organisms secrete a biofilm over itself inside the catheter's lumen which acts as a protective layer. Symptoms of systemic inflammation occur once the bacterial count reaches a certain threshold and sheds into the bloodstream.

It is indeed reported that bloodstream infections occur at a higher rate in patients using CVCs for haemodialysis. Taylor et al. reported that compared to AVF, the relative risk of bloodstream infection in patients was 8.49 (95% confidence interval [CI], 3.03–23.78) for cuffed CVCs, and 9.87 (95% CI, 3.46–28.20) for uncuffed CVCs.[11] In addition, Banerjee et al. pointed in their study that there was greater inflammation and mortality in haemodialysis patients with CVC compared to AVF, and therefore recommended the early removal or avoidance of CVC if feasible.[12]

Putting CRBSI rate aside, in our study, patients with AVF had less admission days in the hospital, less procedures done and less mortality cases. Our results align with international and regional findings. Karkar et al. from Saudi Arabia concluded in their study that AVF was superior to CVCs in terms of less clotting, better quality of haemodialysis, less hospitalisation and better patient outcomes.[13] All of the latter outcomes fall into decreasing the burden on healthcare services and provide better care for those in need.


  Conclusion Top


Our haemodialysis centre is doing a comparable job to international and regional standards. We conclude the superiority of AVF over CVC in terms of the overall procedures and admission days needed, infections rate and mortality, even if CVC was used temporarily while waiting for the AVF maturation. In light of these statements, the dialysis team should decide on the type of vascular access for each patient carefully, on case by case basis. We recommend to be keen towards waiting to use AVF whenever possible and safe. We advocate for quality improvement projects to address the issue of our CRBSI rate.

Ethical clearance

The study was approved by the institutional Ethics Committee of Tawam Hospital, Al Ain, UAE. (Approval THEC-602) Khaled.

Declaration of patient consent

The authors certify that they have obtained all appropriate patients consent forms. The patients understand that his/her/ their names and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Allon M, Robbin ML. Increasing arteriovenous fistulas in hemodialysis patients: Problems and solutions. Kidney Int 2002;62:1109-24.  Back to cited text no. 1
    
2.
Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, et al. KDOQI Vascular Access Guideline Work Group. KDOQI clinical practice guideline for vascular access: 2019 update. Am J Kidney Dis 2020;75 Suppl 2:S1-164.  Back to cited text no. 2
    
3.
Miller LM, Clark E, Dipchand C, Hiremath S, Kappel J, Kiaii M, et al. Canadian Society of Nephrology Vascular Access Work Group. Hemodialysis Tunneled Catheter-Related Infections. Can J Kidney Health Dis 2016;3:2054358116669129. DOI: https://doi.org/10.1177/2054358116669129. PMID: 28270921; PMCID: PMC5332080.  Back to cited text no. 3
    
4.
Hallam C, Jackson T, Rajgopal A, Russell B. Establishing catheter-related bloodstream infection surveillance to drive improvement. J Infect Prev 2018;19:160-6.  Back to cited text no. 4
    
5.
Haddad N, Van Cleef S, Agarwal A. Central venous catheters in dialysis: The good, the bad and the ugly. Open Uro Nephro Jou 2012;5 (Suppl 1: M3):12-8.  Back to cited text no. 5
    
6.
Martin K, Lorenzo YS, Leung PY, Chung S, O'flaherty E, Barker N, et al. Clinical outcomes and risk factors for tunneled hemodialysis catheter-related bloodstream infections. Open Forum Infect Dis 2020;7:ofaa117.  Back to cited text no. 6
    
7.
Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-32.  Back to cited text no. 7
    
8.
Albadawi AS, AlBakheet Y, Abou Yassine K, AlGhamdi E, Caswell A, Marhoun S, et al. 2 Successful intervention to reduce central line-associated bloodstream infection rate in adult intensive care unit at a specialized tertiary care hospital in riyadh, saudi arabia. BMJ Open Quality 2019;8. doi: 10.1136/bmjoq-2019-PSF.2.  Back to cited text no. 8
    
9.
Wu PP, Liu CE, Chang CY, Huang HC, Syu SS, Wang CH, et al. Decreasing catheter-related bloodstream infections in the intensive care unit: Interventions in a medical center in central Taiwan. J Microbiol Immunol Infect 2012;45:370-6.  Back to cited text no. 9
    
10.
Fletcher S. Catheter-related bloodstream infection. Continuing Educ Anaesth Critical Care Pain 2005;5:2.  Back to cited text no. 10
    
11.
Taylor G, Gravel D, Johnston L, Embil J, Holton D, Paton S, et al. Incidence of bloodstream infection in multicenter inception cohorts of hemodialysis patients. Am J Infect Control 2004;32:155-60.  Back to cited text no. 11
    
12.
Banerjee T, Kim SJ, Astor B, Shafi T, Coresh J, Powe NR. Vascular access type, inflammatory markers, and mortality in incident hemodialysis patients: The Choices for Healthy Outcomes in Caring for End-Stage Renal Disease (CHOICE) Study. Am J Kidney Dis 2014;64:954-61.  Back to cited text no. 12
    
13.
Karkar A, Chaballout A, Ibrahim MH, Abdelrahman M, Al Shubaili M. Improving arteriovenous fistula rate: Effect on hemodialysis quality. Hemodial Int 2014;18:516-21.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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