Catheter-Associated Bloodstream Infections among Patients on Hemodialysis: Progress before and during the COVID-19 Pandemic

The impact of the COVID-19 pandemic on hospital-acquired infections at a comprehensive cancer center

BACKGROUND

Robust infection prevention and control (IPC) measures were deployed across health care institutions at the start of the COVID-19 pandemic, resulting in increased use of personal protective equipment, enhanced contact precautions, and an emphasis on hand hygiene. Here, we evaluate the effect of enhanced IPC practices on the occurrence of various hospital-associated infections (HAIs) in a comprehensive cancer center.

METHODS

From September 2016 through March 2022, we calculated the incidence rates (IRs) of HAIs for C. difficile infection, multidrug-resistant organisms, respiratory viral infections (RVIs), and device-related infections. We analyzed the incidence rate ratios for all HAIs during the periods before the pandemic, during the pandemic, at the time of the surges, and in COVID-19-designated wards.

RESULTS

When comparing the prepandemic to the pandemic period, the IR across all MRDOs was similar. We observed a decrease in the IR of central line-associated bloodstream infections and a stable IR of catheter-associated urinary tract infections. A significant decrease was observed in the IR of C. difficile infection. The total IR of nosocomial RVIs decreased, as did for each respiratory virus. A similar IR of nosocomial RVIs between COVID-19 community surge versus nonsurge periods was observed except for SARS-CoV-2, RSV, and influenza. multidrug resistant organisms were 5 times more likely to occur on the COVID-19 wards compared with the non-COVID-19 wards.

CONCLUSIONS

Implementing strict IPC measures during the COVID-19 pandemic in a cancer hospital led to a significant decrease in many HAIs and a reduction in nosocomial RVIs.

Multifaceted Quality Improvement Interventions to Prevent Hemodialysis Catheter-Related Bloodstream Infections: A Systematic Review

RATIONALE & OBJECTIVE

Central venous catheters (CVCs) are widely used for hemodialysis but are prone to burdensome and costly bloodstream infections. We determined whether multifaceted quality improvement interventions in hemodialysis units can prevent hemodialysis catheter-related bloodstream infections (HDCRBSI).

STUDY DESIGN

Systematic review.

SETTING & STUDY POPULATIONS

PubMed, EMBASE, and CENTRAL were searched from inception to April 23, 2022, to identify randomized trials, time-series analyses, and before-after studies that examined the effect of multifaceted quality improvement interventions on the incidence of HDCRBSI or access-related bloodstream infections (ARBSI) among people receiving hemodialysis outside of the intensive care unit (ICU).

DATA EXTRACTION

Two people independently extracted data and assessed the risk of bias and quality of evidence using validated tools.

ANALYTICAL APPROACH

Intervention effects, validity, and characteristics of studies with the same design were compared. Differences between study designs were described.

RESULTS

We included 21 studies from 8,824 identified by our search. Among 15 studies that measured HDCRBSI, 2 methodologically heterogenous cluster randomized trials reported discordant intervention effects, 2 interrupted time-series analyses reported favorable interventions with discordant patterns of effect, and 11 before-after studies reported favorable interventions with a very high risk of bias. Among 6 studies that only measured ARBSI, 1 time-series analysis and 1 before-after study did not find a favorable intervention effect, and 4 before-after studies reported a favorable effect with a very high risk of bias. The overall quality of evidence was low for HDCRBSI and very low for ARBSI.

LIMITATIONS

Nine definitions of HDCRBSI were used. Ten studies included hospital-based and satellite facilities but did not report separate intervention effects for each type of facility.

CONCLUSIONS

Multifaceted quality improvement interventions may prevent HDCRBSI outside the ICU. However, evidence supporting them is of low quality, and further carefully conducted studies are warranted.

REGISTRATION

Registered at PROSPERO with registration number CRD42021252290.

PLAIN-LANGUAGE SUMMARY

People with kidney failure rely on central venous catheters to facilitate life-sustaining hemodialysis treatments. Unfortunately, hemodialysis catheters are a common source of problematic bloodstream infections. Quality improvement programs have effectively prevented catheter-related infections in intensive care units, but it is unclear whether they can be adapted to patients using hemodialysis catheters in the community. In a systematic review that included 21 studies, we found that most quality improvement programs were reported to be successful. However, the findings were mixed among higher-quality studies, and overall the quality of evidence was low. Ongoing quality improvement programs should be complemented by more high-quality research.

Risk of COVID-19 and Cost Burden in End-Stage Renal Disease Patients and Policy Implications for Managing Nephrology Services during the COVID-19 Pandemic

The aim of this study was to evaluate the risk of COVID-19 in end-stage renal disease (ESRD) patients, the cost burden of the COVID-19 pandemic on the management of ESRD and the cost of catheter infections. In this multicentre, retrospective study, data were obtained from the records of four dialysis centres providing care for ESRD patients in Northern Cyprus. Of the 358 ESRD patients that were receiving haemodialysis (HD) 13 were diagnosed with COVID-19. The average cost of HD treatment per patient was $4822.65 in 2019 and $3759.45 in 2020 (p ≤ 0.001). The average control cost of HD treatment per patient was $618.80 in 2019 and $474.03 in 2020 (p ≤ 0.001). The outpatient treatment costs of catheter infections were not significantly different in 2019 (before) compared to 2020 (after) the pandemic ($54.61 in 2019 compared to $54.74 in 2020, p = 0.793). However, the inpatient treatment costs were significantly greater before the pandemic compared to after the pandemic ($315.33 in 2019 compared to $121.03 in 2020, p = 0.015). The costs for monitoring COVID-19 transmission in patients having ESRD management were significantly higher in HD compared to in peritoneal dialysis (PD) and transplants. Since there is a high risk of transmission of infections in the hospital environment during a pandemic, it is important to implement alternative ESRD management methods, such as enhancing transplants in populations, switching to PD, and implementing home dialysis programmes to reduce the risk of infection and associated complications, as well as the health costs associated with infection monitoring.

The evolving panorama of vascular access in the 21st century

There are three major types of hemodialysis vascular access: hemodialysis catheters, arteriovenous grafts, and arteriovenous fistulas. Arteriovenous fistulas provide the best access due to their reliability and long-term patency. They are recommended by the current Kidney Disease Outcomes Quality Initiatives (K-DOQI) guidelines; however, not all patients benefit from arteriovenous fistulas due to poor maturation or a lack of adequate vasculature. Currently, hemodialysis is initiated via catheters in the majority of patients. Catheters are associated with high morbidity and mortality due to infection, lower quality of dialysis, and the development of central vein stenosis. The varied responses of patients to the different access types exemplify the need to choose the "right access for the right patient" based on scores that can predict death risk and progression of chronic kidney disease. Additionally, vascular access, often referred to as the "Achilles' heel" of hemodialysis patients, represents a significant percentage of the Medicare budget that continues to increase yearly. The purpose of this paper is to review the current literature on the management of vascular access complications and infection treatment and prevention. The paper also explores emerging research regarding the devices and methods to improve access outcomes such as early cannulation arteriovenous grafts, endovascular arteriovenous fistula creation, and regenerative grafts with resorbable scaffolds, among others. The data were collected through literature searches via PubMed, Athens and web search engines.

Designing healthcare for human use: Human factors and practical considerations for the translational process

In recent years, the focus of implementation science (IS) shifted to emphasize the influence of contextual factors on intervention adaptations in clinical, community, and corporate settings. Each of these settings represent a unique work system with varying contexts that influence human capabilities, needs, and performance (otherwise known as "human factors"). The ease of human interaction with a work system or an intervention is imperative to IS outcomes, particularly adoption, implementation, and maintenance. Both scientific approaches consider the "big picture" when designing interventions for users and stakeholders to improve work and health outcomes. IS and human factors are therefore complementary in nature. In this paper, the authors will (1) provide perspective on the synergistic relationship between human factors and IS using two illustrative and applied cases and (2) outline practical considerations for human factors-based strategies to identify contextual factors that influence intervention adoption, implementation, and maintenance dimensions of the RE-AIM framework. This article expands on recent research that developed user- and human-centered design strategies for IS scientists to use. However, defining the complementary relationship between IS and human factors is a necessary and valuable step in maximizing the effectiveness of IS to transform healthcare. While IS can complement practitioners' identification of intervention adaptations, human interaction is a process in the work system often overlooked throughout implementation. Further work is needed to address the influence that organizational endorsement and trust have on intervention adaptations and their translation into the work system.