Dialysis
Figure 2: Methicillin-resistant Staphylococcus aureus Bacteraemia Cases in the Haemodialysis Unit at Cambridge University Hospitals NHS Foundation Trust from 2005 to 2011
2 3 4 5
0 1
2005 2006 2007 2008 2009 2010 2011 Years
MRSA bacteraemia MRSA = Methicillin-resistant Staphylococcus aureus. Table 3: Prevention of Catheter-related Infections
Guidelines Recommendations 1
We recommend that venous catheters should be employed as a method of last resort for long-term vascular access to reduce the overall risk of infectious complications in HD patients
2 3 4
We suggest that aseptic technique should be mandatory at every manipulation of central venous dialysis catheters
We recommend that the catheter exit site should be cleaned with chlorhexidine 2 %
We suggest that an antimicrobial or antibiotic lock solution be used to reduce catheter-related bacteraemia and other infections
HD = haemodialysis. Source: Renal Association Standard (RAS) Guidelines (2011).5
All patients at CUHNFT with methicillin-resistant S. aureus (MRSA) bacteraemia from September 2006 to May 2011 have been identified by the infection control team based on data obtained from the microbiology and transplant database, the electronic medical records and electronic discharge files. The HD patient’s microbiology result has been segregated and the incidences of MRSA bacteraemia of CVC in patients within the dialysis unit have been reviewed. All incidences of MRSA bacteraemia in all patients with permanent and temporary dialysis lines in situ were investigated and those where the line was the site or source of infection were further reviewed. Between January and June 2007 there were 12 recorded incidences of dialysis line infections in 11 patients undergoing HD via a line on the dialysis unit or renal ward at CUHNFT.
Result
citrate prevents the activation of clotting co-factors, factor X and prothrombin and hence, the ultimate formation of fibrin. Systemic anticoagulation does not occur.17
The antimicrobial effect of TSC
Therefore, it is expected that it would diminish the bacterial content of catheters after chance contamination of the catheter hub. On the other hand, a similar antibacterial effect could be obtained through the effect of citrate on biofilm: if the mild corrosive action of citrate helps to eliminate the biofilm, it would also eliminate bacteria trapped within the biofilm. The effect of citrate on bacterial contamination of catheters may decrease the risk of symptomatic bacteraemia in patients with catheters, without the risk of developing resistant strains of the bacteria (as will occur with antibiotic lock solutions).18
46.7 % occurs through the binding and removal of calcium, which may inhibit the growth and survival of microbes. Through a variety of actions, concentrated citrate is bactericidal and sporicidal when tested in vitro.18
Safety and Adverse Effects
The adverse effects commonly reported with TSC 46.7 % solutions are dysgeusia and paraesthesia. These adverse effects usually disappear within one minute but are a sign that the catheter lock volume is too great, leading it to pass out of TSC 46.7 % solution from the distal tip into the bloodstream. The recommendation from the manufacturers is that should this occur, the volume used at the next instillation should be reduced by 0.1 ml. The catheter, however, should be completely filled and have no air space left, in case a clot should develop.
140
With the introduction of TSC 46.7 % between September 2006 and February 2007, the incidence of dialysis line infections in patients undergoing HD via a line on the dialysis unit at CUHNFT had fallen to four recorded incidences in 2006 and one case in February 2007 (see Figure 2). Since March 2007 to May 2011, we have had no incidence of MRSA bacteraemia in the HD unit. This is an excellent innovation and contributes to the reduction of MRSA rates at CUHNFT, which placed the hospital as the best acute hospital in the UK in 2008 (Health Service [HS] Journal Award, 2008).
Cost and Usage Since the Introduction of Trisodium Citrate 46.7 %
Since the introduction of TSC 46.7 % solution in September 2006, the spending on urokinase by the dialysis unit has fallen and is now at less than 60 % of that prior to the introduction of TSC 46.7 % solution. Since September 2006, the number of urokinase (10,000 international units [IU]) vials used by the dialysis unit has fallen by approximately two-thirds over the six-month period. Locking the CVC with TSC 46.7 % is not the only factor that reflects the reduction rate of MRSA bacteraemia. The competency of our HD nursing staff when taking care of the dialysis line is also a major contributing factor.
Nursing Care Plan and Catheter Care Record Patients on dialysis have an increased risk of infection with 25 % of mortalities related to infection.7
This increased risk relates to
underlying uraemia, increased exposure to the hospital environment and to the method of renal replacement therapy, in particular the type of vascular access utilised. The use of CVC is the most common factor contributing to bacteraemia in dialysis patients.7
HD catheter is EUROPEAN NEPHROLOGY
Within the HD unit, there has been a very low incidence of adverse effects. Prior to TSC 46.7 % solution being introduced, all patients with catheters were written to by the clinical governance team to explain the changes in the solution, which would be used to lock their line and the adverse effects that may occur. Mild and transient tingling of the fingers has been reported, as has a metallic taste in the mouth, but no patient has found these effects to be problematic and none has discontinued use of TSC 46.7 % solution as a result.
Haemodialysis Patient Study
We conducted a retrospective study for HD patients receiving HD through tunnelled HD catheter. The patients were identified using our electronic patient database. The number of dialysis patients at CUHNFT gradually increased and so we expanded to haemo homecare in 2010, which incorporates home HD and PD.
Number of cases
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