A multi-disciplinary approach to reducing haemodialysis catheter-related bloodstream infections Dr Karen Burns Consultant Clinical Microbiologist, Beaumont

A multi-disciplinary approach to reducing haemodialysis catheter-related bloodstream

infections

Dr Karen BurnsConsultant Clinical Microbiologist, Beaumont Hospital

4th Annual Transplant & Nephrology ConferenceNovember 27th 2015

Karen Burns November 2015 2

Presentation Outline

1. Introduction2. Why do we care about haemodialysis catheter-

related infection?3. Where we were4. What we’ve done5. Conclusion


Introduction

• Data presented on behalf of our multi-disciplinary team:– Maeve Crudge & Maria Greene, Renal IPCNs– Mairead Skally, Microbiology Surveillance Scientist– Haemodialysis Nursing Team, led by Veronica Francis– Nephrology Clinical & Nursing Team– Clinical Microbiology Team– Infection Prevention & Control Team

• Beaumont Hospital Kidney Centre– 162 hospital haemodialysis patients:

• Haemodialysis catheter: 60%• Fistula/graft: 40%

– 45 PD patients– 25 home haemodialysis patients Nov 2015 data courtesy: C Collier & F Auguste

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http://www.hse.ie/eng/about/Who/NRO/epidemiology.pdf

Karen Burns November 2015


5

Resident Flora10 times more bacterialive on and in a human,

than the sum of that person’s own cells

Bacteria found in and on the human body usually causing no harm – “normal flora” / “colonisers”

Important to our survivalProtect us from infection with C. difficile


6WHO Guidelines for Hand Hygiene in Healthcare 2009

Transient Flora – Social & healthcare hand hygiene


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Skin Barrier

Healthcare increases a patient’s risk of developing infection



Introduction

• Haemodialysis:– Temporary vascular

access– Long-term vascular

access

Intravascular catheters are a risk factor for infection:•Exit site infection•Catheter tunnel infection•Catheter-related bloodstream infection (CRBSI)/bacteraemia



What bugs cause haemodialysis catheter-related infection?

• Any microorganism can cause infection: bacteria, yeasts/candida

• Important factors: – Bacteria: virulence, antimicrobial resistance– Opportunity/portal of entry: skin break, breach in sterile

technique, biofilm, personal hygiene – Host/patient’s immune response: sepsis, critical illness,

immunocompromise, prior antimicrobial exposure, skin breaks– Haemodialysis status: acutely unwell vs chronic stable– Haemodialysis access: temporary non-tunnelled vs long-term

tunnelled

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Biofilm

Surface

Primary Attachment

Accumulation Microcolony Formation

Community of bacterial cells enclosed in a self-produced matrix (slime) adherent to a surface e.g; catheter tubing

60% of HCAI involve biofilms


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BSI Diagnosis



Staphylococcus aureusSTAPHYLE = “BUNCH OF GRAPES”, KOKKOS = “GRAIN/BERRY”

• Gram-positive cocci in clusters• Coagulase positive• Normal flora/coloniser of nasal passages of up to 30% of

general population – carriage may be intermittent or chronic

• Skin carriage promoted in setting of skin breaks/conditions

• Estimate 53 million people colonised with S. aureus in US• 26% of 2,374 patients undergoing haemodialysis nasal

carriers of S. aureusGrothe C et al BMC Nephrology 2014;15:202

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On blood agar: Large beta haemolytic creamy-white colonies typical of S.aureus



S. aureus & infection

• Skin/soft tissue – cellulitis, abscess, surgical site infections, device exit site infection

• Bloodstream infection (BSI)• Deep-seated infection: endocarditis, discitis,

osteomyelitis, epidural, psoas abscess etc. • Infection caused by S. aureus can result in

sepsis, septic shock, death

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T1 weighted MRI image reveals abnormalsignal at intervertebral disc level L2-3 with associatedvertebral osteomyelitis. CT-guided biopsy aspirate grew S.aureus

Large ulcerovegetative lesion on mitral valve.Culture grew S.aureus

BONE INFECTION INFECTIVE ENDOCARDITIS

Large buttock carbuncle which developedover 7-10 days and required incision, drainageand IV antibiotics. Pus grew S.aureus

SKIN & SOFT TISSUE INFECTION



Staphylococcus aureusS. aureus

• Antimicrobial resistance is an issue for S. aureus:– Meticillin susceptible S. aureus (MSSA)– Meticillin resistant S. aureus (MRSA)

– Glycopeptide intermediate S. aureus (GISA)– Glycopeptide/vancomycin resistant S. aureus (GRSA/VRSA)


What do we know about S. aureus infection in Ireland?

• We don’t know the total burden of S. aureus infection in Ireland

• S. aureus bloodstream infection (SA BSI) reported by microbiology laboratories to HPSC on a quarterly basis:

• 2015 HSE annual service plan: KPI for national rate of MRSA BSI in acute hospitals of <0.057/1000 bed days used (2014 national rate = 0.055)

SA BSI in Ireland 2005 2014

Total cases 1,424 1,118

Total MRSA (%) 592 (41.6) 218 (19.5%)

What do we know about S. aureus infection in Ireland?

• 21 labs provided additional information on SA BSI in 2014:

• Since April 2014, mandatory monthly reporting of: new hospital-acquired SA BSI, by each acute hospital to HSE for monthly performance assurance report – data remains unpublished to date – doesn’t include burden of outpatient haemodialysis SA BSI

MSSA BSI MRSA BSI

Total 378 92

% Community-acquired 35% 23%

% Haemodialysis 8% 3%

http://www.hse.ie/eng/services/publications/corporate/performancereports/aug15pr.pdf 19Karen Burns November 2015

http://www.hse.ie/eng/services/publications/corporate/performancereports/aug15pr.pdf


What do we know about S. aureusBSI in our hospital?

2010 2011 2012 2013 2014 2015†0

20

40

60

80

100

120

0%

5%

10%

15%

20%

25%

30%

MRSA no. MSSA no. %MRSA Tertiary %MRSA

Year

Num

ber o

f iso

late

s

%M

RSA

SAU/MRSA no.s and %:

Beaumont Hospital

vs. Tertiary %MRSA

2010 2011 2012 2013 2014 2015†0

20

40

60

80

100

120

0.000

0.050

0.100

0.150

0.200

0.250

0.300

0.350

0.400

MRSA no. MSSA no. MSSA rate Tertiary MSSA rate

Year

Num

ber

of is

olat

es

%M

RSA

SAU/MSSA no.s and rates:Beaumont Hospital

vs. Tertiary MSSA rate

106 SA BSI in 2014, 21 MRSA BSI (19.8%)

Ϯ2015 data to end Q2 only

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What do we know about S. aureus BSI in our haemodialysis patients?

• All haemodialysis patients with SA BSI diagnosed in our microbiology laboratory: 1998 – 2009

• 304 patients with 394 episodes of SA BSI• 69% MSSA vs 31% MRSA• Majority of episodes due to intravascular catheter (83%)• 11% of episodes associated with infectious complication

Fitzgerald S et al. J Hosp Infect 2011 (79);218-221.Karen Burns November 2015


What do we know about S. aureus BSI in our haemodialysis patients?

• Clinical microbiology team reviews all inpatients with significant sterile site isolates

• January 2007 – June 2012: Renal patients accounted for 20% of all positive blood cultures processed in our laboratory:– Coagulase-negative staphylococci– S. aureus– E. coli

– Renal patients accounted for 30% of all S. aureus BSI

Source S. aureus (n=171) CVC 56.7% None 12.3% Unknown 8.2%

Skin/Soft tissue 8.2% AV Fistula 2.3% Other 12.3%

Source E coli (n=130) Urinary Tract 55.4% IA/GI Tract 11.5% UT Catheter 10.8% None 9.2% Unknown 7.7% Other 5.4%

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Why should we care about SA BSIin our haemodialysis patients?

• Increasing prevalence of patients with ESKD in Ireland

http://www.hse.ie/eng/about/Who/NRO/epidemiology.pdfKaren Burns November 2015


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• Vascular catheter use for haemodialysis is high in Ireland

• 2011 national survey: none of 19 Irish HD units met NKF-KDOQI targets of AVF prevalence >65% & CVC prevalence <10%

McCann M. National survey of routine practice in Irish haemodialysis units 2011; Report Jan 2013



• S. aureus BSI results in morbidity & mortality for our haemodialysis patients

• S. aureus BSI results in requirement for hospitalisation, removal of permcath, temporary catheter placement and replacement of permcath, invasive investigation for infectious complications (e.g., TOE), minimum of 14 days intravenous antimicrobial therapy

• Reduced future vascular access site options



Critical control points for infection prevention

1. Device insertion

2. Device maintenance

3. Device use

4. Surveillance of device-related infection: You can’t manage it if you’re not measuring it


National guidance

2009

2005

2005


Do you know what’s going on inyour haemodialysis unit?

McCann M. National survey of routine practice in Irish haemodialysis units 2011; Report Jan 2013


October 2012 – MDT convened

• Screening for carriage of S. aureus:– ? All S. aureus (MRSA & MSSA)– ? Just MRSA– Timing, frequency, logisitics of screening, lab workload– What to do with the positive patient?



• Improving surveillance of S. aureus BSI:– Real-time surveillance– Information for action – feedback and review of data– Timely root cause analysis and action– Calculation of rates of infection - ? Denominator – patient

months, line days– Stratification of rates by BH dialysis unit



• Standardisation of vascular catheter insertion – procedure, documentation – ICU, theatre, radiology, ward

• Standardisation of vascular catheter maintenance – care bundles, procedures, dressings

• Audit and feedback – are we doing what we’ve agreed to do?

• Education of staff and patients• Ongoing promotion of fistula route• Plan for further MDT meetings


What did we do?

• Q1 2013: Renal IPCN appointed• January 2013: Enhanced surveillance of renal S. aureus BSI• July 2013: Quarterly screening of haemodialysis patients for MRSA

carriage: nasal, catheter exit site, other skin breaks, device sites as indicated:– Tell patients why they’re being screened– Do the screening – HD unit– Process and report specimens – clinical micro lab and team– Identify, communicate with and manage MRSA positive patients – nose positive,

exit site positive, multiple sites positive - MDT– Follow-up screening post-decolonisation– Management of chronic MRSA carriers

• We found no new MRSA carriers on our first round of screening: 2/173 patients positive, both previously known



Our first six months

• Eight S. aureus BSI (MSSA;5, MRSA;3)• Seven patients had prior positive microbiology

results for S. aureus• Two patients had exit site infection • Six BSI secondary to infected vascular catheter• Two CRBSI arose within 48 hours of device insertion• Room to improve with regard to documentation of

device insertion and device maintenance• Suboptimal personal hygiene an issue in three cases• Infection rates higher in acute HD setting


Ongoing work - 2014

• Maintain surveillance & feedback• Maintain quarterly MRSA screening – no new

positive patients identified• Feedback results at unit level• Continue MDT meetings

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New changes - 2014

• Increased ANTT training• Transition to Chlorprep applicator for exit site to facilitate

ANTT• Unit level run charts, with latest data displayed in staff room• QIP with additional focus at HD unit CNM meetings• Patients and staff wear surgical mask for CVC care procedures• Staff providing education to patients on importance of sterile

field during HD• Dermatology referral for patients with skin sensitivity issues• Exit site infection management protocol• Routine S. aureus decolonisation protocol pre-permcath

insertion or AVG creationKaren Burns November 2015


New changes - 2014

ELECTIVE Permanent CVC/ AVG formation Regimen:Triclosan 1 % (Skinsan) skin wash daily for 5 days (2 of the 5 days hair to be washed with this also)

Mupirocin 2% (Bactroban Nasal Ointment) intranasally, 3 times daily for 5 days

Day before procedure Day of Procedure 1st Day after procedure 2nd day after procedure 3rd day after procedure

Wash hair and body with Triclosan 1 % (Skinsan) and nasal Mupirocin 2%, 3 times a day

Wash hair and body with Triclosan 1 % (Skinsan) and nasal Mupirocin 2%, 3 times a day

Wash only body with Triclosan 1 % (Skinsan) and nasal Mupirocin 2%, 3 times a day




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The first two years

• 12% reduction in renal S. aureus BSI due to vascular catheters

• Reduction in S. aureus BSI infection rate in acute haemodialysis setting

• More data gathered on infection risk factors:Risk factors 2014 2013

S. aureus colonisation 6 10

Exit site/tunnel infections 3 5*

Exit site irritation/sensitivity 4 0

Poor flows- requiring additional manipulation during treatment 3 2

Dwell time of CVC: >2years 2 1

Recent device insertion procedure (<1 week): 0 4

Recent holiday haemodialysis 1 1

*3 initially had sensitivities to dressing/ cleaning agent Karen Burns November 2015


The third year (to end Q3 2015)

• 64% reduction in vascular catheter related S. aureus BSI vs same period 2014

• 18% increase in vascular catheter line days Q1 – Q3 2015

• Ongoing education – standard precautions, hand hygiene, decolonisation protocol

• ANTT intervention kit• Learning points shared from RCA findings• Electronic flags to identify patients with prior S.

aureus infection


To wrap up…

• HD patients are at-risk of infection• Risk escalates for HD patients with vascular catheters• While S. aureus is the major player in vascular

catheter-related infection, other bugs can be implicated, particularly in acute HD and temporary catheter settings

• The vascular catheter is not the cause of every haemodialysis patient’s SA-BSI


The key ingredients

1. Multi-disciplinary team work & communication2. Consistent application of proven evidence-based

interventions3. Continuous quality improvement & keeping up-to-

date4. Ongoing surveillance, root cause analysis, with

timely feedback to those who need to know5. Local leadership, enthusiasm and commitment to

patient safety and quality of care

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Updated national guidance

2013

2014



Thanks to my colleagues &thanks to you for your attention

[email protected]

mailto:[email protected]

Documents

A multi-disciplinary approach to reducing haemodialysis catheter-related bloodstream infections Dr Karen Burns Consultant Clinical Microbiologist, Beaumont