A multi-disciplinary approach to reducing
haemodialysis catheter-related bloodstream
infections
Dr Karen Burns
Consultant Clinical Microbiologist, Beaumont Hospital
4th Annual Transplant & Nephrology Conference
November 27th 2015
Presentation Outline
1. Introduction
2. Why do we care about haemodialysis catheterrelated infection?
3. Where we were
4. What we’ve done
5. Conclusion
Karen Burns November 2015
2
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
Karen Burns November 2015
3
http://www.hse.ie/eng/about/Who/NRO/epidemiology.pdf
Karen Burns November 2015
4
Resident Flora
10 times more bacteria
live 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 survival
Protect us from infection with C. difficile
Karen Burns November 2015
5
Transient Flora –
Social & healthcare hand hygiene
WHO Guidelines for Hand Hygiene in Healthcare 2009
Karen Burns November 2015
6
Skin Barrier
Healthcare increases a patient’s risk of developing infection
Karen Burns November 2015
7
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
Karen Burns November 2015
8
Karen Burns November 2015
9
What bugs cause haemodialysis catheterrelated 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
Karen Burns November 2015
10
Biofilm
Community of bacterial cells enclosed in a self-produced
matrix (slime) adherent to a surface e.g; catheter tubing
Surface
Primary
Attachment
Accumulation
Microcolony
Formation
60% of HCAI involve biofilms
11
Karen Burns November 2015
BSI Diagnosis
Karen Burns November 2015
12
Staphylococcus aureus
STAPHYLE = “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. aureus
Grothe C et al BMC Nephrology 2014;15:202
Karen Burns November 2015
13
On blood agar:
Large beta
haemolytic
creamy-white
colonies typical
of S.aureus
Karen Burns November 2015
14
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
Karen Burns November 2015
15
BONE INFECTION
INFECTIVE ENDOCARDITIS
Large ulcerovegetative lesion on mitral valve.
Culture grew S.aureus
SKIN & SOFT TISSUE INFECTION
T1 weighted MRI image reveals abnormal
signal at intervertebral disc level L2-3 with associated
vertebral osteomyelitis. CT-guided biopsy aspirate
grew S.aureus
Karen Burns November 2015
Large buttock carbuncle which developed
over 7-10 days and required incision, drainage
16
and IV antibiotics. Pus grew S.aureus
Staphylococcus aureus
S. 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)
Karen Burns November 2015
17
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:
SA BSI in Ireland
2005
2014
Total cases
1,424
1,118
Total MRSA (%)
592 (41.6)
218 (19.5%)
• 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)
Karen Burns November 2015
18
What do we know about
S. aureus infection in Ireland?
• 21 labs provided additional information on SA BSI in 2014:
Total
MSSA BSI
MRSA BSI
378
92
% Community-acquired 35%
23%
% Haemodialysis
3%
8%
• 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
http://www.hse.ie/eng/services/publications/corporate/performancereports/aug15pr.pdf
Karen Burns November 2015
19
What do we know about S. aureus
BSI in our hospital?
SAU/MRSA no.s and Beaumont Hospital
%:
120
vs. Tertiary %MRSA
30%
SAU/MSSA no.s and
rates:
120
25%
100
Beaumont Hospital
0.400
vs. Tertiary MSSA rate
0.350
100
15%
40
10%
0.250
%MRSA
60
80
%MRSA
20%
Number of isolates
80
Number of isolates
0.300
60
0.200
0.150
40
0.100
20
5%
20
0
0%
0
2010
2011
2012
2013
2014
2015†
0.050
0.000
2010
2011
2012
Year
MRSA no.
MSSA no.
2013
2014
2015†
Year
%MRSA
Tertiary %MRSA
MRSA no.
MSSA no.
MSSA rate
Tertiary MSSA rate
106 SA BSI in 2014, 21 MRSA BSI (19.8%)
Karen Burns November 2015
20only
Ϯ2015 data to end Q2
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
Karen Burns November 2015
21
Fitzgerald S et al. J Hosp Infect 2011 (79);218-221.
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
Source
S. aureus (n=171)
– E. coli
CVC
56.7%
None
12.3%
Unknown
8.2%
Skin/Soft tissue
8.2%
AV Fistula
2.3%
Other
12.3%
Source
Urinary Tract
IA/GI Tract
UT Catheter
None
Unknown
Other
E coli (n=130)
55.4%
11.5%
10.8%
9.2%
7.7%
5.4%
– Renal patients accounted for 30% of all S. aureus BSI
Karen Burns November 2015
22
Why should we care about SA BSI
in our haemodialysis patients?
• Increasing prevalence of patients with ESKD in
Ireland
http://www.hse.ie/eng/about/Who/NRO/epidemiology.pdf
Karen Burns November 2015
23
Why should we care about SA BSI
in our haemodialysis patients?
• 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
Karen Burns November 2015
24
Why should we care about SA BSI
in our haemodialysis patients?
• 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
Karen Burns November 2015
25
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
Karen Burns November 2015
26
National guidance
2005
2005
2009
Karen Burns November 2015
27
Do you know what’s going on in
your haemodialysis unit?
McCann M. National survey of routine practice in Irish haemodialysis units 2011; Report Jan 2013
Karen Burns November 2015
28
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?
Karen Burns November 2015
29
October 2012 – MDT convened
• 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
Karen Burns November 2015
30
October 2012 – MDT convened
• 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
Karen Burns November 2015
31
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
Karen Burns November 2015
32
Karen Burns November 2015
33
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
Karen Burns November 2015
34
Ongoing work - 2014
• Maintain surveillance & feedback
• Maintain quarterly MRSA screening – no new
positive patients identified
• Feedback results at unit level
• Continue MDT meetings
Karen Burns November 2015
35
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 creation
Karen Burns November 2015
36
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
Wash only 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
Karen Burns November 2015
37
Karen Burns November 2015
38
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:
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
Risk factors
*3 initially had sensitivities to dressing/ cleaning agent
Karen Burns November 2015
39
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
Karen Burns November 2015
40
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
Karen Burns November 2015
41
The key ingredients
1. Multi-disciplinary team work & communication
2. Consistent application of proven evidence-based
interventions
3. Continuous quality improvement & keeping up-todate
4. Ongoing surveillance, root cause analysis, with
timely feedback to those who need to know
5. Local leadership, enthusiasm and commitment to
patient safety and quality of care
Karen Burns November 2015
42
Updated national guidance
2013
2014
Karen Burns November 2015
43
Thanks to my colleagues &
thanks to you for your attention
karenburns@beaumont.ie
Karen Burns November 2015
44