Surveillance cuts infection rates in dialysis patients

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LONDON --The number of infections and hospitalizations among dialysis patients can be reduced by using a surveillance system designed to monitor blood stream infection, according to a recent study in the British Medical Journal.

Researchers at the Imperial College of London and Hammersmith Hospitals NHS Trust found the levels of bacteria in the blood stream fell to 2 percent of patients a month from 6.2 percent of patients a month.

"The results from this study show we could have a nationwide way to effectively reduce the rates of blood stream infection and improve the quality of care in hemodialysis units through a simple and highly cost effective monitoring system," said Dr. Alison Holmes of Imperial College, who was the lead author of the study.

The use of vascular catheters or fistulas and grafts in dialysis patients can increase the risk of infection. According to the report, the United Kingdom has a higher rate of catheter use than the United States. The use of catheters carries the greatest risk of risk of blood stream infections.

The United Kingdom does not have a standardized surveillance scheme, but Holmes said she hopes the recent BMJ study will encourage its creation.

In 1999, the U.S. Centers for Disease Control and Prevention established the Dialysis Surveillance Network, which is a voluntary national surveillance system that monitors bloodstream and vascular infections in U.S. dialysis clinics.

The U.K. researchers worked with the CDC to implement the U.S. scheme in the Hammersmith Hospital dialysis unit, which had approximately 112 patients. The research compiled 3,418 patient-months of data between June 2002 and December 2004.

A simple form was filled out whenever a patient went to a hospital or began using intravenous antibiotics. The vascular access type and blood infection results were also recorded. At the end of each month, the lead clinician and nurse double-checked the data before sending it to the Dialysis Surveillance Network to be analyzed by a computer algorithm.

The program required two hours a month of the physician's time, according to the report. The authors said staff felt continuous surveillance was more efficient than intermittent surveillance. This led staff to use a day-to-day scheme, which, the authors said, "fostered local ownership and clinical engagement."

In addition to the drop in infection, researchers found education and awareness in the clinic were fueled by weekly multidisciplinary meetings on infections that were started as a result of the surveillance program.

With the surveillance program, researchers said they saw a drop in the initiation of intravenous antibiotics, which fell from 7.7 per patient month to 4.1 per patient month. And the rates of initiating intravenous vancomycin dropped from 6.4 to 3.6.

"By reducing antibiotic use, not only do we reduce the risks of bacteria becoming more resistant and potentially harder to treat, but we can also reduce complications associated with antibiotic therapy and the cost to [the healthcare system]," Holmes said.

The overall hospitalization rate in the Hammersmith clinic was 15 per 100 patient months when the study started and dropped to 12.3 by the end of the study. According to the report, hospitalizations caused by access-related infection had a more dramatic decrease, falling from 4 per 100 patient months to 1.4 by the end of the research period.

"We demonstrated that a dialysis-specific surveillance scheme could easily and successfully be embedded in a busy London dialysis unit," the authors wrote. "Local knowledge of data at a unit level is critical to generating change and quality improvement."

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