Dr Karen Burns Consultant Clinical Microbiologist Beaumont Hospital 4 th Annual Transplant amp Nephrology Conference November 27 th 2015 Presentation Outline Introduction Why do we care about haemodialysis catheterrelated infection ID: 564373
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A multi-disciplinary approach to reducing haemodialysis catheter-related bloodstream infections
Dr Karen BurnsConsultant Clinical Microbiologist, Beaumont Hospital4th Annual Transplant & Nephrology ConferenceNovember 27th 2015Slide2
Presentation Outline
IntroductionWhy do we care about haemodialysis catheter-related infection?Where we wereWhat we’ve doneConclusion
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Introduction
Data presented on behalf of our multi-disciplinary team:Maeve Crudge & Maria Greene, Renal IPCNsMairead Skally, Microbiology Surveillance ScientistHaemodialysis Nursing Team, led by Veronica FrancisNephrology Clinical & Nursing TeamClinical Microbiology TeamInfection Prevention & Control
TeamBeaumont Hospital Kidney Centre162 hospital haemodialysis patients:Haemodialysis catheter: 60%
Fistula/graft: 40%45 PD patients25 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
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Resident Flora
10 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 survival
Protect us from infection with
C.
difficile
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WHO 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
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Introduction
Haemodialysis:Temporary vascular accessLong-term vascular access
Intravascular catheters are a risk factor for infection:
Exit site infection
Catheter tunnel infection
Catheter-related bloodstream infection (CRBSI)/bacteraemia
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What bugs cause haemodialysis catheter-related infection?
Any microorganism can cause infection: bacteria, yeasts/candidaImportant factors: Bacteria: virulence, antimicrobial resistanceOpportunity/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
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Staphylococcus aureusSTAPHYLE = “BUNCH OF GRAPES”, KOKKOS = “GRAIN/BERRY”
Gram-positive cocci in clustersCoagulase positiveNormal flora/coloniser of nasal passages of up to 30% of general population – carriage may be intermittent or chronicSkin carriage promoted in setting of skin breaks/conditionsEstimate 53 million people colonised with S. aureus in US26% of 2,374 patients undergoing haemodialysis nasal carriers of
S. aureus
Grothe
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
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S. aureus & infection
Skin/soft tissue – cellulitis, abscess, surgical site infections, device exit site infectionBloodstream 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 abnormal
signal at intervertebral disc level L2-3 with associated
vertebral 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 developed
over 7-10 days and required incision, drainage
and IV antibiotics. Pus grew
S.aureus
SKIN & SOFT TISSUE INFECTION
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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)
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What do we know about S. aureus infection in Ireland?
We don’t know the total burden of S. aureus infection in IrelandS. 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%)
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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
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What do we know about S. aureus
BSI in our hospital?
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 BSI69% MSSA vs 31% MRSAMajority 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.
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What do we know about S. aureus BSI
in our haemodialysis patients?Clinical microbiology team reviews all inpatients with significant sterile site isolatesJanuary 2007 – June 2012: Renal patients accounted for 20% of all positive blood cultures processed in our laboratory:Coagulase-negative staphylococciS. aureus E. coli
Renal patients accounted for 30% of all S. aureus
BSI
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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.pdf
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Why should we care about SA BSIin our haemodialysis patients?
Vascular catheter use for haemodialysis is high in Ireland2011 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
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S. aureus BSI results in morbidity & mortality for our haemodialysis patientsS. 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 therapyReduced future vascular access site options
Why should we care about SA BSI
in our haemodialysis patients?25
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Critical control points for infection prevention
Device insertionDevice maintenanceDevice useSurveillance of device-related infection:
You can’t manage it if you’re not measuring it
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National guidance
2009
2
005
2005
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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
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October 2012 – MDT convened
Screening for carriage of S. aureus:? All S. aureus (MRSA & MSSA)? Just MRSATiming, frequency, logisitics of screening, lab workloadWhat to do with the positive patient?
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October 2012 – MDT convened
Improving surveillance of S. aureus BSI:Real-time surveillanceInformation for action – feedback and review of dataTimely root cause analysis and actionCalculation of rates of infection - ? Denominator – patient months, line daysStratification of rates by BH dialysis unit
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October 2012 – MDT convened
Standardisation of vascular catheter insertion – procedure, documentation – ICU, theatre, radiology, wardStandardisation of vascular catheter maintenance – care bundles, procedures, dressingsAudit and feedback – are we doing what we’ve agreed to do?Education of staff and patientsOngoing promotion of fistula routePlan for further MDT meetings
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What did we do?
Q1 2013: Renal IPCN appointedJanuary 2013: Enhanced surveillance of renal S. aureus BSIJuly 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 screenedDo the screening – HD unitProcess and report specimens – clinical micro lab and teamIdentify, communicate with and manage MRSA positive patients – nose positive, exit site positive, multiple sites positive - MDT
Follow-up screening post-decolonisationManagement of chronic MRSA carriersWe found no new MRSA carriers on our first round of screening: 2/173 patients positive, both previously known
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Our first six months
Eight S. aureus BSI (MSSA;5, MRSA;3)Seven patients had prior positive microbiology results for S. aureusTwo patients had exit site infection Six BSI secondary to infected vascular catheterTwo CRBSI arose within 48 hours of device insertionRoom to improve with regard to documentation of device insertion and device maintenanceSuboptimal personal hygiene an issue in three cases
Infection rates higher in acute HD setting
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Ongoing work - 2014
Maintain surveillance & feedbackMaintain quarterly MRSA screening – no new positive patients identifiedFeedback results at unit levelContinue MDT meetings
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New changes - 2014
Increased ANTT trainingTransition to Chlorprep applicator for exit site to facilitate ANTTUnit level run charts, with latest data displayed in staff roomQIP with additional focus at HD unit CNM meetingsPatients and staff wear surgical mask for CVC care proceduresStaff providing education to patients on importance of sterile field during HDDermatology referral for patients with skin sensitivity issuesExit site infection management protocol
Routine S. aureus decolonisation protocol pre-permcath insertion or AVG creation
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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
1
st
Day after procedure
2
nd
day after procedure
3
rd
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
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The first two years
12% reduction in renal S. aureus BSI due to vascular cathetersReduction in S. aureus BSI infection rate in acute haemodialysis settingMore 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
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The third year (to end Q3 2015)
64% reduction in vascular catheter related S. aureus BSI vs same period 201418% increase in vascular catheter line days Q1 – Q3 2015Ongoing education – standard precautions, hand hygiene, decolonisation protocolANTT intervention kitLearning points shared from RCA findingsElectronic flags to identify patients with prior S. aureus infection
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To wrap up…
HD patients are at-risk of infectionRisk escalates for HD patients with vascular cathetersWhile 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
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The key ingredients
Multi-disciplinary team work & communicationConsistent application of proven evidence-based interventionsContinuous quality improvement & keeping up-to-dateOngoing surveillance, root cause analysis, with timely feedback to those who need to knowLocal leadership, enthusiasm and commitment to patient safety and quality of care
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Updated national guidance
2013
2014
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Thanks to my colleagues &thanks to you for your attention
karenburns@beaumont.ie
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