1999: Surveillance of IV Antimicrobial Starts, Infection Incidence,
and Hospitalization Incidence in Outpatient Hemodialysis Centers

Project Description & Background:  Infections are a threat to dialysis patients because of co-morbid conditions and reduced immune response.  Dialysis providers need systems that track sources and types of infections occurring in the chronic dialysis population.  However, there are few studies of rates of such infections, and no standardized methods for ongoing data collection.  ESRD Network 5, the Mid-Atlantic Renal Coalition (MARC), contracted with the Centers for Disease Control and Prevention (CDC) to pilot test a voluntary surveillance system that tracked IV antimicrobial starts, infection, and hospitalization incidence.  Dialysis providers abstracted and entered data into an Excel spreadsheet over a three-month period. 

Methodology:  Network 5 invited dialysis facilities to participate in this data collection effort.  Eighteen (18) facilities signed agreements to collect retrospective data February through April 1999.  Patients meeting selection criteria included adult, chronic, in-center hemodialysis patients who had received dialysis for more than 90 days.  MARC trained one staff member at each facility to abstract and computerize the required data.

Monthly information abstracted by participating facilities included:

• number of hemodialysis patients treated by the facility
• type of vascular access, patient specific
• number of hospital admissions, patient specific
• list of all IV antimicrobial medication started during the month, patient specific
• result of all blood and access site cultures submitted during the month, patient     specific.

Summary of Findings: 

• Intravenous (IV) antimicrobial use was studied in 18 hemodialysis centers in Virginia, West Virginia, Maryland, and Washington DC, for the period February  - April 1999. 

• The number of patients treated, number of IV antimicrobial starts, whether a blood culture was done, blood culture results, and blood culture isolate antimicrobial susceptibilities were recorded. 

• Two thousand twenty eight (2,028) patients were observed for 5,682 patient-months (median 107.5, range 50-209 patients/center). 

• There were 326 antimicrobial starts, with an overall rate of 5.7 starts/100 patient-months.  The rate of antimicrobial starts varied by center (mean 5.5, range 1.1-11.4 starts/100 patient-months).  On average, starts included 1.4 (range 1-3) antimicrobials.

• The most frequently prescribed antimicrobials were vancomycin (58.6% of starts), followed by gentamicin (31.3% of starts) and cefazolin (24.9% of starts).

• The most frequent reasons given for antimicrobial prescription were non-access site infection (46.3% of starts), access site infection (39.8% of starts), and 'unknown' (7.1% of starts).

• Only 115 (35.3%) of antimicrobial starts were accompanied by blood culture.  Of the blood cultures performed, 39.1% were positive.  Among centers reporting ³10 antimicrobial starts, median percent of starts for which a blood culture was done was 31.6% (range 12.0-75.0%). 

• The CDC stated, "These data suggest that use of blood cultures and IV antimicrobials vary greatly among HD centers.  More widespread use of blood cultures to document infection and etiologic agents may allow more judicious use of antimicrobials such as vancomycin, and help prevent development of antimicrobial-resistant organisms".

Recommendations:  Every dialysis facility is encouraged to abstract and aggregate data to identify facility hospitalization and infection rates, infection sources, and vancomycin use.  Facility-specific data identifies existing problems such as higher risk of infection for some vascular access types (Catheter, temporary or permanent), and allows identification of trends in antimicrobial use and infection source (organisms).  Internal review will allow quality improvement activity in areas such as reduction of vancomycin use, patient referral for permanent access placement, review of facility policy and procedure for criteria for obtaining blood or access site cultures, and prevention of cross contamination.