Multi-Part Approach to Cut Dialysis Cath Complications Disappoints

Little benefit was seen after implementing a bundle of interventions aimed at reducing hemodialysis catheter-related bloodstream infection (HD-CRBSI), the REDUCCTION trial found.

In a large study of central venous hemodialysis catheter outcomes, implementing a suite of interventions at the renal service levels yielded a similar rate of bloodstream infections (rate ratio 1.30, 95% CI 0.78-2.16, P=0.31), reported Martin Gallagher, MBBS, MPH, PhD, of The George Institute for Global Health in Newtown, New South Wales, Australia.

Prior to the intervention, there was an event rate of 0.313 per 1,000 catheter days for confirmed HD-CRBSI versus 0.240 per 1,000 catheter days during the nearly 29-month intervention phase.

“Whilst the rate of infections during the study fell…the measured effect of the bundle did not suggest the bundle was associated with reduction in risk,” Gallagher explained during a presentation at the American Society of Nephrology virtual Kidney Week.

Gallagher also highlighted that even though the intervention failed to reduce the number of bloodstream infections, the total rate still remained generally low at a national level in Australia. He called it “surprisingly low,” but pointed out this rate still equates to about one in every 10 patients having an episode of a blood stream infection per year.

The stepped wedge randomized trial drew upon data from 37 renal services in Australia. Prior to the intervention, there was data on 5,246 catheters inserted in 3,506 patients. Outcomes were compared with 4,610 catheters placed in 3,114 patients during the intervention phase.

“At the start of this study, we did a survey of 48 renal services from Australia and New Zealand, and the key finding of that survey was the variation in practice of catheter care — so variations in the skin preparations used for insertion, in the locking solution used in managing catheters, and the catheter dressings that are used to prevent exit site infections,” Gallagher noted.

The suite of evidence-based interventions were implemented during three separate phases: at insertion of the hemodialysis catheter, during catheter maintenance, and during the removal of the catheter. A list of all the specific interventions implemented were published in a design article in the August 2020 Kidney360.

At insertion, some new interventions implemented were:

• Using a surgical aseptic technique, including full personal protective equipment, a sterile environment, and an antiseptic solution of a minimum of 2% chlorhexidine with 70% alcohol
• Using a semi-permeable transparent dressing
• Using the right internal jugular vein as the best site for insertion
• Avoiding femoral catheters where possible

All patients also received extensive education on hygiene and recognizing signs of infection. No specific type of catheter was recommended.

During the maintenance phase, new hygiene strategies were implemented, along with regular dressing changes at least every 7 days, or each time the dressing looked soiled or loose. Catheter locking solutions with dressings such as chlorhexidine-impregnated patch or sponge, or antimicrobial or antibacterial catheter locking solutions, were used. The authors also recommended against the routine use of mupirocin ointment or medicated honey at the catheter exit site.

During the removal phase, catheters were recommended for removal as soon as they were no longer needed, within a maximum of 2 weeks of their last use, or at the first signs of infection. Non-tunneled femoral catheters were not recommended to be in place for longer than 5 days, while non-tunneled upper limb catheters were not recommended to be in for longer than 7 days.

Among the study cohort, the vast majority had catheters placed in the internal jugular vein (92.3% at baseline vs 94.3% during intervention), followed by the femoral vein (13.5% vs 10.5%).

Implementation of the intervention package also didn’t reduce any of the three secondary outcomes of the trial:

• Suspected of possible HD-CRBSI: RR 0.54 (95% CI 0.23-1.23, P=0.14)
• Confirmed and suspected/possible HD-CRBSI: RR 0.97 (95% CI 0.61-1.55, P=0.90)
• Total HD-CRBSI-related infection: RR 0.71 (95% CI 0.46-1.10, P=0.13)

Similarly, there were no differences seen in pre-specified sub-group analysis, including in service sizes less than a median of 63 patients (RR 1.07, 95% CI 0.57-2.02) or larger than 63 patients (RR 1.14, 95% CI 0.82-2.42). There was also no difference seen when looking only at patients who required a change to dressing or catheter-locking solution during the intervention (RR 1.15, 95% CI 0.62-2.15), or when limited only to patients that didn’t require this during intervention (RR 1.31, 95% CI 0.76-2.25).

Gallagher pointed out that the wide confidence intervals seen were likely driven by the lower than expected event rate.

“Future studies here will be challenging because of the low event rates, and the fact that multifaceted dimensions, or bundles, of complex systems may require large numbers of components in those bundles which are then, by definition, may be harder to implement,” he concluded.