Standardized Care Practices and Risk of CA-BSIs in Children

In the United States, children with kidney failure are most commonly treated initially with hemodialysis. In children undergoing hemodialysis, infections are a major cause of both morbidity and mortality. Rates of infection-related complications are particularly high among children who receive dialysis via a catheter. The risk of infection among children with catheter access is nearly five-fold that of children with arteriovenous (AV) fistulas or grafts.

Due to increased longevity and lower infection rates compared with catheters, AV accesses are the preferred access types. However, catheters remain the most commonly used form of hemodialysis access in children.

According to Rebecca L. Ruebner, MD, MSCE, and colleagues infection prevention rates should include measures to reduce catheter-associated bloodstream infections (CA-BSIs). The Children’s Hospital Association’s Standardizing Care to Improve Outcomes in Pediatric End-Stage Kidney Disease (SCOPE) Collaborative is a multicenter quality transformation initiative designed to utilize standardized care practices to minimize infection-related complications among children receiving maintenance dialysis.

Previous studies of SCOPE’s hemodialysis project have focused on infection rates at a collaborative-wide level. The current prospective cohort study, led by Dr. Reubner, was designed to describe the epidemiology of and identify patient-level factors for infections associated with hemodialysis in children. The researchers also sought to examine the association between change in dialysis center-level compliance with SCOPE hemodialysis care practices over time and the risk of CA-BSI. Results were reported in the American Journal of Kidney Diseases [2022;80(2):186-195].

The study cohort included children who were enrolled in the SCOPE project between June 2013 and July 2019. Data on patient characteristics and center-level compliance with hemodialysis catheter care practices across the study period were collected. The centers were characterized as consistent, dynamic (improved compliance over the study period), or inconsistent performers based on frequency of compliance audit submission and changes in compliance with hemodialysis care practices over time. The outcome of interest was CA-BSI incidence.

The SCOPE hemodialysis catheter care bundles address five categories of catheter care: (1) catheter dressing/site assessment; (2) catheter connection; (3) catheter disconnection; (4) cap care; and (5) catheter dressing change/exit site care. At each participating center, compliance with hemodialysis care bundles was assessed through direct observation of patient care on a randomly selected group of patients. Monitoring was conducted by study team members and submitted via a care observation form.

The study cohort included 1277 children from 35 pediatric dialysis centers. Of the 1277 participants, 79.7% (n=1018) had a catheter and 20.3% (n=259) had an AV access. In comparisons of demographic characteristics of children with catheter access with children with AV access, older age and a history of kidney transplant were associated with increased likelihood of AV access versus catheter use (P<.001 for both).

During the study period, there were 277 positive blood cultures reported. Of those, 67% (n=185) were adjudicated as an access-related BSI and 33% (n=92) were attributed to a source that was not related to dialysis access. There were 171 CA-BSIs among 123 catheters and 14 AV access-associated BSIs among 13 AV accesses (11 in fistulas and three in grafts). The overall rates of infection were 0.95 per 100 patient-months for CA-BSIs and 0.27 per 100 patient-months for BSI associated with AV access.

Results of a generalized linear mixed model of individual patient-level risk factors for CA-BSI demonstrated that mupirocin use at the catheter exit site was associated with an increased rate of CA-BSI (rate ratio [RR], 4.45; 95% CI, 1.60-12.35 vs chlorhexidine-impregnated dressing; P=.004). There was a nominal association between the use of no antibiotic ointment at the exit site and an increased rate of CA-BSI (RR, 1.79; 95% CI, 1.01-3.18 vs chlorhexidine-impregnated dressing), but the difference was of borderline statistical significance (P=.05). There were no significant associations between rates of CA-BSI and age, underlying cause of kidney failure, history of kidney transplant, or type of dressing used.

The secondary analysis included 33 centers and 983 children with catheters. Of the 33 centers, six were classified as consistent performers, 11 as dynamic performers, and 16 as inconsistent performers. Of the 16 inconsistent performers, eight centers did not submit the required number of audits and eight submitted the audits but did not achieve the target improvement in compliance. The centers designated as consistent performers tended to have longer participation in SCOPE and contributed significantly more catheter-months to the analysis.  There were no significant differences in patient characteristics or in the proportion of patients with multiple infections across compliance groups.

Overall median compliance with hemodialysis catheter care practices was 87.5%. Centers classified as dynamic performers demonstrated a significant decrease in CA-BSI rates over time (from 2.71 to 0.71 per 100 person-months; RR, 0.98; 95% CI, 0.97-0.99; P<.001). There was no change in CA-BSI rate over time among consistent (RR, 1.00; 95% CI, 0.98-1.01; P=.5) or inconsistent centers (RR, 1.00; 95% CI, 0.98-1.02; P=.9).

The researchers cited some limitations to the study findings, including the inability to draw conclusions regarding the influence on risk of infection of individual patient-level adherence to SCOPE hemodialysis care practices, the inability to assess risk factors associated with AV access due to the small number of infections, and missing data on treatment for CA-BSIs (including whether the catheter was removed) resulting in the inability to comment on the association between catheter removal and risk of infections.

In summary, the authors said, “Dialysis-associated BSIs are an important complication among children with kidney failure and are associated with significant morbidity. Consistent improvement in compliance with standardized hemodialysis care practices can lead to a reduction in the risk of dialysis-associated infections among children with kidney failure.”

Takeaway Points

1. Researchers reported results of a prospective cohort study describing patient-level risk factors for catheter-associated bloodstream infections (CA-BSIs) in children on hemodialysis; the study also examined the association between center-level compliance with standardized care practices and the risk of CA-BSI.
2. Among the participants with a catheter for dialysis access, the use of mupirocin at the catheter exit site was associated with an increased rate of CA-BSIs.
3. Among the 33 centers included in a secondary analysis, overall mean compliance with hemodialysis catheter care practice was 87.5%.