BMJ  2006;332:1435 (17 June), doi:10.1136/bmj.332.7555.1435

Practice

Quality improvement report

Reducing dialysis associated bacteraemia, and recommendations for surveillance in the United Kingdom: prospective study

¹ Renal Unit, Hammersmith Hospitals NHS Trust, ² Centers for Disease Control and Prevention, Atlanta, GA, USA, ³ Imperial College London and Hammersmith Hospitals NHS Trust, ⁴ Department of Infectious Diseases, Imperial College London and Hammersmith Hospitals NHS Trust, London W12 0NN

Abstract

Problem Bacteraemia in dialysis units accounts for major morbidity, mortality, and antibiotic usage. Risk is much greater when lines rather than fistulas are used for haemodialysis. Surveillance is critical for infection control, but no standardised surveillance scheme exists in the United Kingdom.

Design Prospective study in a London dialysis unit of the implementation and applicability of a dialysis associated bacteraemia surveillance scheme developed in the United States and its effect on bacteraemia, antibiotic usage, and admission.

Setting Hammersmith Hospital dialysis unit, London, where 112 outpatients receive dialysis three times weekly. Between June 2002 and December 2004, 3418 patient months of data were collected.

Key measures for improvement Successful adoption of the scheme and reductions in bacteraemia rates, antibiotic usage, and admission to hospital.

Strategy for improvement Embedding the surveillance scheme in the unit's clinical activity.

Effects of change Raised awareness of bacteraemia prevention, prudent antibiotic prescribing, and the need for improved provision of vascular access. The scheme required two hours a month of consultant time. Significant downward trends were seen in bacteraemia rates and antibiotic usage: mean rate ratios from quarter to quarter 0.90 (95% confidence interval 0.85 to 0.94) and 0.91 (0.87 to 0.96), respectively. The rate of admission to hospital also showed a significant downward trend, with admissions directly connected to access related infection declining more rapidly: mean rate ratio of successive quarters 0.90 (0.84 to 0.96). The overall proportion of patients dialysed through catheters was significantly higher than in US outpatient centres (62.3% v 29.4%, P < 0.01). Study data were successfully used in a business case to improve access provision.

Lessons learnt Dialysis specific surveillance of bacteraemia is critical to infection control in dialysis units and improving quality of care. Such a scheme could be adopted across the United Kingdom.

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• Thomson, P.C., Stirling, C.M., Geddes, C.C., Morris, S.T., Mactier, R.A. (2007). Vascular access in haemodialysis patients: a modifiable risk factor for bacteraemia and death. QJM 100: 415-422 [Abstract] [Full text]  

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