vascular access procedures and infection: time for
TRANSCRIPT
ASDIN 9th Annual Scientific Meeting
1
Charmaine Lok, MD, MSc, FRCPC
ASDIN 2013
Washington, DC
February 16, 2013
Vascular Access Procedures and Infection: time for evidence based policy
Objectives
Instructions to Dr. Lok:
“Come up with something to go into this
section�along the line of vascular access
society participation in policy� it could be
worthwhile research initiatives or
particular vascular access problems
(CRBSI) that would benefit from greater
societal focus”
The Process to Policy
Clinical Problem Solution Guideline Policy
Implement
Identify
&
Test
Stenosis Leads to Thrombosis → Loss of Patency
Severe Stenosis
Stenosis with Thrombus
Courtesy of A. Besarab
Courtesy D. Rajan
Observational Studies: Surveillance is GOOD
Observational studies
0
0.2
0.4
0.6
0.8
1
1.2
Schwab,
1989
Besarab,
1995
Safa,
1996
Allon,
1998
Cayco,
1998
McCarley,
2001
Thromboses per year
Control Surveillance
Courtesy of M. Allon
Association
ASDIN 9th Annual Scientific Meeting
2
Association RCTs: Surveillance is unhelpful
Randomized studies
0
0.2
0.4
0.6
0.8
1
1.2
Lumsden,
1997
Moist,
2003
Ram,
2003
Dember,
2004
Robbin,
2006
Thromboses per year
Control Surveillance
TOO LATE, Already in guidelines and CMS mandates
Evidence Pyramid
RCT
Multi-
blind
Bias
Confoundin
g
RCTs in Nephrology
Nephrology
Strippoli, G. et al. J Am Soc Nephrol; 2004
The Process to Policy
Clinical Problem Solution Guideline Policy
MORTALITY AND SEPSIS
Foley et. al, JASN 15:1038, 2004
N=393 451
MISepsis
No Sepsis
ASDIN 9th Annual Scientific Meeting
3
Recent USRDS 2012 data
7x
Incident Patients
Exit Site Infection → Bacteremia
Extraluminal CRB prophylaxis
Elimination of Exit Site Colonization:
• Poviodine–iodine, Mupirocin, Medihoney
• Poly-antibiotic Ointment
� Hemodialysis
� Infection
� Prevention
� Polysporin Triple (PT)
� Ointment
Ointment Comparison
GramGramGramGram----Positive Positive Positive Positive
BacteriaBacteriaBacteriaBacteriaPolysporinPolysporinPolysporinPolysporin MupirocinMupirocinMupirocinMupirocin
Staph. aureus
Staph. Epidermidis
Aerobic streptococci
Corynebacterium
Spp.
Anaerobic
streptococci
Enterococci
Clostridia Spp.
GramGramGramGram----Negative Negative Negative Negative
BacteriaBacteriaBacteriaBacteriaPolysporinPolysporinPolysporinPolysporin MupirocinMupirocinMupirocinMupirocin
Pseudomonas
Neisseria gonorrhea
Treponema pallidum
Corynebacterium Spp.
Escherichia coli
Bacteriodes
Ointment Comparison
COSTCOSTCOSTCOST $5.99/15g$5.99/15g$5.99/15g$5.99/15g $14.49/15g$14.49/15g$14.49/15g$14.49/15g
The HIPPO Study: Multicentre RCT
Design
Tunneled CVC
PolysporinTriple
Placebo
ASDIN 9th Annual Scientific Meeting
4
REDUCED MORBIDITY WITH
PROPHYLAXIS
10%
24%
10%
27%
7%
24%
0%
5%
10%
15%
20%
25%
30%
Bacteremia CVC removal Hospital
PT Control
P =0.007 P =0.004P =0.02
Lok,C.E., JASN 2003
Bacitracin 500 U/g (Gram +ve),Polymyxin B 10,000 U/g (Gram –ve), Gramicidin 0.25 mg/g (Both gram +ve and –ve)
Placebo PT RRR NNT P value
Bacteremia 2.480.6
360% 7 P<0.0004
Death 16% 4% 78% 8 P=0.004
* Number of events/1000 catheter days
Survival Advantage of Polysporin Triple at the
CVC Exit Site
P=0.0027
Hurdles to get to “Guideline” Step
Guidelines
•Long term
effectiveness
•No new side
effects
•Cost effective
AAa long
process
TRACK YOUR OWN INFECTION RATES
Beathard and Urbanes, Semin Dial, 21(6):528-538, 2008
What’s your Infection RATE?
0
0.5
1
1.5
2
2.5
3
Bacte
rem
ias (
ep
iso
des/1
000 cath
ete
r d
ays)
Years
Bacteremias by Definition
All
Definite
Probable
Battistella, M. et al. AJKD; 2011;57:432-41
COST SAVINGS
Table 1 Resource Use Associated with Catheter Related Infections
Catheter Related Infection Outcome Total Cost
Catheter removal, and insertion $ 1,146,642.98
Outpatient treatment for bacteremia $ 630,934.02
Hospitalization for bacteremia $21,116,099.84
Infection Outcome Related Costs of Standard of
Care vs. PTO$22,893,676.84
Total Cost of Implementation of PTO Program in
Ontario - Infection Outcome Related Costs
$1,449,615.36 -
$22,893,676.84 =
-21,444,061.48
Exit Site Infection → Bacteremia
ASDIN 9th Annual Scientific Meeting
5
ASDIN
� Some Ideas
• After new CVC exchange or insertion – prescription to patient and note back to HD unit to use PTO until exit site healed
• Study fibrin sheath
• Are they infected?
• What happens if you leave them in?
• Impact of antibiotic prophylaxis at time of procedure
• Effective?
• Cost savings?
• Start dialysis without a catheter
• Payment for procedures performed predialysis if HD start without a catheter – see JASN 22:426-430, 2011
� Whatever you do,Follow up with PDSA
ASDIN needs a SWOT Analysis
ASDIN
Everyone else(PEST)
ASDIN
Research & Policy Consortium
ASDIN
A
S
D
I
N
Acknowledge Problem
Study Solution
Disseminate findings
Implement Strategies
Needs Assessment
THANK YOU FOR YOUR ATTENTION