Tunneled catheters' outcome optimization among diabetics on dialysis through antibiotic-lock placement.

Efficacy and safety of antibiotic 'locks', in prevention of thrombotic and infectious complication-related morbidity and mortality, among diabetics dialyzed through tunneled-cuffed catheters (TCCs) has not been effectively investigated. This trial was designed to investigate the outcome of TCCs (n = 109), inserted among 96 diabetic end-stage renal disease patients (March 2002-February 2003), by comparing the catheter thrombosis, catheter-related bloodstream infections (CRBSI), catheter survival, and mortality rates, between the cohorts of 49 patients who had TCCs (n = 51) 'locked' with cefotaxime/heparin (group I) and 47 patients with TCCs (n = 58) filled with standard heparin (group II). Thrombosis was defined as the inability to use catheter at a blood flow of 200 ml/min despite intraluminal thrombolysis. Primary end points were catheter thrombosis and CRBSI; elective catheter removal and CRBSI-related death led to sensor of TCCs follow-up. Patients with intraluminal cefotaxime/heparin lock, on cumulative survival analysis, showed a superior thrombosis-free (86.3 vs 63.8%, P = 0.023, log rank), infection-free (72.9 vs 27.1%, P = 0.004, log rank), and thrombosis- and infection-free TCC survival (78.4 vs 37.9%, P = 0.001, log rank) at 365 days, besides having significantly lower incidence of CRBSI (1.56 vs 3.68 episodes/1000 catheter days, P < 0.0001) and CRBSI-related mortality (9.8 vs 23.4%, P = 0.015), compared with the heparin-alone group. Deployment of cefotaxime-heparin 'lock' enhances catheter survival; reduces thrombotic and infectious complications and ensuing mortality, among diabetics on dialysis. However, further studies are needed to define the long-term implications of antibiotic locks in terms of the risk of emergence of antimicrobial resistance.

Compliance to hepatitis B vaccination and subsequent development of seroprotection among health care workers of a tertiary care center of Saudi Arabia.

BACKGROUND: There is lack of reliable data on compliance to hepatitis B virus (HBV) vaccine and development of seroprotective levels of antibodies among health care workers (HCWs) from the countries with high HBV endemicity such as Saudi Arabia. This study aimed to assess the compliance with HBV vaccine and subsequent levels of seroprotection among HCWs of a large tertiary care center of the Eastern Province of Saudi Arabia. METHODS: All the HCWs (n = 1302) involved in direct patient care, including 374 (28.7%) physicians, 619 (47.6%) nurses, and 309 (23.7%) technicians, were enrolled for the study. Those having antibody to hepatitis B surface antigens (anti-HBs) levels less than 10 mIU/mL were advised to take 3 doses of yeast-derived recombinant HBV vaccine at 0, 1, and 6 months of 1 mL (20 microg/mL) in the deltoid muscle. Blood samples were checked for anti-HBs antibody levels by enzyme immunoassay during the initial screening of HCWs and 3 months after the third dose of HBV vaccine. The group of physicians included 34.5% (129/374) of consultants, 16.8% (63/374) of specialists, and 48.6% (182/374) of residents. RESULTS: An overall HBV vaccine compliance rate of 71.6% (932/1302) was observed among HCWs including that of 79.5% (492/619) among nurses, 78.3% (242/309) among technicians, and 52.9% (198/374) among physicians. Thus, physicians recorded the lowest compliance (OR, 3.211; 95% CI, 2.259-4.567; P < .0001) to HBV vaccine. Among physicians, the lowest compliance of 42.3% (77/182) was observed in residents (OR, 3.690; 95% CI, 1.067-3.703; P < .0001). The overall seroprotection after vaccination was achieved in 92.2% of the compliant HCWs, and 7.8% of them failed to mount adequate response to HBV vaccine. Nonresponders included mainly the physicians (OR, 2.229; P = .05)-consultants in particular (OR, 3.476; P < .0001). The mean age of nonresponders was higher than those who mounted an adequate anti-HBs response (46.7 +/- 6.3 vs. 32.2 +/- 3.3 years OR, 1.845; 95% CI, 0.999-3.414; P < .05). CONCLUSIONS: Poor compliance to HBV vaccine among physicians--residents in particular-is an issue of immense concern, which demands close examination and identification of the specific action that needs to be taken to enhance the uptake of the vaccine by this target population.

Vascular access related infections in hemodialysis patients.

Hemodialysis (HD) patients are at considerably high risk for vascular access-related blood stream infections (VRBSI) that result in serious complications. Such severe infections are a great deal more frequent with central venous catheters (CVCs) and polytetrafluoroethylene (PTFE) grafts than with arteriovenous fistula (AVF). Nonetheless, the CVCs, though having "undesirable" side effects, remain "unavoidable" for the patients requiring instant dialysis access, as a consequence of the unpredictable course of chronic renal disease. Although early antibiotic treatment should include the coverage for Staphylococcus aureus, the treatment of catheter-related blood stream infections (CRBSI) remains controversial. Antimicrobial- anticoagulant 'locks' have shown promising results in several recent randomized controlled trials in the treatment and prevention of CRBSI. Policy of increasing AVF prevalence beyond 50% is bound to have an enduring positive effect on HD outcomes. Standard infection control measures for hygiene and aseptic handling of CVCs cannot be overemphasized. The catheters with 'bioactive' surface with thrombo-resistant and infection-resistant properties will be available in the near future.

Emerging nalidixic acid and ciprofloxacin resistance in non-typhoidal Salmonella isolated from patients having acute diarrhoeal disease.

BACKGROUND: Non-typhoidal Salmonella are one of the key etiological agents of diarrhoeal disease. The appearance of multiple drug resistance along with resistance to quinolones in this bacterium poses a serious therapeutic problem. We determined the prevalence of nalidixic acid and ciprofloxacin resistance in non-typhoidal Salmonella isolated from faecal samples of patients with acute diarrhoeal disease attending the outpatient and inpatient department of a hospital in Saudi Arabia during the years 1999 to 2002. METHODS: Non-typhoidal Salmonella were isolated from faecal samples. Antimicrobial susceptibility was tested by the disc diffusion test. MICs to nalidixic acid and ciprofloxacin were determined by the agar dilution method. RESULTS: During the study period, 524 strains of non-typhoidal Salmonella were isolated. Strains belonging to serogroup C1 were the commonest (41.4%) followed by serogroups B and D (15.6% and 14.5%, respectively). Resistance to ampicillin was observed in 22.9% and to trimethoprim/sulfamethoxazole in 18.5% of the strains. Nalidixic acid resistance was encountered in 9.9% and ciprofloxacin resistance in 2.3% of the strains. Resistance to nalidixic acid significantly increased from 0.1% in 1999 to 5.5% in 2002 (P=0.0007) and ciprofloxacin resistance increased significantly from 0.1% in 1999 to 0.9% in 2002 (P=0.0001). MICs to nalidixic acid and ciprofloxacin were determined among 29 nalidixic acid-resistant strains of non-typhoidal Salmonella isolated during 2002. The MIC was >256 microg/mL to nalidixic acid and 8 to 16 microg/mL to ciprofloxacin. CONCLUSION: The increasing rates of antimicrobial resistance encountered among non-typhoidal Salmonella necessitate the judicious use of these drugs in humans. Moreover, these findings support the concern that the use of quinolones in animal feed may lead to an increase in resistance and should be restricted.

Advancing age and the risk of nasal carriage of Staphylococcus aureus among patients on long-term hospital-based hemodialysis.

BACKGROUND: Elevated nasal carriage rates of Staphylococcus aureus and ensuing complications among the elderly and in those on long-term hemodialysis (HD) are well recognized. The aim of the present study was to determine the extent to which advancing age is associated with the risk of persistent S. aureus nasal carriage among end-stage renal disease (ESRD) patients on long-term HD. PATIENTS AND METHODS: This prospective study involved 205 ESRD patients enrolled for maintenance HD from July 1997 to July 2000. Persistent nasal carriage was defined by two or more positive cultures for methicillin-susceptible (MSSA) or methicillin-resistant S. aureus (MRSA). Five standardized swabs were taken from the anterior nares of all the patients on long-term HD. S. aureus nasal carriage rates were estimated and compared among ESRD patients of different age groups. RESULTS: Overall, a prevalence of 38.05% (78/205) for S. aureus nasal carriage was observed, including 27.3% (56/205) for MSSA and 10.7% (22/205) for MRSA. Patients aged 75 to 84 years had the highest (84.6%, 11/13) prevalence of S. aureus nasal carriage (RR, 7.000, 95% CI, 4.350-11.763, P<0.00001). Those aged 65 to 74 years had the next highest (49.0%, 25/51) nasal carriage rates (RR, 4.083, 95% CI, 2.302-7.658, P<0.0001) while patients aged 15 to 24 years (reference group) had the lowest (12.8%, 1/8) prevalence of nasal carriage. The 75 to 84 year age group also had the highest rates of MSSA (46.2%, 6/13), (RR- 3.833, 95% CI, 2.144-7.234, P<0.0001) and MRSA (38.5 %, 5/13) (RR, 6.333, 95%CI, 2.767-16.198, P<0.0001) nasal carriage compared to the reference group. CONCLUSIONS: Significantly higher persistent MSSA and MRSA nasal carriage rates among ESRD patients >75 years of age are suggestive of an elevated risk of potentially serious S. aureus- related complications among the very elderly during long-term HD. These findings might be helpful in the identification of elderly HD patients as a high-risk group for S. aureus-linked vascular access-related septicemia (VRS) and to evolve appropriate preventive strategies.

Emerging nalidixic acid and ciprofloxacin resistance in non-typhoidal Salmonella isolated from patients having acute diarrhoeal disease.

BACKGROUND: Non-typhoidal Salmonella are one of the key etiological agents of diarrhoeal disease. The appearance of multiple drug resistance along with resistance to quinolones in this bacterium poses a serious therapeutic problem. We determined the prevalence of nalidixic acid and ciprofloxacin resistance in non-typhoidal Salmonella isolated from faecal samples of patients with acute diarrhoeal disease attending the outpatient and inpatient departments of a hospital in Saudi Arabia during the years 1999 to 2002. METHODS: Non-typhoidal Salmonella were isolated from faecal samples. Antimicrobial susceptibility was tested by the disc diffusion test. MICs to nalidixic acid and ciprofloxacin were determined by the agar dilution method. RESULTS: During the study period, 524 strains of non-typhoidal Salmonella were isolated. Strains belonging to serogroup C1 were the commonest (41.4%) followed by serogroups B and D (15.6% and 14.5%, respectively). Resistance to ampicillin was observed in 22.9% and to trimethoprim/sulfamethoxazole in 18.5% of the strains. Nalidixic acid resistance was encountered in 9.9% and ciprofloxacin resistance in 2.3% of the strains. Resistance to nalidixic acid significantly increased from 0.1% in 1999 to 5.5% in 2002 (P=0.0007) and ciprofloxacin resistance increased significantly from 0.1% in 1999 to 0.9% in 2002 (P=0.0001). MICs to nalidixic acid and ciprofloxacin were determined among 29 nalidixic acid-resistant strains of non-typhoidal Salmonella isolated during 2002. The MIC was >256 microg/mL to nalidixic acid and 8 to 16 microg/mL to ciprofloxacin. CONCLUSION: The increasing rates of antimicrobial resistance encountered among non-typhoidal Salmonella necessitate the judicious use of these drugs in humans. Moreover, these findings support the concern that the use of quinolones in animal feed may lead to an increase in resistance and should be restricted.

The impact of nurse understaffing on the transmission of hepatitis C virus in a hospital-based hemodialysis unit.

OBJECTIVE: To determine the impact of nurse understaffing on the transmission of hepatitis C virus (HCV) infection in a large hospital-based hemodialysis (HD) unit with a high HCV prevalence. SUBJECTS AND METHODS: The records of 198 patients (107 males and 91 females) with end-stage renal disease enrolled on long-term HD at King Fahad Hospital and Tertiary Care Center, Hofuf, Saudi Arabia, from August 1995 to August 2000, were retrospectively reviewed. The patients were assigned to HD groups of varying patient-to-nurse (P/N) ratios: group I, 2:1; group II, 3:1, and group III, 4:1. HCV prevalence, seroconversion rates, history of blood transfusion and dialysis age (time span since the initiation of the HD treatment) were recorded and compared. RESULTS: The overall HCV prevalence and seroconversion rate per year were 43.4 and 8.6%, respectively. Group I had the lowest HCV prevalence and annual seroconversion rate (26.8%; 5.3%), followed by group II (43.6%; 8.7%); group III had the highest HCV prevalence and seroconversion rate (71.8%; 14.4%). Anti-HCV positivity was associated with a higher dialysis age. CONCLUSION: The finding that the patients in the groups with the relatively higher P/N ratio had the significantly higher HCV prevalence and seroconversion rates per year indicates that understaffing is likely to play a major role in the transmission of HCV in HD units, and we suggest that improved staffing may be helpful in reducing the HCV transmission in such dialysis units.

Impact of dedicated space, dialysis equipment, and nursing staff on the transmission of hepatitis C virus in a hemodialysis unit of the middle east.

BACKGROUND: Infection with the hepatitis C virus (HCV) is endemic in hemodialysis (HD) units, especially in Middle Eastern countries. The meticulous isolation policy recommended for patients with the hepatitis B virus (HBV) in an HD unit resulted in a significant drop in HBV incidence globally. This study was developed to prospectively investigate the impact of an identical isolation policy on incidence of nosocomial HCV infection in this HD unit of the Middle East. METHODS: In phase I of the study, we retrospectively reviewed the records of 189 patients with a mean age of 47.5 +/- 11.4 years (range, 15-85 years) who were receiving maintenance HD from December 7, 1995, to December 6, 2000, for the mean duration of 73 +/- 6.3 months (range, 3-144 months) to record the prevalence of HCV. Factors such as blood transfusions and dialytic age (time span that patient has received dialysis since its initiation) implicated in transmission of HCV in the HD unit also were recorded. Phase II involved stringent isolation of anti-HCV positive patients detected during phase I through provision of dedicated space, dialysis equipment, and nursing staff from December 7, 2000, to December 6, 2001. Liver function and anti-HCV tests were repeated for all the 198 patients every 6 months to identify new HCV seroconversions. RESULTS: An HCV prevalence rate of 43.9% (83/189) and an annual HCV seroconversion rate of 6.8% were identified in this cohort. No significant association with blood tranfusion was observed. Eighty-three anti-HCV positive (43.9%) patients had a mean dialytic age of 48.5 +/- 14.2 months compared with 25.0 +/- 8.6 months among 106 (56.1%) anti-HCV negative patients (relative risk [RR], 1.89; 95% confidence interval [CI], 1.39-5.86; P <.001). Only 2 new HCV seroconversions (1.01% [2/198]) were identified. CONCLUSIONS: Evidently, the sharing of facilities in a high-risk HD environment for a prolonged dialytic age facilitates the nosocomial transmission of HCV infection. A significant decline of annual seroconversion rate from 6.8% to 1.01% (odds ratio [OR], 7.535; 95% CI, 1.598-48.89; P <.005) suggests that a comprehensive, strictly enforced isolation policy for HCV-positive patients may play a significant role in limiting HCV transmission in HD units, just as it has in drastically reducing HBV transmission in these settings.