Prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and use of tunneled hemodialysis catheters

Background: Hemodialysis patients are at higher risk of contracting infections particularly methicillin-resistant Staphylococcus aureus (MRSA). MRSA is a serious infection and could be fatal within hours to days if undiagnosed. Dialysis catheter commonly known as permacath is a tunnel catheter used for maintenance hemodialysis which is associated with serious complications, especially infections and thrombosis. Different methodologies were designed and tested to determine the relation of infection with permcath. The use of a cuff was thought to prevent catheter related infections but none proved beneficial.(1) This finding was supported further in a systematic review conducted in 2009.(2) Usage of permacath is on the rise despite awareness of its higher risk of morbidities and mortalities which is contrary to the slogan of Fistula First Initiative.(3) We aimed to evaluate the prevalence of MRSA infections in hemodialysis patients with tunneled hemodialysis catheters. Methods: This is a retrospective, qualitative cross-sectional and non-experimental single center study conducted at Sultan Qaboos University Hospital (SQUH) Hemodialysis Unit over eight years. Inclusion criteria include: Adult patients >18 years of age with diagnosis of end stage renal disease requiring hemodialysis. Exclusion criteria included age < 18 years old and patients on peritoneal dialysis. Records of hemodialysis patients from 1(st) January 2010 through 6(th) May 2018 were retrieved through TrackCare (electronic medical records). The patients were divided into two groups. Positive MRSA infection (defined as a positive Gram stain with cocci in clusters and which was further confirmed by positive DNA polymerase chain reaction (PCR) for MRSA) either from the periphery or central line or pus swab from the catheter tunnel site at the time of admission or during hospitalization.(4) The remaining screened patients were classified as negative MRSA. Informed consent was waived as it is a retrospective study and our work was based on collecting information from TrackCare. All patients’ data were de-identified prior to analysis. Results: From 2010 to 2018, 1356 hemodialysis patients were identified within the hospital information system (HIS). Based on our inclusion criteria, a total of 1064 screened patients were included in our study. Those remaining who were not screened were been excluded. Fifteen patients were detected positive with MRSA infection (Figure 1), 12 patients had permacath and three had arteriovenous fistula (AVF). Overall, the prevalence of MRSA infection was 1.1% (12/1064) in hemodialysis patients with tunneled catheters. Conclusions: In our study, the MRSA prevalence rate was lower than the international reported statistics (4.2–6.5 per 100 patients).(5) This supports the use of adequate infection control policies and practices adopted in the unit. We propose that fistula should be the preferred access option for the maintenance hemodialysis. However, in cases where catheter is the only option, due to whatever reason, then using chlorhexidine impregnated dressings in addition to standard catheter care techniques result in reduced infection incidence. Furthermore, use of topical antibiotics at catheter exit sites can reduce the risk of infection.