Evidence-based intervention fails to reduce haemodialysis catheter-related bloodstream infection

An evidence-based, multifaceted intervention aimed at reducing haemodialysis catheter-related bloodstream infections (HD-CRBSIs) failed to improve this outcome, results of the REDUCCTION* trial showed.

The study population comprised patients receiving central venous catheters (CVCs) for haemodialysis in 37 participating renal centres in Australia. The centres were randomized to three different time points for implementation of an evidence-based multifaceted intervention to reduce HD-CRBSI incidence (April 2018, September 2018, March 2019).

During the baseline phase, 3,519 patients had used 3,726 catheters, while in the intervention phase, 2,845 patients used 4,027 catheters. This amounted to >1.1 million catheter exposure days. Data was collected between catheter insertion and removal and various interventions were applied at catheter insertion, maintenance, and removal. More than 300 HD-CRBSI events were documented.

Mean age of patients was about 61 years and about 60 percent were male. More than 40 percent of patients had diabetes. Most catheters were tunnelled catheters (87.8 and 90.9 percent in the baseline and intervention populations, respectively) and catheters were primarily used for acute kidney injury or maintenance dialysis.

The primary endpoint of confirmed HD-CRBSI** did not significantly differ between the baseline and intervention phases (0.313 vs 0.240 per 1,000 catheter-days; rate ratio [RR], 1.30, 95 percent confidence interval [CI], 0.78–2.16; p=0.31). [ASN Kidney Week 2020, abstract FR-OR56]

The secondary outcome of suspected or possible infection*** was comparable between the baseline and intervention phases (0.122 vs 0.125 per 1,000 catheter-days; RR, 0.54, 95 percent CI, 0.23–1.23; p=0.14).

Confirmed or suspected/possible HD-CRBSI^# also did not significantly differ between the baseline and intervention phases (0.435 vs 0.365 per 1,000 catheter-days; RR, 0.97, 95 percent CI, 0.61–1.55; p=0.90), nor did total haemodialysis CVC-related infection^## (0.634 vs 0.494 per 1,000 catheter-days; RR, 0.71, 95 percent CI, 0.46–1.10; p=0.13).

Subgroup analyses based on size of renal service (more or less than median size of 63 patients; RRs, 1.41 and 1.07, respectively; p=0.33) and requirement of dressing or catheter locking solution change during the intervention (yes or no; RRs, 1.15 and 1.31, respectively; p=0.64) did not affect the primary outcome findings. 

“Catheter usage is an independent predictor of mortality in dialysis populations. As such, there have been [multiple] initiatives in [previous years] to reduce exposure to catheters,” said study lead author Associate Professor Martin Gallagher from The George Institute of Global Health, New South Wales, Australia, at ASN Kidney Week 2020.

Despite the negative results, Gallagher noted that HD-CRBSI rates declined from already low baseline rates. “The wide CIs were likely driven, in part, by the lower than expected event rate [of the primary outcome],” he pointed out, not ruling out a chance finding.

For every 10 patients using a haemodialysis CVC per year, one will have a HD-CRBSI, Gallagher added. This has implications for services with higher catheter exposure, he said.

“These results show the importance of using such robust study designs to understand the effect of complex intervention packages in real-world settings and embedding clinical trials within routine practice. Data from this national study will allow a better understanding of the reasons for variation in patients’ risk of such infections,” he concluded.