Hemodialysis Infection Prevention Protocols Ontario—Shower Technique (HIPPO-ST): A Pilot Randomized Trial

Abstract

IntroductionWe developed the Hemodialysis Infection Prevention Protocols Ontario—Shower Technique (HIPPO-ST) to permit hemodialysis (HD) patients with central venous catheters (catheters) to shower without additional infection risk. Our primary objective was to determine the feasibility of conducting a parallel randomized controlled trial (RCT) to evaluate the impact of HIPPO-ST on catheter-related bacteremia (CRB) in adult HD patients.MethodsAdult HD patients using catheters were recruited from 11 HD units. Patients were randomized to receive HIPPO-ST or standard care and were followed up for 6 months. Only CRB-outcome assessors were blinded. For the study to be considered feasible, 4 of 5 feasibility outcomes, each with its own statistical threshold for success, must have been achieved.ResultsA total of 68 patients were randomized (33 HIPPO-ST and 35 control) and were followed up to 6 months. Of 5 measures of feasibility, 4 were achieved: (1) accurate CRB rate documented (threshold: κ level >0.80); (2) 97.8% (279/285) of satellite HD patients with catheters were screened (threshold: >95%); (3) 88% (23/26) in the HIPPO-ST arm were successfully educated by 6 months (threshold: >80%); and (4) 0% (0/29) patients in the control arm were “contaminated,” that is, using HIPPO-ST (threshold: <5%). However, only 44.2% (72/163) of eligible patients consented to participate (threshold: >80%). The rate of CRB was similarly low in HIPPO-ST and control groups (0.68 vs. 0.88/1000 catheter days).DiscussionThis HIPPO-ST pilot study demonstrated the feasibility of the larger HIPPO-ST study, especially given the high levels of education success with the HIPPO-ST arm and the low levels of contamination in the control arm.

Prevention of Bloodstream Infections in Patients Undergoing Hemodialysis

“…Sheet and pouch products have been designed to prevent water contamination of the hemodialysis catheter during showering, but may be cost-prohibitive. There is insufficient evidence to determine whether showering with a protocol that includes hemodialysis catheter hub protection or after-shower exit-site care decreases catheter-associated bloodstream infection rates (35,36). In a small study, comparable bloodstream infection rates were reported in patients on hemodialysis trained in after-shower exit-site care and a control group for which standard catheter care was performed by hemodialysis nurses (35).…”

“…There is insufficient evidence to determine whether showering with a protocol that includes hemodialysis catheter hub protection or after-shower exit-site care decreases catheter-associated bloodstream infection rates (35,36). In a small study, comparable bloodstream infection rates were reported in patients on hemodialysis trained in after-shower exit-site care and a control group for which standard catheter care was performed by hemodialysis nurses (35). Similarly, another small trial compared showering without an exit-site dressing (with catheter hub protection) to a no-showering policy.…”

Catheter related infection in hemodialysis patients with double lumen catheter.

“…Infection in central venous catheter causes more morbidity and life threatening complications in hemodialysis patients. 16 The incidence of bacteremia is 0.5 to 13 per 1000 patient-days with central venous catheters. The rate of infection is low with permanent silicone catheters and high rate is observed with temporary polyurethane catheters.…”

Management of a Patient with Catheter-Related Bloodstream Infection

“…As part of general hygiene, whether a patient can shower with a catheter after the exit site is healed without increased risk of CRBSI is still unclear. A recent pilot randomized, controlled trial showed no difference in CRBSI rates and feasibility in conducting a larger definitive trial to answer this question (9). Until then, choice D is incorrect, and showering should be discouraged if the exit site is not completely healed.…”