Abstract:
Background: Hemodialysis central venous catheter-related bloodstream infections (HD-CRBSI) are a significant source of morbidity and mortality among dialysis patients, but benchmarking remains difficult due to varying definitions of HD-CRBSI. This study explored the effect of clinical adjudication process on HD-CRBSI reporting.
Methods: The REDUcing the burden of Catheter ComplicaTIOns: a National approach (REDUCCTION) trial implemented an evidence-based intervention bundle using a stepped-wedge design to reduce HD-CRBSI rates in 37 Australian kidney services. Six New Zealand services participated in an observational capacity. Adult patients with a new hemodialysis catheter between December 2016 and March 2020 were included. HD-CRBSI events reported were compared to the adjudicated outcomes using the endpoint definition and adjudication processes of the REDUCCTION trial. The concordance level was estimated using Gwet’s agreement coefficient (AC1) adjusted for service-level effects and implementation tranches (Australia only), with the primary outcome being the concordance of confirmed HD-CRBSI.
Results: A total of 744 hemodialysis catheter-related infectious events were reported among 7,258 patients, 12,630 catheters and 1.3 million catheter-exposure days. The majority were confirmed HD-CRBSI, with 77.9% agreement and ‘substantial’ concordance (AC1=0.77, 95% confidence interval [CI]: 0.73, 0.81). Exit site infections have the highest concordance (AC1=0.85, 95% CI 0.78, 0.91); the greatest discordance was in events classified as Other (AC1=0.33, 95% CI 0.16, 0.49). The concordance of all hemodialysis catheter infectious events remained ‘substantial’ (AC1=0.80, 95% CI 0.76, 0.83) even after adjusting for the intervention tranches in Australia and overall service-level clustering.
Conclusions: There was a substantial level of concordance in overall and service-level reporting of confirmed HD-CRBSI. A standardized endpoint definition of HD-CRBSI resulted in comparable hemodialysis catheter infection rates in Australian and New Zealand kidney services. Consistent endpoint definition could enable reliable benchmarking outside clinical trials without the need for independent clinical adjudication.
Reference:Catiwa J, Gallagher M, Talbot B, Kerr PG, Semple DJ, Roberts MA, Polkinghorne KR, Gray NA, Talaulikar G, Cass A, Kotwal S; REDUCCTION Investigators (Supplemental Table 1 and Supplemental Table 2). Clinical Adjudication of Hemodialysis Catheter-Related Bloodstream Infections: Findings from the REDUCCTION Trial. Kidney360. 2024 Feb 8. doi: 10.34067/KID.0000000000000389. Epub ahead of print. PMID: 38329768.