Original Investigation
Staphylococcus aureus Bacteremia Among Patients Receiving Maintenance Hemodialysis: Trends in Clinical Characteristics and Outcomes

https://doi.org/10.1053/j.ajkd.2021.06.018Get rights and content

Rationale & Objective

Staphylococcus aureus (S aureus) bacteremia (SAB) is associated with morbidity and mortality in patients receiving maintenance hemodialysis (HD). We evaluated changes in clinical and bacterial characteristics, and their associations with clinical outcomes with SAB in this population over a 21-year period.

Setting & Participants

453 hospitalized, non-neutropenic adults receiving maintenance HD who developed monomicrobial SAB between 1995 and 2015.

Exposure

Clinical characteristics and bacterial genotype.

Outcome

All-cause and SAB-attributable mortality, persistent bacteremia, and metastatic complications.

Analytical Approach

Proportions of participants experiencing each outcome were calculated overall and by calendar year. Secular trends were estimated using binomial risk regression, a generalized linear model with the log link function for a binomial outcome. Associations with outcomes were estimated using logistic regression.

Results

Over the 21-year study period, patients receiving maintenance HD experienced significant increases in age- and diabetes-adjusted SAB-attributable mortality (0.45% [95% CI, 0.36%-0.46%] per year), persistent bacteremia (0.86% [95% CI, 0.14%-1.55%] per year), metastatic complications (0.84% [95% CI, 0.11%-1.56%] per year), and infection with the virulent S aureus clone USA300 (1.47% [95% CI, 0.33%-2.52%] per year). Over time, the suspected source of SAB was less likely to be a central venous catheter (−1.32% [95% CI, −2.05 to −0.56%] per year) or arteriovenous graft (−1.08% [95% CI, −1.54 to −0.56] per year), and more likely to be a nonvascular access source (1.89% [95% CI, 1.29%-2.43%] per year). Patients with a nonvascular access suspected source of infection were more likely to die as a result of their S aureus infection (OR, 3.20 [95% CI, 1.36-7.55]). The increase in USA300 infections may have contributed to the observed increase in persistent bacteremia (OR, 2.96 [95% CI, 1.12-7.83]) but did not explain the observed increases in SAB-attributable mortality (OR, 0.83 [95% CI, 0.19-3.61]) or metastatic complications (OR, 1.34 [95% CI, 0.53-3.41]).

Limitations

Single-center, inpatient cohort.

Conclusions

The clinical and molecular epidemiology of SAB in patients receiving maintenance HD has changed over time, with an increase in SAB-attributable mortality and morbidity despite a decline in catheter-related infections.

Section snippets

Database and Study Population

The S aureus Bacteremia Group Prospective Cohort Study (SABG-PCS) is an ongoing, prospective cohort at Duke University Medical Center (DUMC). The overall cohort, study design, and ascertainment strategies have been described elsewhere.15 SABG-PCS and the present study were approved by the Duke institutional review board. Patients or their legal representatives provided written informed consent. If patients died before notification of their blood culture results, they were included in the SABG

Study Population

Between January 1, 1995, and December 31, 2015, a total of 2,423 unique patients were enrolled in the SABG-PCS. A total of 53 patients were excluded because their initial bloodstream isolates could not be retrieved, another 22 were excluded due to inconsistent data regarding clinical outcomes, and 7 were excluded due to inconsistent data entry for key covariates. For analyses focused on patients receiving maintenance HD, we excluded an additional 26 participants who required kidney replacement

Discussion

This study demonstrates that the clinical and molecular epidemiology of SAB in patients receiving maintenance HD has changed significantly over the past 2 decades. These findings have several key implications.

The suspected source of infection changed during the study period. Fewer patients had a CVC or AVG as the suspected source of infection, while the frequency of a non–vascular access suspected source of infection increased. The decrease in suspected CVC-associated infections may reflect the

Article Information

Authors’ Full Names and Academic Degrees

Matthew R. Sinclair, MD, Maria Souli, MD, PhD, Felicia Ruffin, PhD, MSN, RN, Lawrence P. Park, PhD, Michael Dagher, MD, Emily M. Eichenberger, MD, Stacey A. Maskarinec, MD, PhD, Joshua T. Thaden, MD, PhD, Michael Mohnasky, MBS, Christina M. Wyatt, MD, MS, and Vance G. Fowler Jr, MD, MHS.

Authors’ Contributions

Research idea and study design: MRS, MS, FR, LPP, MD, EME, SAM, JTT, MM, CMW, VGF; data acquisition: MRS, MS, FR, VGF; data analysis/interpretation: MRS, MS, FR, LPP, VGF; statistical analysis: MRS, LPP;

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