Preventing bacterial infections and antimicrobial resistance in dialysis patients

Antimicrobial use, in concert with patient-to-patient transmission of resistant strains, has caused a rapid increase in the prevalence of antimicrobial resistance in recent years. This increase is a particular threat to dialysis patients, who often have been in the forefront of the epidemic of resistance. In this report, which was written in collaboration between the American Society of Nephrology and the Centers for Disease Control and Prevention and has been endorsed by the Executive Council of the Infectious Diseases Society of America, we review and summarize existing clinical practice guidelines and recommendations concerning the prevention, diagnosis, and treatment of certain bacterial infections in dialysis patients and present four strategies to limit the spread of antimicrobial resistance in dialysis patients. First, preventing infection eliminates the need for antimicrobials, thereby reducing selection pressure for resistant strains. Efforts to prevent infection include avoidance of hemodialysis catheters, when possible, and meticulous care of hemodialysis and peritoneal catheters and other hemodialysis vascular access sites. Second, diagnosing and treating infections appropriately can facilitate the use of narrower spectrum agents, rapidly decrease the number of infecting organisms, and reduce the probability of resistance emerging. This entails the collection of indicated specimens for culture and avoidance of contamination of cultures with common skin microorganisms. Third, optimizing antimicrobial use helps protect the efficacy of such critical agents as vancomycin. Published guidelines for the use of vancomycin should be followed, and alternate agents should be used when infections with beta-lactam-resistant bacteria are unlikely or not documented. Fourth, preventing transmission in health care settings is important to limit the spread of resistant organisms. In this regard, such basic measures as glove use and hand hygiene are most important.