Long-term Follow-up of the Hemodialysis Infection Prevention With Polysporin Ointment (HIPPO) Study: A Quality Improvement Report
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BACKGROUND: Infection is a common and serious complication in hemodialysis patients accessed using central venous catheters (CVCs). Previously, a randomized double-blinded trial (HIPPO [Hemodialysis Infection Prevention With Polysporin Ointment] Study) showed that application of a topical polyantibiotic ointment at the CVC exit site decreased CVC-related infections, including bacteremias and their adverse consequences. Based on this study's results, our institution implemented a policy of routine topical polyantibiotic ointment application for CVC-related infection prophylaxis. The main purpose of this prospective observational study was to determine whether the low rate of CVC-related infection achieved by topical polyantibiotic ointment use during a randomized controlled trial would be observed during long-term prophylaxis as part of routine clinical care. STUDY DESIGN: Quality improvement report. SETTING & PARTICIPANTS: All adult long-term hemodialysis patients using a tunneled cuffed CVC in a large university-affiliated outpatient hemodialysis program in 2004-2009 were included. QUALITY IMPROVEMENT PLAN: To prospectively monitor the impact of a policy-wide strategy of topical polyantibiotic ointment application at CVC exit sites (1 time/wk) as infection prophylaxis. A multidisciplinary team approach to the surveillance, prospective tracking, and management of hemodialysis CVC-related infection was used. OUTCOMES & MEASUREMENTS: Rates of CVC-related infections (exit-site infections and bacteremias), percentages of contributing organisms, and consequences of CVC-related infections. RESULTS: After 6 years, CVC exit-site infection and bacteremia rates remained low (<1.0/1,000 catheter-days). Gram-positive organisms accounted for 61.2% of exit-site infections and 72.1% of bacteremias. LIMITATIONS: A center effect of the same institution conducting the randomized trial and the quality improvement study may limit the study's generalizability to other centers. The impact of possible unmeasured cointerventions cannot be excluded. CONCLUSION: Long-term use of topical antibiotic application at CVC exit sites resulted in a sustained decrease in all CVC-related infections. A multidisciplinary effort to monitor and track outcomes allowed safe and effective implementation of a new prophylactic strategy.
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