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Catheter-Related Bloodstream Infection for End Stage Renal Disease Patients -Evaluation in the Era of Low Budget National Health Insurance Coverage in Indonesia-

Erwin Hadi Chandra, Nyityasmono Tri Nugroho, Tom Ch. Adriani, Mulawardi

Introduction: The use of central venous catheter (CVC) plays an essential role in patient care. The catheter-related bloodstream infection (CRBSI) is one of complications and associated with morbidity and mortality. In Indonesia, the national health coverage for single CVC procedure claim is only US$ 197-286. The aim of this study is to evaluate CRBSI number after subclavian and femoral non-tunnelled catheter insertion for urgent haemodialysis access.

Method: A retrospective study with the simple consecutive sampling was conducted. The inclusion criteria were adult and end stage renal disease (ESRD) patients required urgent haemodialysis access with infection on the site of insertion on the subclavian or femoral access. Exclusion criteria were artery catheter placement, pacing catheter, and another sources of previously infection was defined. Patients were divided into subclavian and femoral access group then we evaluate them retrospectively based on medical record data.

Results: Forty patients with 20 patients were subclavian inserted, and rest were femoral inserted. Infections rate was 7.84%. Demographic showed 55% was male (22/40) & age 51.8±14.3 years. Catheter duration in subclavian and femoral group were 47.7±34.2 and 36.7±18.4 days, respectively. Hospital stays in subclavian and femoral group were 9.9±6.4 and 9.3±7.2 days, respectively. From SIRS criteria, in subclavian group showed the heart rate, respiratory rate, body temperature and white blood cell (WBC) count were 90.1±7.8 x/min, 21.1±2.6 x/min, 37.4±0.8 °C, 15.5.0±7.0 *103/μL, respectively. For femoral group were 86.8±10.5 x/min, 21.6±4.0 x/min, 36.9±0.6 °C, 14.9±8.4 *103/μL, respectively. The p- values of them were 0.273, 0.612, 0.041, and 0.793 respectively. Eighty percent in subclavian group was first insertion, and for femoral group was 50% (p=0.047). In subclavian group was 10% (2/20) patients had more than three times insertion and femoral group was 25% (5/20) (p=0.225). Creatinine and ureum level in subclavian group were 9.4±5.8 and 155.5±83.6 mg/dL and for femoral group were 11.4±6.2 and 133.6±50.3 mg/dL (p=0.298 and 0.322, respectively). A 62.5% of all patients (25/40) was treated with third generation cephalosporin. The p-value for amount of intravenous antibiotic (single, double, triple) between subclavian and femoral group was 0.352. There was no blood culture taken for all patients. Sepsis and death as complication was 10% and 5% from all patients, respectively.

Conclusion: Prolonged use of central venous catheter more than 2 weeks and recurrent procedure were the cause of increasing incidence of CRBSI. Ultrasound guiding is needed to decrease complication. In a low budget system for national health insurance in Indonesia, a good strategy (pre-ESRD arteriovenous fistula, internal jugular vein access, nosocomial infection prevention, and rational antibiotic usage with a rational blood culture) need to be developed to prevent the infection of CRBSI.

Keywords: catheter, infection, prevention, health insurance, Indonesia.

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