Risk of Vascular Access Infection Associated With Buttonhole Cannulation of Fistulas: Data From the National Healthcare Safety Network

Abstract

Rationale & objective: Compared with conventional (rope-ladder cannulation [RLC]) methods, use of buttonhole cannulation (BHC) to access arteriovenous fistulas (AVFs) may be associated with increased risk for bloodstream infection and other vascular access-related infection. We used national surveillance data to evaluate the infection burden and risk among in-center hemodialysis patients with AVFs using BHC.

Study design: Descriptive analysis of infections and related events and retrospective observational cohort study using National Healthcare Safety Network (NHSN) surveillance data.

Setting & participants: US patients receiving hemodialysis treated in outpatient dialysis centers.

Predictors: AVF cannulation methods, dialysis facility characteristics, and infection control practices.

Outcomes: Access-related bloodstream infection; local access-site infection; intravenous (IV) antimicrobial start.

Analytic approach: Description of frequency and rate of infections; adjusted relative risk (aRR) for infection with BHC versus RLC estimated using Poisson regression.

Results: During 2013 to 2014, there were 2,466 access-related bloodstream infections, 3,169 local access-site infections, and 13,726 IV antimicrobial starts among patients accessed using BHC. Staphylococcus aureus was the most common pathogen, present in half (52%) of the BHC access-related bloodstream infections. Hospitalization was frequent among BHC access-related bloodstream infections (37%). In 2014, 9% (n=271,980) of all AVF patient-months reported to NHSN were associated with BHC. After adjusting for facility characteristics and practices, BHC was associated with significantly higher risk for access-related bloodstream infection (aRR, 2.6; 95% CI, 2.4-2.8) and local access-site infection (aRR, 1.5; 95% CI, 1.4-1.6) than RLC, but was not associated with increased risk for IV antimicrobial start.

Limitations: Data for facility practices were self-reported and not patient specific.

Conclusions: BHC was associated with higher risk for vascular access-related infection than RLC among in-center hemodialysis patients. Decisions regarding the use of BHC in dialysis centers should take into account the higher risk for infection. Studies are needed to evaluate infection control measures that may reduce infections related to BHC.

Keywords: Hemodialysis (HD); arteriovenous fistula (AVF); bloodstream infection (BSI); buttonhole cannulation; end-stage renal disease (ESRD); infection; renal replacement therapy (RRT); rope-ladder cannulation; surveillance data; vascular access.