The prevalence of patients with infections caused by multidrug-resistant organisms (MDROs) has dramatically increased across health care systems. MDROs represent a significant public health issue,1 and outpatient dialysis centers are increasingly being called upon to accept and care for these patients.

Hemodialysis facilities serve a critical role in communities, caring for some of the most complex and vulnerable patients in the health care system. The efficient operation of these facilities is essential for the functioning of acute care, post–acute care, and long-term care networks. As medical leaders of the major dialysis provider organizations, we want to share our perspective on the effect and unique challenges of caring for these patients who present differential burden for dialysis facilities.

MDROs are characterized by resistance to one or more classes of antimicrobials.1 They are especially problematic because of their hardiness and endurance in the environment, high transmissibility, difficulty with detection, frequent asymptomatic colonization, and significant associated morbidity and mortality.1 Once present, they are challenging and costly to eradicate,2 increasing the risk of spread to other patients through environmental and staff contamination.

More than 550,000 patients in the United States receive maintenance dialysis for kidney failure; the majority are treated in communal settings. Most are chronically ill and functionally immunocompromised with multiple comorbidities. They are frequent utilizers of health care facilities and often have in-dwelling medical devices. Recent data indicate that over 50% of patients with kidney failure receive antibiotics annually.3 These factors render patients on dialysis uniquely susceptible to colonization and infection with MDROs, and bacterial colonization and infection rates in patients receiving dialysis greatly exceed those of other at-risk populations.4–7

Data on prevalence and incidence of MDROs in outpatient dialysis facilities are limited. A meta-analysis from 2014 including 23 reports revealed a 6.3% pooled prevalence for colonization of patients receiving dialysis with vancomycin-resistant enterococcus.5 However, rates varied across studies from <1% to 30%.4–7 A prospective cohort study in patients on dialysis in which serial surveillance cultures were obtained demonstrated that 28% of patients were colonized with one or more MDRO.4

General recommendations for preventing the emergence and spread of these organisms are presented in Table 1.9 Specific measures for management and treatment of infected patients vary by organism but may include isolation or cohorting, contact investigation and reporting, contact precautions, staff training and education, routine/active surveillance, dedicated staff, unique personal protective equipment requirements, augmented cleaning (Environmental Protection Agency list P or K), and extra disinfection of equipment (Table 1).1,2,9,10 The Centers for Disease Control and Prevention has not published guidelines for the management of these patients in outpatient dialysis facilities. While it is common practice to extrapolate the same standards designed for acute care settings, these current recommendations are not uniformly transferable.

Table 1 - Select recommendations for prevention and control of multidrug-resistant organism control measures Control Measure Type Administrative  1. Implementing system changes to ensure prompt and effective communication to identify patients known to be infected or colonized with MDROs  2. Providing the necessary number and appropriate placement of hand washing sinks and alcohol-containing hand rub dispensers in the facility  3. Maintaining staffing levels appropriate to the intensity of care required  4. Enforcing adherence to recommended infection control practices for MDRO control  5. Obtain expert consultation from persons with experience in infection control and the epidemiology of MDRO Education  1. Facility-wide, unit-targeted, and informal educational interventions to encourage a behavior change through improved understanding of the problem of targeted MDRO  2. Provide education and training on risks and prevention of MDRO transmission at new-hire orientation and periodically Judicial antimicrobial use  1. Review local susceptibility patterns and include appropriate antimicrobial agents on formulary to foster appropriate use  2. Implement systems and process to review antibiotic use and distribute reports to providers Surveillance  1. Establish systems to ensure that clinical microbiology laboratories promptly notify facility when novel resistance pattern for that facility is identified  2. In an outbreak setting, develop and implement protocols to obtain active surveillance cultures from patients in populations at risk Infection control precautions  1. Follow standard precautions in all health care settings  2. Implement contact precautions for all patients known to be colonized/infected with target MDRO  3. When active surveillance cultures are obtained in outbreak setting, implement contact precautions until the culture is reported negative for the target MDRO  4. Use single-patient rooms if available for patients with MDRO  5. When single-patient rooms are not available, cohort patients with the same MDRO in the same patient care area  6. No recommendation can be made regarding when to discontinue contact precautions Environmental measures  1. Follow recommended cleaning, disinfection, and sterilization guidelines for maintaining patient care areas and equipment based on the MDRO  2. Dedicate non-critical medical items to use on individual patients known to be infected or colonized with an MDRO Decolonization  Not recommended routinely Siegel et al.8 MDRO, multidrug-resistant organism.

These recommendations are difficult to implement in an outpatient setting and often require substantial additional human and material resources. The literature suggests that many dialysis facilities are challenged with ensuring infection control and, consequently,11 that transmission of MDROs does occur in the outpatient dialysis setting. A prospective cohort study in an outpatient dialysis facility where colonization with MDROs was present demonstrated acquisition of one or more MDRO in 40% of patients who were negative at enrollment.4 Current characteristics of the dialysis facilities contribute to these challenges including staffing challenges, capacity issues, as well as shared treatment space, staff, equipment, bathrooms, and waiting areas. In addition, proximity to many other patients and frequent and prolonged contact between health care workers and patients create substantial opportunity for spread of MDROs. Standard precautions used in dialysis facilities do not reliably halt MDRO transmission in all circumstances.10

Requiring a level of care that approaches that of acute care settings without the necessary infrastructure negates the efficiencies that allow hemodialysis units to operate at scale. The recommended infection control interventions, physical environment changes, and pharmaceutical costs to care for patients with MDROs can be prohibitive and disruptive for dialysis facilities.1,2 Management of patients with MDRO may necessitate altering patient and staff scheduling, limiting or eliminating the use of shared equipment and space, and at times even closure or suspension of new admissions.2,12 These additional precautions are costly and impose additional staff demands, further exacerbating unprecedented labor shortages, supply cost inflation, and caregiver burnout. Unlike acute care settings, it is not possible to provide one-on-one nursing for these patients in an outpatient setting.

For many of these organisms, given the difficulties with eradication and challenges of identifying the organisms by standard laboratory techniques, current guidance suggests that contact precautions are continued indefinitely.9 Isolation of colonized or infected individuals can create unwarranted fear, stigma, and psychological burden for patients and their families. There are often additional laboratory costs created by the specific culture methods required for MDRO surveillance. If the patients require treatment of an MDRO, the options are often limited, costly, and frequently associated with significant side effects and/or require extra monitoring. Dialysis facilities do not have on-site infectious disease consultants, infection preventionists, or laboratory and pharmacy resources to assist with these added demands.

As a result of these complex logistic issues, many dialysis facilities, facing untenable operational trade-offs, are unable to accept patients with MDRO infection or colonization. The current system was structured to deliver efficient treatment of large numbers of generally stable patients with kidney failure; however, it is not equipped or staffed to care for patients requiring prolonged isolation treatments.

Alternative solutions to accommodate the patient on dialysis with an MDRO include independent or staff-assisted home dialysis or dialysis in skilled nursing facilities; however, costs and logistic barriers may not permit these options. The extensive comorbidities common to patients with MDRO limit the number of patients suitable for home dialysis. Staffing shortages limit the ability of individual skilled nursing facilities to provide dialysis care for small numbers of such patients.

Additional funding to compensate for the increased costs of care and exemption from hospital-based guidelines, coupled with the development of guidelines specific to outpatient dialysis facilities, would likely increase the willingness and ability of facilities to care for these patients. Research must be dedicated to understanding the most cost-effective means of mitigating and managing MDROs in outpatient dialysis facilities and exploring novel options for the care of these patients. A better understanding of the transmission dynamics, the benefits of barrier measures, separation of patients with MDRO, and sanitization of personnel and equipment is needed to facilitate the care of these patients. Developing and testing innovative strategies to limit risk of MDROs and their spread requires collaboration between dialysis providers, physicians, acute and post-acute settings, long-term residential facilities, transport providers, and payers. The increasing adoption of at-risk financial government and commercial payor programs opens opportunities for offsetting the increased expenditures to fund innovation and pilot infection control interventions. Initiatives, such as KidneyX, can spur innovation in these areas. Partnership with the local ESKD networks and the American Society of Nephrology, Nephrologists Transforming Dialysis Safety, may yield additional expertise and solutions. In addition, collaboration with state and local health departments and the Centers for Disease Control and Prevention may bring additional resources, and often, these are reportable infections.

Dialysis providers look forward to participating in policy discussions and research efforts that consider the need to align MDRO vigilance and interventions across a broad spectrum of care.

Disclosures

J.G. Bhat reports employment with and ownership interest in Atlantic Dialysis Management Services, LLC. S.R. Blue reports employment with Saint Alphonsus Health System, Sawtooth Epidemiology and Infectious Diseases, and St. Lukes Health System. M. Dittrich reports employment with US Renal Care; ownership interest in multiple dialysis units, Signify Health, and US Renal Care; and advisory or leadership role as US Renal Care Chief Medical Officer. R. Durvasula reports employment with Puget Sound Kidney Centers. B.I. Freedman reports employment with Health Systems Management, Inc.; consultancy for AstraZeneca Pharmaceuticals and RenalytixAI; research funding from AstraZeneca Pharmaceuticals and RenalytixAI; role on the Editorial Boards of American Journal of Nephrology, JASN, and Kidney International; and other interests or relationships as Chief Medical Officer, Health Systems Management, Inc. and Wake Forest University Health Sciences, and B.I. Freedman has rights to a US patent related to APOL1 genetic testing. J. Giullian reports employment with and ownership interest in DaVita, Inc. G. Green reports current employment with Satellite Healthcare and former employment with Nephrology Associates Medical Group of Santa Rosa (through September 30, 2021); ownership interest in Doximity and MedWave Software Solutions; advisory or leadership role for Akebia Therapeutics Advisory Board (paid at hourly fair market value rate), American Society of Nephrology Emergency Partnership Initiative (steering committee membership, workgroup co-chair, unpaid), and National Kidney Foundation serving Northern California Medical Symposium Program Planning Committee; and other interests or relationships with Kidney Care Council (member). G. Green’s spouse reports current employment with The Permanente Medical Group, ownership interest in MedWave Software Solutions and The Permanente Medical Group; and other interests or relationships with Society for Vascular Surgery (member). J.L. Hymes reports employment with Fresenius Medical Care North America; ownership interest in DaVita, Fresenius Medical Care, and Nephroceuticals; advisory or leadership role for Fresenius Medical Care; and other interests or relationships with KCP. J. Silberzweig reports employment with The Rogosin Institute; consultancy work for Alkahest, Bayer, Honeywell, Kaneka, and St. Gobain; stock in American Express, AT&T, IBM, and Wells Fargo; research funding as the national principal investigator for two clinical trials sponsored by Kaneka: one is using their Lixelle device for treatment of beta-2-microglobulin amyloidosis in patients with ESKD, and the other is using lipid apheresis for the treatment of focal glomerulosclerosis; and advisory or leadership roles for American Society of Nephrology: Nephrologists Transforming Dialysis Safety COVID-19 and Other Current and Emerging Threats workgroup, COVID-19 Response team, and Emergency Partnership Initiative. J. Silberzweig’s wife is an employee of Elevance Health and holds stock in American Express, AT&T, Elevance Health, IBM, and Wells Fargo. R. Spech reports employment with Centers for Dialysis Care and Nephrology and Hypertension Associates, Inc.; ownership interest in Bank of America, Microsoft, Moderna, Nutrien, and Range Resources; advisory or leadership role for Centers for Dialysis Care; and other interests or relationships with Centers for Dialysis Care and Nephrology Associates of Cleveland. L. Spry reports the employment with Lincoln Nephrology & Hypertension; consultancy for Guidepoint Network for Nephrology; shares with Home Dialysis of Lincoln, a for-profit home dialysis provider in Lincoln, Nebraska; research funding as a primary investigator for Nebraska Nephrology Research, a CRO based in Lincoln, Nebraska; research funding from Outset as the primary investigator at the Dialysis Center of Lincoln, Lincoln, Nebraska; research funding from Baxter International as the primary investigator at the Dialysis Center of Lincoln, Lincoln, Nebraska; research funding as a primary investigator for Somnos, is a CRO in Lincoln, Nebraska; honoraria from the Southeast Nebraska Rural Physician Association (SERPA) related to a presentation on Kidney Disease in September 2021; role on the Board of Directors for the Bryan Health Connect, a physician hospital organization in Lincoln, Nebraska; and other interests or relationships as the Chief Medical Officer for the Dialysis Center of Lincoln, a non-profit Dialysis Provider. R. Taylor reports employment with REACH/DCi incorporated and advisory or leadership role for Alive Hospice. L.P. Wong reports employment with Intermountain Healthcare; consultancy for Baxter and Fresenius Medical Care; honoraria from Baxter; advisory or leadership role for Nephrologists Transforming Dialysis Safety Board of Directors, role on BMC Nephrology Editorial Board, and role as a Member-at-Large for ASN Excellence in Patient Care Committee.

Funding

None.

Acknowledgments

The content of this article reflects the personal experience and views of the authors and should not be considered medical advice or recommendation. The content does not reflect the views or opinions of the American Society of Nephrology (ASN) or CJASN. Responsibility for the information and views expressed herein lies entirely with the authors.

Author Contributions

Conceptualization: J. Ganesh Bhat, Mary Dittrich, Raghu Durvasula, Barry I. Freedman, Jeff Giullian, Gopa Green, Jeffrey L. Hymes, Jeffrey Silberzweig, Richard Spech, Leslie Spry, Robert Taylor, Leslie P. Wong.

Data curation: J. Ganesh Bhat, Mary Dittrich, Raghu Durvasula, Barry I. Freedman, Jeff Giullian, Gopa Green, Jeffrey L. Hymes, Jeffrey Silberzweig, Richard Spech, Leslie Spry, Robert Taylor, Leslie P. Wong.

Methodology: Sky R. Blue.

Writing – original draft: J. Ganesh Bhat, Mary Dittrich, Raghu Durvasula, Barry I. Freedman, Jeff Giullian, Gopa Green, Jeffrey L. Hymes, Jeffrey Silberzweig, Richard Spech, Leslie Spry, Robert Taylor, Leslie P. Wong.

Writing – review & editing: J. Ganesh Bhat, Sky R. Blue, Mary Dittrich, Raghu Durvasula, Barry I. Freedman, Jeff Giullian, Gopa Green, Jeffrey L. Hymes, Jeffrey Silberzweig, Richard Spech, Leslie Spry, Robert Taylor, Leslie P. Wong.

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