An interventional controlled trial comparing 2 management models for the treatment of tunneled cuffed catheter bacteremia: a collaborative team model versus usual physician-managed care.
BACKGROUND
The management of tunneled cuffed catheter (TCC)-associated bacteremias varies among nephrologists. To determine whether patient outcomes after TCC-associated bacteremia can be improved by modifying the management model, we performed an interventional controlled trial comparing a collaborative team model, intervention (INT), with the usual physician-managed model, usual care (UC).


METHODS
INT consisted of an infection manager who worked closely with nephrologists and dialysis staff and made treatment recommendations using the available published guidelines at the time of the study's conception (Dialysis Outcomes Quality Initiative guideline no. 26, 1997) and additional literature-based recommendations. Nephrologists made the final treatment decisions. TCC-associated bacteremia was physician managed in the UC group.


RESULTS
Two hundred twenty-three episodes of TCC-associated bacteremia occurred in 7 outpatient hemodialysis units during the 2-year study period. The INT was associated with a significantly lower incidence of recurrent bacteremia with the same organism (INT, 6% versus UC, 18%; odds ratio, 0.28; 95% confidence interval, 0.09 to 0.8; P = 0.015) and death from sepsis (INT, 0% versus UC, 6%; P < 0.02). In INT units, there was a 45% decrease in the practice of TCC salvage (TCC not removed; P = 0.05). Antibiotic prescribing practices (final antibiotic selection, dose, and duration of therapy) were improved in INT units compared with UC units. By using multivariate analysis, the INT was associated with a 73% decrease in the combined outcome of recurrent bacteremia or septic death (P < 0.02).


CONCLUSIONS
Implementation of a collaborative team model for the management of TCC-associated bacteremic episodes is associated with improvement in the quality of heath care delivery and patient outcomes.
Mokrzycki
Michele Helene
MH
Montefiore Medical Center, Moses and Weiler Divisions, Albert Einstein College of Medicine, Bronx, NY 10457, USA. mokrzm@aol.com
Zhang
Meilin
M
Golestaneh
Ladan
L
Laut
Jeffrey
J
Rosenberg
Stuart O
SO
D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D016470:Bacteremia / Q000188:drug therapy* / Q000209:etiology*; D002404:Catheterization / Q000009:adverse effects*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007674:Kidney Diseases / Q000628:therapy; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010348:Patient Care Team; D010817:Physician-Patient Relations; D011446:Prospective Studies; D011787:Quality of Health Care; D006435:Renal Dialysis / Q000009:adverse effects / Q000295:instrumentation; D013211:Staphylococcus aureus; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents