Editorial epilogue: ten points well taken.

被引量：- 发表：2001

Peritoneal infections.

:Peritoneal dialysis related infections include infection of the catheter exit site, subcutaneous pathway, or effluent. Exit-site infections, predominately owing to Staphylococcus aureus, are defined as purulent drainage at the exit site, although erythema may be a less serious type of exit-site infection. Tunnel infections are underdiagnosed clinically, and sonography of the tunnel is useful to delineate the extent of the infection and to evaluate response to antibiotic therapy. S aureus infections occur more frequently in S aureus carriers and immunosuppressed patients and can be reduced by mupirocin prophylaxis either intranasally or at the exit site. Patients with peritonitis present with cloudy effluent and usually pain, although 6% of patients may initially have pain without cloudy effluent. A white blood cell count of 100 or greater per microL, 50% of which are polymorphonuclear cells, has long been the hallmark of peritonitis. Empiric therapy is controversial, with some recommending cefazolin and others vancomycin (with cefatazidime for Gram-negative coverage). The choice should depend on the center's antibiotic sensitivity profile; those centers with a high rate of Enterococcus- or methicillin resistant organisms should use vancomcycin. Peritonitis episodes occurring in association with a tunnel infection with the same organism seldom resolve with antibiotics and require catheter removal. Other indications for catheter removal are refractory peritonitis, relapsing peritonitis, tunnel infection with inner-cuff involvement that does not respond to antibiotic therapy (based on ultrasound criteria), fungal peritonitis, and enteric peritonitis owing to intra abdominal pathology. Centers can reduce dialysis related infections to very low levels by proper catheter selection and insertion, careful selection and training of patients, avoidance of spiking techniques, and use of antibiotic prophylaxis against S. aureus. Further research is required to identify methods to reduce the risk of enteric peritonitis.

被引量：- 发表：2000

Improving adequacy of hemodialysis in Northern California ESRD patients: a final project report. Provider Participants and Medical Review Board of the TransPacific Renal Network.

被引量：- 发表：2000

Network 12 hepatitis B vaccination quality improvement program: an educational program directed at physicians, staff, and patients.

:Hepatitis B is easily spread via contact with infected blood. Hemodialysis patients and staff are particularly at risk for acquiring hepatitis B. Consequently, vaccination of hemodialysis patients and staff is strongly recommended. However, the vaccination rate among dialysis patients in this country remains below 50%. End-Stage Renal Disease (ESRD) Network 12 developed a quality improvement project directed at increasing patient vaccination by regular surveys, reports, and education of physicians, staff, and patients. Seventy-seven percent of facilities in the 4-state Network participated. Overall vaccination rate increased from 66.9% to 73.2% over 18 months (P <.05). The greatest improvement was seen among units with less than 60% of patients vaccinated initially, with mean facility vaccination rate increasing from 31.2 +/- 20.5% to 57.5 +/- 30.1% in the last available data period (P <.001). Only 3 of these 29 units failed to improve. The 90 units that had 60% to 97% vaccination rates initially improved significantly from 79.8 +/- 9.6% to 82.4 +/- 15% (P =.015). Three quarters of these units showed improvement. Only units with 100% vaccination deteriorated, but still maintained vaccination rates of 74.5 +/- 25.6%. An education-based quality improvement project can improve the hepatitis B vaccination rate of hemodialysis patients.

被引量：- 发表：2000

Unraveling the realities of vascular access: the Network 11 experience.

Arteriovenous (AV) fistulae are well recognized as the preferred vascular access for hemodialysis, yet national data show that only 23% of patients used an AV fistula in 1997. To identify barriers to the placement of native AV fistulae, the Renal Network of the Upper Midwest, Inc. (End-Stage Renal Disease [ESRD] Network 11) initiated a vascular access project to look at the process of referral for patients beginning hemodialysis in the first 6 months of 1999. Of these patients, 63% began hemodialysis with a catheter as the only access, 22% had an AV fistula placed (but only 14% used an AV fistula for their first dialysis treatment), and 15% began with a graft. About 40% of patients were referred to a nephrologist less than 1 month before dialysis, allowing little chance for permanent access placement. Yet 27% of patients used a catheter on the first hemodialysis treatment and were seen by a nephrologist more than 1 month before starting dialysis, indicating the presence of an opportunity to improve. At 6 months after initiation of dialysis, 25% of patients who began dialysis using a catheter were using an AV fistula and 35% were using a graft. Network 11 plans to use this information to promote early referral of patients to a nephrologist and subsequent prompt referral of such patients to a vascular surgeon. Other activities to improve vascular access management are also indicated.

被引量：- 发表：2000