Higher Access-Associated Bacteremia but Less Hospitalization Among Saudi Compared with US Hemodialysis Outpatients Aiman El-Saed,*† Abdullah Sayyari,†‡ Fayez Hejaili,†‡ Mahmoud Sallah,* Nimfa Dagunton* and Hanan Balkhy*† *Department of Infection Prevention and Control, King Abdulaziz Medical City, Riyadh, Saudi Arabia, †King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia and ‡Division of Nephrology & Renal Transplantation, King Abdulaziz Medical City, Riyadh, Riyadh, Saudi Arabia ABSTRACT Comparison of Saudi patients with chronic hemodialysis to an international benchmark was not performed before. We con- ducted a prospective surveillance study for all end-stage kidney disease patients served by the hemodialysis unit at King Abdu- laziz Medical City (KAMC) in Riyadh, SA, between May 2008 and December 2009. US National Healthcare Safety Network (NHSN) definitions were used for comparison. Among 227 patients with adverse events, 55% were women and their age was 60.2 ± 20.2 years. Events recorded included 339 all-cause hospitalizations, 302 outpatient start of intravenous antimicro- bials, and 174 access-associated bacteremias. In comparison with NHSN, hospitalization rate per 100 patient-months was lower (8.6 vs. 10.7, p < 0.001), rates of both antimicrobial start (7.6 vs. 3.5, p < 0.001) and access-associated bacteremia (4.4 vs. 1.3, p < 0.001) were higher, and blood cultures were more likely to grow gram-negative rods (47.9% vs. 21.3%, p < 0.001). Similar to NHSN, permanent catheter was associ- ated with highest, while arterio-venous fistula was associated with lowest event rates, irrespective of event type. KAMC had 2–4 times higher rates of access-associated bacteremia and anti- microbial start as well as a higher catheter prevalence (42% vs. 31%). The lower hospitalization may indicate good control of comorbidities at outpatient level or underutilization of inpatient services. There has been a constant increase in the number of patients receiving hemodialysis in Saudi Arabia (SA) over the last two decades. The number increased from about 3350 patients in 1993 to almost 11,000 in 2009 and expected to exceed 15,000 patients by 2015 (1). Being a long-term replacement therapy, hemodialysis is associ- ated with a high risk of morbidity and mortality (2–4). Among the three types of adverse events examined in he- modialysis centers participating in the US National Healthcare Safety Network (NHSN), hospitalization was the most frequently encountered adverse events fol- lowed by the start of intravenous (IV) antimicrobials and finally access-associated bacteremia (5). A hemodi- alysis patient in this network experienced on aver- age 7.7–34.7 hospitalization per 100 patient-months depending on the type of access used. Rates of hospital- ization were estimated in few studies in Saudi Arabia (2,6). However, none of these studies created NHSN comparable rates or rates adjusted to the type of access. Many factors contribute to the vulnerability of hemodialysis patients to infections. The presence of vas- cular access and frequent hemodialysis sessions expose the already immunosuppressed hemodialysis patients to a high risk of bacterial Infections (7,8). Access-associ- ated bacteremia in United States is an increasing cause for hospital admission among hemodialysis patients over the last two decades, despite the relatively constant hospitalization rates and decreasing mortality rates dur- ing the same period (9). Although the rates of access- associated bacteremia were estimated in few studies in SA (10,11), benchmarking is difficult because of the vari- ability of methods used as well as the lack of access-spe- cific rates. Although closely related to infections and hospitalization, we could not identify any study estimat- ing the use of IV antimicrobials among hemodialysis patients in SA. The objectives of this study were to esti- mate the standardized rates of adverse events associated with chronic hemodialysis in a Saudi hemodialysis center and to compare such rates with those reported by the NHSN centers. Address correspondence to: Hanan Balkhy, M.D., M.Med., FAAP, Director, GCC Center for Infection Control, Execu- tive Director, Infection Prevention and Control Depart- ment-2134, King Saud Bin Abdulaziz University for Health Sciences, P.O. Box 22490, Riyadh 11426, Saudi Arabia, Tel.: 96612520088-43720 / 13250, Fax: 96612520772, or e-mail: balkhyh@ngha.med.sa; balkhyh@hotmail.com Seminars in Dialysis—Vol 24, No 4 (July–August) 2011 pp. 460–465 DOI: 10.1111/j.1525-139X.2011.00919.x ª 2011 Wiley Periodicals, Inc. 460