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Relationship between Clinical Outcomes and Vascular Access Type among Hemodialysis Patients with Staphylococcus aureus Bacteremia

Jula K. Inrig^*, Shelby D. Reed, Lynda A. Szczech^*, John J. Engemann, Joelle Y. Friedman, G. Ralph Corey, Kevin A. Schulman, L. Barth Reller, and Vance G. Fowler, Jr.

^* Department of Medicine, Division of Nephrology, Department of Medicine, Division of Infectious Diseases, and Department of Medicine, Duke University Medical Center, and Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Durham, North Carolina

Address correspondence to: Dr. Jula K. Inrig, Duke University Medical Center, North Pavilion, 2400 Pratt Street, Box 3646, Durham, NC 27705. Phone: 919-668-7516; Fax: 919-668-7128; E-mail: inrig001{at}mc.duke.edu

The association between hemodialysis vascular access type, costs, and outcome of Staphylococcus aureus bacteremia (SAB) among patients with ESRD remains incompletely characterized. This study was undertaken to compare resource utilization, costs, and clinical outcomes among SAB-infected patients with ESRD by hemodialysis access type. Adjusted comparisons of costs and outcomes were based on multivariable linear regression and multivariable logistic regression models, respectively. A total of 143 hospitalized hemodialysis-dependent patients had SAB at Duke University Medical Center between July 1996 and August 2001. A total of 111 (77.6%) patients were hospitalized as a result of suspected bacteremia; 32 (22.4%) were hospitalized for other reasons. Of the 111 patients, 59.5% (n = 66) had catheters as their primary access type, 36% (n = 40) had arteriovenous (AV) grafts, and 4.5% (n = 5) had AV fistulas. Patients with fistulas were excluded from analyses because of small numbers. Patients with catheters were more likely to be white, had shorter dialysis vintage, and had higher Acute Physiology and Chronic Health Evaluation II scores compared with patients with grafts. Unadjusted 12-wk mortality did not significantly differ between patients with catheters compared with patients with grafts (22.7 versus 10.0%; P = 0.098); neither did 12-wk costs differ by access type ($22,944 ± 18,278 versus $23,969 ± 13,731, catheter versus graft; P > 0.05). In adjusted analyses, there was no difference in 12-wk mortality (odds ratio 1.63; 95% confidence interval 0.29 to 9.02; catheter versus graft) or 12-wk costs (means ratio 0.84; 95% confidence interval 0.60 to 1.17; catheter versus graft) among SAB-infected patients with ESRD on the basis of hemodialysis access type. Twelve-week mortality and costs that are associated with an episode of SAB are high in hemodialysis patients, regardless of vascular access type. Efforts should focus on the prevention of SAB in this high-risk group.