Nasal and Cutaneous Flora Among Hemodialysis Patients and Personnel: Quantitative and Qualitative Characterization and Patterns of Staphylococcal Carriage

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Abstract

Staphylococcal sepsis is a leading cause of morbidity and mortality among chronic hemodialysis (HD) patients. We studied nasal and cutaneous flora of HD patients and personnel and their patterns of staphylococcal carriage. HD patients had significantly increased cutaneous total bacterial colony counts (p less than 0.01) as well as both nasal (p less than 0.0001) and cutaneous (p less than 0.0001) carriage of Staphylococcus aureus compared to personnel. Cutaneous staphylococcal carriage could be significantly correlated with nasal carriage (p less than 0.01). Cutaneous streptococcal species and gram-negative bacilli were not different between patients and personnel. Staphylococcal phage typing of nasal isolates from staphylococcal carriers revealed a mean of 90% of isolates from each subject belonging to a predominant phage type. Predominant nasal staphylococcal phage types corresponded with respective predominant cutaneous phage types in 93% of HD patients carriers. These studies substantiate autoinoculation of S. aureus from the nasal vestibule to the skin overlying the vascular access site.

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Most cited references 25

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We attempted to define the substances that contribute to the characteristic "uremic breath" of patients with end-stage renal disease. Breath samples from nine patients underwent direct analysis before and after hemodialysis with use of gas chromatography and confirmation by mass spectrometry, and indirectly assessment by an organoleptic panel. Concentrations of secondary and tertiary amines, dimethylamine and trimethylamine were increased, with subsequent reduction after hemodialysis (dimethylamine from 2.00 +/- 0.19 [S.E.M.] to 0.88 +/- 0.12 microng per 30 minutes, P less than 0.001, and trimethylamine from 0.79 +/- 0.22 to 0.44 +/- 0.15 microng per 30 minutes, P less than 0.003). Treatment with nonabsorbable antibiotics in two patients reduced both serum and breath amine levels without dialysis. Loss of nitrogen via the breath was not quantitatively important. We conclude that uremic breath reflects the systemic accumulation of potentially toxic volatile metabolites, among which dimethylamine and trimethylamine have been positively identified and correlated with the classic fishy odor.

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Septicemia in patients on chronic hemodialysis.

N H Steigbigel, J F Dobkin, M. H. MILLER (1978)

Bacterial sepsis, a major complication of chronic hemodialysis, is due mainly to infections of the vascular access site despite increasing use of internal fistulas. Sixty episodes of septicemia occurred in two chronic dialysis centers, with an incidence of 0.15 episodes of significant bacteremia per patient-dialysis-year in each. Forty-four of the 60 episodes were judged to be due to vascular access site infection by clinical, bacteriologic, and histologic criteria. Seventy percent (31 of 44) of the vascular access site-related episodes were due to staphylococci and 25% (11 of 44) to Gram-negative bacilli; nonvascular access site-related episodes were often due to transplant site infections caused by Gram-negative bacilli or streptococci. Mortality was about 18% in both vascular access site-related and nonrelated septic episodes. Bovine heterograft arteriovenous fistulas more often led to sepsis than did Brescia arteriovenous fistulas. Treatment with appropriate antibiotics was successful in most cases. Routine removal or ligation of the vascular access site was not necessary.