JOURNAL READING

Oleh: dr. Yosefin Ratnaningtyas*

Pembimbing: Dr. dr. Atma Gunawan, Sp.PD-KGH**

Resident of Internal Medicine, Saiful Anwar General Hospital, Malang*

Supervisor at Nephrology Division, Internal Medicine Department, Saiful Anwar General Hospital, Malang **
INTRODUCTION
• Total number of end-stage renal
disease (ESRD) patients increased
>60% in a decade
• Infections cause more than one-
third of deaths in this population.
• Meticillin-resistant Staphylococcus
aureus (MRSA) : 14,041 invasive
infections in 2012 20% of MRSA-
colonized hemodialysis patients will
develop a severe infection during
the following 6-20 months
• Aim : to determine the risk factors
of MRSA colonization among
dialysis patients.
METHODS
• PubMed and EMBASE literature search
term as follows: (MRSA OR
Staphylococcus OR (methicillin AND
resistant) AND (dialysis OR
hemodialysis OR peritoneal).
• All studies were accessed full text,
considered eligible : nasal MRSA
carriage data among dialysis patients
 necessary inclusion criteria
• Study could include screening data > 1
anatomical site.
• English studies
• If there’s reason to clarify data
contact the authors
D a t a E x t r a c t i o n a n d
Q u a l i t y A s s e s m e n t
• Primary outcome : risk factors
identification for MRSA colonization
• 2 reviewers independently assessed
methodological quality using Newcastle
- Ottawa Quality Assessment Scale
(NOS)
• ‘Stars’ were given in the context :
representativeness of exposed cohort,
ascertainment of exposure, assessment
of outcome, adequacy of follow-up
time (outcomes), and adequacy of
follow-up of cohorts.
Data Synthesis and Analysis
• Risk factors reported as relative
risks (RRs) and odds ratios (ORs)
with 95% confidence intervals (CIs),
with heterogeneity measured by
Cochran’s Q.
• Publication bias was sought using
Egger’s regression test.
• Analyses were conducted using the
Stata, version 13, software package
(StataCorp LP, College Station, TX,
USA).
• The significance threshold was set
at P < 0.05.
R E S U LT S
R E S U LT S
 Recent hospitalization : 1.93 times higher compared to
patients without a hospitalization over the previous
year [odds ratio (OR): 1.93; 95% confidence interval
(CI): 1.04-3.58]
• MRSA colonization risk factors :
 the use of temporary dialysis
access : 66.2% increased
probability of being colonized
with MRSA (relative risk: 1.66;
95% CI: 1.06–2.60)
R E S U LT S
• MRSA colonization risk factors :
 MRSA carriage was associated
with lower serum albumin levels
compared to non-carriage (OR:
0.8; 95% CI: 0.68–0.95)
 MRSA carriage was 2.16 times
higher among patients with
chronic lung disease (OR: 2.16;
95% CI: 1.04–4.51)
DISCUSSION
• Dialysis patients more susceptible to
infections. Severity and mortality 
remains high
•  need to identify dialysis patient
that are at high risk for MRSA
colonization
• MRSA colonization more common
among patients with :
 recent hospitalization,
 temporary catheters,
 lower serum levels of albumin
 chronic lung disease
DISCUSSION
• Hospitalization during the previous
year  The crowded hospital setting
facilitates MRSA transmission,
contribution of MRSA spread when
patient return to HD unit
• However, these patients can be
easily identified  infection control
protocols = screening, isolation and,
decolonization policies.
• Previous history of MRSA  another
indication to intensified
decolonization protocols.
DISCUSSION
• Temporary catheters with MRSA
colonization  supports the use of
permanent access (i.e. fistula and graft)
that has less serious complications
• Patients who have to use catheters 
contribute to increased rates of MRSA
colonization
• Decreased albumin frequently caused
by poor nutrition  similar to the
association between hypo-
albuminaemia
• and MRSA colonization in geriatric
population  linked to increased
susceptibility to infection.
DISCUSSION
• Dialysis patients have impaired and
deregulated immune responses and
cellular immunity that is significantly
compromised
• Association between MRSA
colonization ~ chronic lung disease.
• defective mucus clearance in
lower airways, which predisposes to
pathogen colonization
L I M I TAT I O N
• All relative effects are unadjusted
for potential confounders
• Small number of studies, particularly
for the lower serum albumin and the
chronic lung disease assessment 
further evaluation with prospective
studies is needed.
• Due to the limited number of
patients per dialysis center
difficult to present adjusted data
 limited detailed data.
CONCLUSION
• Risk factors for MRSA colonization
among HD patients : recent
hospitalization, temporary catheters,
lower serum levels of albumin,
chronic lung disease
• Active monthly surveillance
approaches, including potential
decolonization strategies, are
suggested to focus on these
subgroups of haemodialysis patients
 especially before establishing
dialysis access
CONCLUSION
• Multi-centre collaborations are
needed in order to develop a more
accurate model predicting the
individual risk for MRSA colonization
 further research is required
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THANK YOU