In both the incident and prevalent dialysis patient populations, admissions with a primary discharge diagnosis of bacteremia or septicemia increased steadily during the study era, predating the advent of MS-DRGs. Admission rates in the incident dialysis patient population have been roughly 50 percent higher than those among prevalent patients, likely pointing to the influence of venous catheters as a critically important source of infection-related morbidity in patients initiating chronic dialysis. The relatively large discordance between rates based on primary diagnosis codes and on corresponding rates based on both primary and leading diagnosis codes may partially reflect the development of bloodstream infections during hospitalization for localized infections. Medicare claims in the modern era include present-on-admission (POA) codes that may be exploited to assess the development of complications during hospitalization, although there are no published data about the use of these codes among hospitalized dialysis patients.
While rates varied by 100 percent between the Census Divisions with the lowest and highest first-year admission rates among incident dialysis patients in 2010, the secular trend of increasing rates was consistent across all divisions. Among incident dialysis patients, rates were highest in the Middle Atlantic, East North Central, and Pacific divisions. Among prevalent patients, these same areas were joined by the West North Central division.
Again likely a manifestation of early reliance on catheters for vascular access, admission rates for bacteremia and septicemia during the first year of dialysis actually peak during the second month of dialysis, in contrast to the consistent peaks of admissions for specific forms of cardiovascular disease during the first month. This latency is predictable, as localized catheter infections progress to septicemia during the first weeks on dialysis. The most reliable solution to this problem is to avoid catheters in the first place, but this requires placing fistulas and grafts before dialysis initiation. Doing so is no trivial task and, in any case, is outside the scope of dialysis provider responsibilities. In the absence of higher use of permanent accesses at chronic dialysis initiation, prophylactic use of antibiotic agents may be worthwhile. Pragmatic trials of novel interventions are clearly needed.