Infection control

Hi Dr Agar,
Just looking for info please. I got a staph aureus infection and am in hospital undergoing treatment fluclox x4 times daily IV. My treatment has been excellent and I am extremely greatful for that. Thankfully I am writing to you now! They reckon it is through my access I got it. My access looks perfect, healthy, no evidence of infection around the button holes. I am compulsive obcessive about aseptic technique and think they might be wrong ie. Medical docs. I have had a very sore nose that wasn’t healing for at least three weeks previously, and I think it may have started there. For some bizarre reason I would feel better if that was considered the source!!For a couple of reasons, I try so hard to do my dialysis absolutely correct every time. this is my lifeline and having to accept I may have screwed up is a bit scary, but a real possibility I accept. Probably, if I’m honest my ego is a bit damaged, no longer the model patient!! Slightly nuts I appreciate, infact completely barking!! Here I have a life threatening bug and my poor little old ego is feelin sorry for itself LOL
Finally my questions. Is there a higher incidence of infections generally with home haemodialysis patients, in your experience? Is the incidence for infection higher with button hole needling have you found? What does the research say? Is it possible to definitively say where the infection started?
Hope you are well and are enjoying your enviable Aussie weather.we have 5C and hailstones here.
Bye for now

I am sitting in the Denver airport, passing time till my flight to LA and the start of a 26hr marathon home … I’ll need to make this one brief-ish - so do a f/u if this isn’t enough and I’ll reply when I recover though I go straight to open a national nurses vascular access practical use of ultrasound and needling hands-on workshop our unit runs each year … so it may be a bit of time before I get back with more answers …

1st … I am assuming (you’re being Rx with fluclox) that this is a sensitive staph.

Second - it could have come from either … did they nasally swab your for staph before they started A/B’s? … indeed there is an strong argument for undertaking nasal swabbing and mupirocin clearing of all home HD patient noses on a regular and routine basis. Its a common source for staph infection.

Is there a higher rate of infection in home dialysis patients c/w facility-based patients? … no!

But is there a higher incidence of access related sepsis in buttonhole vs ladder … yes!

We have published this in abstract form (as have out Brisbane colleagues) while Nesrallah and Pierratos has an elegant little paper on this earlier this year in - if my memory serves me correctly - CJASN where they showed a 6(ish) fold reduction (I am in an airport and doing this from memory) with mupirocin applied to the buttons.

We now routinely do the same … a teeny bleb of mupriocin to the needle site after post needle-withdrawal haemostasis and under the dot-bandaid.

There has been some talk of tract contamination (more a theoretical possibility then a proven clinical fact) in even the most fanatical scab-remover and button-cleanser patients - though there has been no proof.

As for the nose - my guess is you may be right. I’d get nasal swabs taken and if staph growth, then follow with mupirocin clearance. If positive, then recolonisation is common and repeated 4-6month swabbing and clearing should be routine … and one could argue do it anyway.

I would get your team to read Gihad Nesrallah’s paper … it came out maybe March or April 2010 … and I am convinced enough of both our own and their findings to suggest all home buttonholers follow their regimen. We have also used MediHoney … and though I personally prefer it to mupirocin and would suggest it as the better way … some of our patients don’t like the stickiness of the honey - though you only need a pins head size application.

So … to answer your questions … both or either is/are a possible source. I’d be taking action to cover both bets for future. Sustain your meticulousness … that’s important.

Have you nose checked and regularly de-staphified with mupirocin due the the inevitability of recolonisation.

Also consider future bleb-application of mupirocin (or MediHoney) to the button sites after haemostasis as an added measure of protection.

Don’t be put off … its sad you have had a staph hit - but its not a reason to desist from your current course … but just a reason to add some defense layers!

Time to fly - literally …

Good luck

Hi Dr Agar, no doubt by now you are well over your flight. I have done Ireland to Seattle a good few times, pre dialysis days, and even thinking about the ‘foreverness’ of the trip fills me with dread!! I’m kinda thinkin having had so much practice sitting in one place on dialysis! it might be heaps easier when I start to travel again. I cannot wait for that day to arrive.

Anyway my apologies for not thanking you for your reply sooner, so thanks a mill. Yes thankfully it is a sensitive staph.
Yes they took nasal swabs, but I had been on antibiotics a couple of days, maybe even 3 days. When I was incentre I had 3 monthly swabs but on home haemo, I have only been swabbed once. Something for me to talk to team about.

I was in for a checkup yesterday, and I suggested I could start using the honey and I think they thought I had finally lost the plot LOL Profs eyes always move in a rolling manner a slight degree upwards when the word ‘naturopathic’ or ‘holistic’ or anything remotely related is included in a sentence! I should mention he is incredibly professional and respectful in his approach, but the man is human. Of course having just reread your email, I realise I said manuka honey instead of medihoney. I think the term medihoney would have been wiser. Anyway Prof said no because I might push some into the tract causing infection. So I said I’d get a research paper on the subject. So I’m finally going to now chase up Gihad Nesrallah’s paper. I like the idea of the honey because, the new protocol is that we wash our fistula arm with antibacterial soap before we put Emla cream on, and use antibacterial soap again after we remove the Emla cream, and soak with chlorhexidine gluconate0.05% for one minute, scrape the scabs and wipe with 2% chlorhexidine swabs. I have no problem with doing any of that but this is so drying on the skin, and it is going to be a potential source of infection when skin cracks. In my opinion honey would protect the skinas well as preventing infection, or at least provide another layer in its prophylaxis.
Having the staph infection, and experiencing now the major nuciance treatment is proving to be! I am greatful to be well. I am even more determined to be as vigilant as I can be regarding aseptic technique, particularly on those days I’m a bit wrecked like everyone gets sometimes. This will nolonger be a valid excuse to give into the human temtation! of speeding up the steps of getting onto my machine.
Any further information or references on this topic would be greatfully received.
Thanks again Dr Agar,
Bye for now,

Dear Sineadee

Medihoney has been around quite a while. you can get info on it at but Johnson et al published work on its use in catheter exit site infections, there is a trial underway in Australia re its use in PD catheter exit site care (Honeypot trial) conducted by the Australian Kidney Trials Network and the Germans have published on it too … so its not quite ‘alternative’ in the sense that many might use that term.

hi Dr Agar,
thank you so much for all your input. I looked up the paper, found a few other relevent papers, followed up on yesterdays link which had loads of research references, composed an email to the Doc, and the honey is being discussed and considered at the next team meeting!! I’m going to buy some and give it a go, as I’ve been given the go ahead. So now onto research for availability on this side of the world and best prices…deals to be done LOL So your influence has gone global.
Thanks again,