Opoku‑Asare et al. BMC Infectious Diseases (2023) 23:664 BMC Infectious Diseases https://doi.org/10.1186/s12879‑023‑08581‑6 RESEARCH Open Access Catheter‑Related Bloodstream Infections among patients on maintenance haemodialysis: a cross‑sectional study at a tertiary hospital in Ghana Bismark Opoku‑Asare1, Vincent Boima1,2, Vincent Jessey Ganu1, Elvis Aboagye3, Olive Asafu‑Adjaye4, Anita Ago Asare5, Isaac Kyeremateng6, Edward Kwakyi1,2, Adwoa Agyei1,2, Eric Sampane‑Donkor7 and Peter Puplampu1,2* Abstract Background Catheter‑Related Bloodstream Infections (CRBSIs) are notable complications among patients receiving maintenance haemodialysis. However, data on the prevalence of CRBSIs is lacking. This study was conducted to deter‑ mine the prevalence and factors associated with CRBSIs among patients receiving haemodialysis in the renal unit of the largest tertiary hospital in Ghana. Methods A hospital‑based cross‑sectional study was conducted on patients receiving maintenance haemodialy‑ sis via central venous catheters (CVC) between September 2021 and April 2022. Multivariate analysis using logistic regression was used to determine the risk factors that were predictive of CRBSI. Analysis was performed using SPSS version 23 and a p‑value<0.05 was statistically significant. Results The prevalence of CRBSI was 34.2% (52/152). Of these, more than half of them (53.9%(28/52)) had Possible CRBSI while 11.5% (6/52) had Definite CRBSI. Among the positive cultures, 62% (21/34) were from catheter sites whilst the rest were from peripheral blood. Gram‑negative cultures made up 53% (18/34) of positive cultures with the rest being Gram positive cultures. Acinetobacter baumannii (33.3% (6/18)) was the commonest organism isolated among Gram‑negative cultures whilst Coagulase negative Staphylococci (43.7% (7/16)) was the commonest organism isolated among Gram‑positve cultures. Gram‑negative bacilli were more predominant in this study making up 52.9% of the total bacteria cultured. Sex, duration of maintenance dialysis, underlying cause of End‑stage kidney disease, mean corpuscular haemoglobin (MCH), neutrophil count and lymphocyte count were significantly predictive of CRBSI status (p<0.05). Conclusion There was a high prevalence of CRBSI among patients undergoing haemodialysis. The commonest causative agent was Coagulase negative Staphylococci, however there was a predominance of Gram‑negative bacilli as compared to Gram positive cocci. There is a need to set up infection surveillance unit in the renal unit to track CRBSI and put in place measures to reduce these CRBSI. Keywords Catheter‑related bloodstream infections, Central venous catheter, Haemodialysis *Correspondence: Peter Puplampu pedpup2@gmail.com Full list of author information is available at the end of the article © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http://creativecom‑ mons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Opoku‑Asare et al. BMC Infectious Diseases (2023) 23:664 Page 2 of 10 Background data on CRBSI prevalence and predisposing risk factors End-stage kidney disease (ESKD) which is an advanced although there are reports of increasing cases of ESKD. stage of chronic kidney disease (CKD) is a common The study, therefore, sought to determine the prevalence global health challenge that is rapidly increasing the bur- of CRBSIs and associated risk factors among patients on den and need for renal replacement therapy [1, 2]. The maintenance haemodialysis at the renal unit of KBTH. prevalence of CKD in Ghana is reported to be 13.3% [3]. This study laid bare the magnitude CRBSI had on chronic The commonest form of renal replacement therapy (RRT) dialysis programme at the KBTH. used to avert the complications of CKD such as uremia is renal haemodialysis [4]. Efficient haemodialysis requires Methods a well-functioning intravascular access which includes Study setting and design a native arteriovenous fistula, an arteriovenous graft or A hospital-based cross-sectional study was conducted a central venous catheter [5] . The most important risk at the renal dialysis unit of KBTH between September factor for bacteremia in patients on dialysis according to 2021 and April 2022. KBTH isthe largest tertiary hospi- studies is central venous catheters [6–8]. Catheter related tal in Ghana. The renal unit is a subspecialty under the sepsis may either be defined by surveillance or clinically. Department of Medicine at the KBTH. There are cur- The incidence of CRBSI during haemodialysis is high in rently a total of 18 dialysis machines with an isolation developed countries such as the United States of America area for dialysis of patients who have tested positive for and Canada as well as India, a middle-income country blood borne viruses (HIV, Hepatitis B, C and SARS- [6, 9–14]. A study in a tertiary referral hospital in South COV-2). The unit provides haemodialysis as a form of India [6] revealed an incidence rate of 7.34 episodes per renal replacement therapy. At the time of study there 1000 catheter days [7] . High incidence and prevalence were about 220 patients receiving chronic haemodialysis of CRBSI have also been reported in countries in Africa and majority of whom received dialysis at least 2 times a and for West Africa, in Nigeria [15, 16]. A laboratory week. surveillance study in Pretoria, South Africa reported the incidence rate of 10.1 episodes per 1000 catheter days, Study population 3.7 episodes per 1000 admissions and 0.57 per 1000 in- The study population included all patients aged 18 years patient days [15].A recent study in Nigeria demonstrated and above, diagnosed with ESKD. Those who had been a CRBSI prevalence of 33.3% in patients undergoing hae- receiving maintenance haemodialysis (MHD) for at least modialysis [17]. 3 months and had central venous catheters-in-situ for at Patients with end-stage renal disease are at increased least 2 weeks were eligible for the study. Patients being risk of infection [18]. The risk of CRSI in patients on hae- treated for alternate sources of infection like pneumonia modialysis increases with the length of central venous and malaria, those with AV fistula, those diagnosed with catheter access dependence [19, 20]. acute kidney injury and those receiving ultrafiltration for Their increased risk is because of impaired immunity, heart failure were excluded from the study. the presence of comorbidities, malnourishment and the repeated introduction of catheters during haemodialysis Operational definitions which breaks down the natural protective barrier [21]. The National Kidney Foundation Kidney Disease Out- Potential risk factors for CRBSI include underly- comes Quality Initiative (KDOQI) [24] definition of ing disease (such as lower haemoglobin level, lower CRBSIs was used. The definition is as follows: serum albumin level, diabetes mellitus, peripheral ath- erosclerosis), method of catheter insertion, site and dura- Definite tion of catheter insertion [22], poor personal hygiene, Same organism from a semiquantitative culture of the occlusive transparent dressing, moisture around the catheter tip (>15 CFU/catheter segment)  and  from a exit-site,  Staphylococcus aureus  nasal colonization, con- blood culture in a symptomatic patient with no other tiguous infections [22], contamination of dialysate or apparent source of infection. equipment, inadequate water treatment, dialyzer re-use, higher total intravenous iron dose, increased recombi- Probable nant human erythropoietin dose, and recent hospitali- Defervescence of symptoms after antibiotic therapy zation or surgery [23]. Hospital records from the Korle with or without removal of the catheter, in the setting in Bu Teaching hospital (KBTH) which is the third largest which blood culture confirms infection, but catheter tip hospital in Africa and the leading national referral cen- does not (or catheter tip does, but blood does not) in a tre in Ghana suggests increasing frequency of admis- symptomatic patient with no other apparent source of sions for dialysis patients. In Ghana, there is limited infection. O poku‑Asare et al. BMC Infectious Diseases (2023) 23:664 Page 3 of 10 Possible records included, whether dialysis was initiated as an Defervescence of symptoms after antibiotic treatment elective procedure or as an emergency, duration of main- or after removal of catheter in the absence of laboratory tenance haemodialysis, frequency of haemodialysis, cath- confirmation of bloodstream infection in a symptomatic eter insertion site, attendance at out-patient department patient with no other apparent source of infection. (OPD) haemodialysis clinic, previous history of CRBSI and the outcomes of the CRBSI treatment. A chest X-ray Sample size was done to rule out pneumonia. Using the standard prevalence study formula based on a study in Nigeria [16], the sample size calculated was 234. Sample collection, transportation and culture However, the patients on MHD at the time of study were A trained laboratory technologist drew 10 mls of whole 220, which was lower than the estimated sample size. blood aseptically from both the catheter lumen and the Hence using the formula for correcting for a finite pop- bloodstream from these patients andtransported to the ulation, the estimated sample size calculated with 10% laboratory in an ice chest in blood culture bottles. Blood attrition was 130. cultures were processed using automated culture sys- tems (BACTEC 9060) and cultures with a positive signal Data collection were sub-cultured by standard methods on Sheep blood Patients who met the inclusion criteria were recruited agar, chocolate agar and MacConkey agar. The agar plates after a written informed consent was sought. Recruited were incubated overnight, and isolated colonies identi- patients were screened and examined for CRBSI (Fig. 1). fied based on colonial morphology, Gram staining and a Trained research assistants administered the study battery of biochemical reactions, such as the triple sugar questionnaires whilst two medical officers physically iron test, catalase test, urease test, indole test and citrate examined the patients diagnosed with CRBSI. Patient utilization test were used to identify the bacterial organ- information collected included, socio-demographic fac- isms [25]. tors such as the age, sex, marital status, occupation, For patients whose blood cultures were negative (both educational level, the underlying cause of the ESKD, co- peripheral or catheter lumen or hub or tip), other alter- morbidities and current medications. Specific details native diagnoses were ruled out including urinary tract of haemodialysis extracted from the patient medical infection, Malaria, chest infection, infective endocarditis, Fig. 1 Flowchart for patients recruited into the study Opoku‑Asare et al. BMC Infectious Diseases (2023) 23:664 Page 4 of 10 or any abscess collection, and extensive clinical exami- Table 1 Background characteristics of study participants with nation was done to rule out any other sources of infec- CRBSI at the Korle Bu Teaching Hospital, Accra, Ghana, 2021‑2022 tion. After ruling out alternative diagnoses, then the most Characteristic Frequency Percentage likely source was determined to be the catheter. Age Mean ± SD 45.2 ± 14.3 Statistical analysis < 25 3 5.8 All data were entered in Microsoft Excel 2016. The data 25‑49 35 67.3 was exported and analyzed using SPSS version 23. Per- 50‑59 8 15.4 centages were computed to present variables such as age, ≥60 6 11.5 sex, causative microorganisms. The chi-square test was Sex performed to compare demographic and clinical vari- Female 20 38.5 ables (age, sex, comorbidities, duration of maintenance Male 32 61.5 haemodialysis, central venous catheter (CVC)insertion Marital status site) between the groups of patients with and without Divorced 1 1.9 Married 31 59.6 CRBSI. The p-value of less than 0.05 was considered sta- Single 17 32.7 tistically significant. Multivariate analysis using logistic Widowed 3 5.8 regression was used to determine the risk factors that are Education level predictive of CRBSI. Functionally illiterate 3 5.8 Primary 10 19.2 Results Secondary 23 44.2 Tertiary 16 30.8 Background characteristics of study participants Underlying cause of ESKD A total of 152 patients undergoing maintenance haemo- Chronic Glomerulonephritis 3 5.8 dialysis were recruited and screened for CRBSI. Of the Diabetes 8 15.4 number screened, 34.2% (52/152) had CRBSI. Of those Hypertension 25 48.1 who had CRBSI, their mean age was 45.2±14.3. Majority Retroviral infection 11 21.1 (61.5% (32/52))were male. Most (44.2% (23/52)) had at Othersa 5 9.6 least secondary form of formal education (Table 1). The Haemodialysis initiation commonest underlying cause of ESKD were hypertension Emergency 45 86.5 (48.1% (25/52)); retroviral infection (21.1% (11/52); and Elective 7 13.5 diabetes (15.4% (8/52)) Eighty seven percent (45/52) of Duration of maintenance dialysis patients had dialysis initiated as an emergency and 73.1% 3‑ <6months 39 74.9 (38/52)had central venous catheters inserted through the 6‑ <12months 7 13.5 right internal jugular vein. (Table 1) 1‑5years 4 7.7 >5years 2 3.9 Frequency of haemodialysis Prevalence of CRBSIs Once a week 8 15.4 The prevalence of CRBSI was 34.2% (95% CI: 26.7 – Once or twice a week 1 1.9 42.3%). Among patients with CSRBI, more than half Twice a week 39 75 (53.9%(28/52))) had Possible CRBSI while 11.5% (6/52) Three times a week 4 7.7 had Definite CRBSI (Fig. 2). Catheter insertion site Majority of the patients presented with general Left femoral vein 1 1.9 malaise(77%), fever(73%),chills/rigors(67.3%), and vomit- Right femoral vein 13 25.0 ing(44.2%). (Table 2). Right internal jugular vein 38 73.1 Regular dialysis clinic attendance No 13 25 Physical examination Yes 39 75 Weight and height could not be measured for 15 par- Previous history of CRBSI ticipants because they were neither able to ambulate No 43 82.7 nor stand. Hence no body mass index was computed for Yes 9 17.3 these patients. Among the 137 participants with BMI, a Alport syndrome, SLE, Polycystic kidney disease, Lupus nephritis; ESKD 38.0% had normal BMI; 34.3% were overweight. Almost End‑stage kidney disease, CRBSI Catheter‑related bloodstream infections, SD Standard deviation all (94.7%) participants were clinically pale. About half (52%) had pedal oedema. O poku‑Asare et al. BMC Infectious Diseases (2023) 23:664 Page 5 of 10 Fig. 2 Classification of CRBSI among study participants at the Korle Bu Teaching Hospital, Accra, Ghana, 2021‑2022. Table 2 Clinical symptoms amongst study participants with have been on maintenance dialysis for a year or more CRBSI at the Korle Bu Teaching Hospital, Accra, Ghana, 2021‑2022 compared those who have been on maintenance dialy- Frequency Percentage sis for less than a year (aOR: 0.07, 95%CI: 0.01 – 0.62). (Table 3) General malaise 40 77.0 Fever 38 73.0 Microbial causative agents Chills/Rigors 35 67.3 Of the 104 cultures that were conducted for patients with Vomiting 23 44.2 CRBSI, the culture positivity rate was 32.7% (34/104). Nausea 17 32.7 For cultures that were positive, 62% (21/34) were from Altered mental status 13 25.0 catheter site and the rest were from peripheral blood Intradialytic hypotension 16 30.7 cultures. Of all positive cultures, 47.1% (16/34) yielded Catheter dysfunction 7 13.5 Gram-positive organisms and 52.9% (18/34) yielded Hypothermia 1 0.2 Gram-negative organisms. Coagulase negative Staphylo- cocci (43.7%) was the commonest cultured Gram-positive organism, followed by Staphylococcus aureus (31.3%) (Table 4). Among the Gram-negative organisms cultured, Predictors of CRBSIs among study participants Acinetobacter baumannii (33.3%), Pseudomonas aerugi- The multivariate logistic regression model showed that nosa (22.2%) and Klebsiella pneumoniae (22.2%) were the sex, duration of maintenance dialysis, underlying cause most cultured organisms. (Table 4) of ESKD, mean corpuscular haemoglobin (MCH), neu- trophil count and lymphocyte count were significantly predictive of CRBSI status (p<0.05). From the adjusted Discussion logistic regression model, the odds of having CRBSI was The prevalence of catheter-related bloodstream infec- about 6 times higher among males compared to females tions (CRBSI) was 34.2% among the study participants. (aOR: 5.74, 95%CI:1.24 -26.55). The odds of developing Among the 52 participants with CRBSI, more than half CRBSI were 78% lower among participants whose ESKD of them had possible CRBSI, 34.9% had probable CRBSI was caused by diabetes compared to those whose ESKD and the rest had definite CRBSI. General malaise, fever was caused by other causes (aOR: 0.22, 95%CI: 0.05 – and chills or rigor were the most common clinical pres- 0.93). After adjusting for all other co-variates, the odds entation. Risk factors that were independently predictive of having CRBSI was 93% lower among participants who of CRBSI included male sex, duration of maintenance Opoku‑Asare et al. BMC Infectious Diseases (2023) 23:664 Page 6 of 10 Table 3 Predictors of CRBSI of study participants at the Korle Bu Teaching Hospital, Accra, Ghana, 2021‑2022 Unadjusted Logistic Regression Model Adjusted Logistic Regression Model uOR 95% CI P-value aOR 95% CI P-value Age 1.01 0.99 – 1.03 0.495 1.05 0.99 – 1.11 0.078 Sex Female 1.00 1.00 Male 1.48 0.74 – 2.93 0.264 5.74 1.24 – 26.55 0.025 Haemodialysis initiation Emergency 1.00 1.00 Elective 0.55 0.22 – 1.4 0.209 0.28 0.04 – 2.14 0.221 Underlying cause of ESKD Others 1.00 1.00 Hypertension 0.55 0.2 – 1.51 0.244 0.30 0.03 – 2.76 0.288 Diabetes 0.63 0.3 – 1.36 0.24 0.22 0.05 – 0.93 0.04 Duration of MHD <1year 1.00 1.00 ≥1year 0.34 0.13 – 0.88 0.026 0.07 0.01 – 0.62 0.017 Frequency of MHD <3times 1.00 1.00 ≥3times 0.61 0.19 – 2.01 0.417 0.24 0.02 – 2.77 0.254 Catheter insertion site Femoral Vein 1.00 1.00 Jugular Vein 1.05 0.49 – 2.28 0.894 0.89 0.15 – 5.26 0.896 Regular clinic follow-up No 1.00 1.00 Yes 1.05 0.49 – 2.28 0.894 0.66 0.14 – 3.12 0.604 Previous CRBSI No 1.00 1.00 Yes 1.53 0.6 – 3.93 0.372 6.61 0.57 – 76.97 0.132 Hb(g/dl) <10 Low Low 1.00 10‑12 Normal 0.45 0.12 – 1.67 0.232 0.22 0.01 – 3.76 0.296 >12 High 0.90 0.08 – 10.22 0.929 1.29 0.05 – 35.86 0.879 MCV (fL) <75 Low 1.00 1.00 75‑100 Normal 0.80 0.33 – 1.92 0.617 1.96 0.28 – 13.82 0.498 MCH (pg) <25 Low 1.00 1.00 25‑30 Normal 0.59 0.28 – 1.23 0.16 0.20 0.03 – 1.49 0.117 >30 High 0.49 0.11 – 2.12 0.343 0.07 0.01 – 0.41 0.003 Neutrophil count (x 109/L) <2 Low 1.00 1.00 2‑7 Normal 0.38 0.08 – 1.72 0.207 0.01 0.001 – 0.12 0.001 >7 High 2.47 0.57 – 10.75 0.229 0.71 0.01 – 34.85 0.865 Lymphocyte count (x 109/L) <1 Low 1.00 1.00 1‑3 Normal 1.87 0.69 – 5.05 0.22 11.29 1.62 – 78.64 0.014 >3 High 1.19 0.24 – 5.99 0.835 0.85 0.07 – 10.73 0.901 Platelet count (x 109/L) <150 Low 1.00 1.00 150‑400 Normal 0.59 0.26 – 1.37 0.219 0.43 0.09 – 2.14 0.301 >400 High 1.34 0.45 – 3.96 0.597 2.58 0.35 – 19.07 0.353 uOR Unadjusted odds ratio, aOR Adjusted odds ratio, CI Confidence interval, HD means haemodialysis, ESKD means end‑stage kidney disease, CRBSI means Catheter‑ related bloodstream infection, Hb means haemoglobin, MCV means mean corpuscular volume, MCH means mean corpuscular haemoglobin, g/dl gram per decilitre, fL Femtolitre, pg: picogram, L Litre O poku‑Asare et al. BMC Infectious Diseases (2023) 23:664 Page 7 of 10 Table 4 Microbial organisms cultured among blood cultures dialysis management protocol in 2011 [32]. A study was conducted among patients with CRBSI at the Korle Bu Teaching carried out with this protocol in 17 outpatient dialy- Hospital, Accra, Ghana, 2021‑2022 sis units which reporting findings of a 54% reduction Gram Positive Organisms (n=16) Gram Negative Organisms (P<0.001) in catheter related blood stream infections (n=18) [29]. Nasal Staphylococcus aureus decolonisation has N (%) N (%) been shown to reduce the risk of CRBSI [33]. A study done in the northern region of Ghana demonstrated Coagulase Negative Staphy- 7(43.7) Acinetobacter baumannii 6(33.3) high Staphylococcus aureus nasal carriage among health lococci care workers, in patients and caregivers with health care Staphylococcus aureus 5(31.3) Pseudomonas aeruginosa 4(22.2) workers having the highest rate of Methicillin-resistant Enterococcus 2(12.5) Klebsiella pneumoniae 4(22.2) Staphylococcus aureus (MRSA) carriage [34]. Further Bacillus (Most likely contami- 2(12.5) Escherichia coli 2(11.1) nant) studies to determine MRSA carriage among health care Enterobacter 1(5.6) workers in our setting is paramount to determine its con- Citrobacter 1(5.6) tribution to CRBSI. From our study, the odds of having CRBSI was about 6 times higher among males compared to females. How- dialysis, the underlying cause of ESKD (diabetes), MCH, ever, this effect should be treated with caution due to neutrophil and lymphocyte count. its wider confidence interval. Studies elsewhere have The prevalence of CRBSI among patients on haemo- reported mixed results with regards to gender. A study dialysis in KBTH according to this study is 34.2%. Other by Hadian et al involving 122 patients on haemodialysis centres globally have reported lower rates of between 4.2 reported that male gender was a statistically significant and 5.6% [26, 27]. The prevalence in this study however risk factor for the development of CRBSI [35]. Another is comparable to a study done in Nigeria which reported study by Gomez et  al reported that more males devel- a prevalence of 33.3% amongst 171 patients on haemo- oped CRBSI compared to females [27]. A study by Fys- dialysis [28]. A previous study in Nigeria reported a araki et  al also found that females had more CRBSI as much lower prevalence of 18.8% and this was attributed compared to males [21] but a study by Mohamed et  al to a majority of the patients being lost to follow up and however demonstrated no gender effect on infection it may therefore have been an under-representation of rates [36]. Age in this study was not found to be signifi- what actually pertains [16]. There are several reasons that cantly associated with CRBSI but a study conducted by could account for the high prevalence of CRBSI in our Murea et al demonstrated that the elderly are at a lower renal unit. Currently at the unit there is no written down risk of catheter related blood stream infections in dialysis protocol with regards to catheter care and infection pre- compared to their younger counterparts [28]. vention. Skin asepsis before the insertion of CVC is done This study found also out that odds of developing CRBSI with povidone iodine and 70% isopropyl alcohol but the was 78% lower among participants whose ESKD was standard of care however is use 2% aqueous chlorhex- caused by diabetes compared to those whose ESKD was idine glucuronate and 70% isopropyl alcohol [29]. The caused by other causes. The study in addition found out use of 2% aqueous Chlorhexidine glucuronate plus 70% that the second most common cause of ESKD was diabe- isopropyl alcohol has been shown to significantly inhibit tes (18.4%) and hypertension was the most common cause growth of normal skin as compared to those with 10% of ESKD making up 52% of the cases seen. In most devel- povidone iodine plus 70% isopropyl alcohol [30]. oping countries though, the leading cause of ESKD [37] is The high prevalence of CRBSI will therefore require a diabetes and presently the leading cause of ESKD in Sub more stringent application of all the preventive strategies Saharan Africa is hypertension but diabetes is fast becom- required like enforcing all patients use of topical antimi- ing the leading cause [38, 39]. The few number of patients crobials like mupirocin in the unit and strict enforcement with diabetes in this study may have affected the outcomes of all infection prevention control (IPC) measures by staff in this study and more work needs to be done in another and patients alike. Another contribution to the increased study with a larger sample size to determine the true effect prevalence of CRBSI as reported by this study may partly of diabetes mellitus on the prevalence of CRBSI. be the result of the non-use of the antiseptic/antibiotic In our study, the culture positivity rate among those lock system. It has been shown that the prophylactic use who had CRBSI was 32.7%. This culture positivity was of a combination of an antibiotic-anticoagulant cath- similar to findings from another study by Bello et  al eter lock system results in a 50-100% reduction in blood reporting a culture positivity among patients with CRBSI stream infections [31]. The Centre for Disease Control of 33.3% [17] but higher than findings of culture posi- Dialysis Collaborative published a list of comprehensive tivity of 27.3% by Amira et  al [16] .. However, a study Opoku‑Asare et al. BMC Infectious Diseases (2023) 23:664 Page 8 of 10 by Farrington et al reported an culture positivity of 85% Abbreviations [19] which was higher than the findings in our study. This CRBSIs Catheter‑Related Bloodstream Infections ESKD E nd‑stage kidney disease higher culture positivity rate could be as a result of well MHC m ean corpuscular haemoglobin enforced restrictions on use of antibiotics in their popu- CKD chronic kidney disease lations and also the ability to culture fastidious organisms RRT renal replacement therapy KBTH Korle Bu Teaching hospital in most of these centres [40] which is lacking in develop- HIV H uman Immunodeficiency Virus ing countries such as Ghana [41]. KDOQI Kidney Disease Outcomes Quality Initiative Most patients after reporting to peripheral clinics in MHD M aintenance Haemodialysis OPD out‑patient department Ghana may have been exposed to antibiotics before a PI Principal Investigator referral to the teaching hospital. Hence, there is a reduced likelihood of culturing any organism in their blood at the Acknowledgements We thank all the patients who participated in the study for their contribu‑ tertiary level Another reason for the lower culture posi- tions. We also thank the staff of the medical wards for their collaboration tivity rate in our study may be that only aerobic cultures during the study. were done in this study and therefore the possibility of Authors’ contributions missing out on diagnosis of fastidious bacteria which will BOA, VB, PP, ESD and VJG were involved in study conception and study design. therefore result in under-reporting of positive cultures. BOA and VJG were involved in data collection. BOA, VJG, EA, OA, AAA and IK In developed countries, the picture is quite different as were involved in data review and analysis, manuscript writing and review. VB, PP, ESD were involved in manuscript writing, review, and finalization of manu‑ they report much higher culture positivity. script. AA and EK were involved in manuscript writing, review, and finalization Notably, a little less than half (47.1%) of the bacteria of manuscript. All authors read and approved the final manuscript. cultured was Gram-positive and 52.9% of the organisms Funding cultured were Gram negative indicating a predominance There was no funding for this study as authors contributed to fund the study of Gram-negative bacteria. This is in keeping with recent themselves. global studies which have reported a shift in the epide- Availability of data and materials miology of CRBSI from Gram positives to Gram nega- The datasets generated and/or analysed during the current study are not tives [42–44]. It has been suggested by El-Kady et al that publicly available due the regulations of the KBTH Ethics Committee and in health settings, a high rate of infection with Gram IRB regulations but are available from the corresponding author (Dr Peter Puplampu, pedpup2@gmail.com) on reasonable request. negative bacilli should raise concern about possible inadequate hand hygiene and poor compliance to cath- Declarations eter maintenance precautions [44]. The most common Gram-positive bacteria cultured in this study however Ethics approval and consent to participate was coagulase negative Staphylococci (20.6%) This find- Ethical approval was obtained from the Scientific and Technical Committee and the Institutional Review Board (IRB) of the Korle‑Bu Teaching Hospital (KBTH), ing is similar to other studies where Coagulase negative with number KBTH‑IRB/00098/2020. Permission was obtained from the Depart‑ Staphylococci was also reported asthe most predominant ment of Medicine and the head of renal unit. An informed consent form was Gram-positive bacterial causative agent [36, 44]. signed or thumb‑printed by participants before enrolment into the study. All methods were carried out in accordance with relevant guidelines and regula‑ tions of the KBTH Ethical Committee, IRB and the Declaration of Helsinki. Study limitations Anaerobic cultures were not conducted in this study Consent for publicationNot applicable. which is limitation. Our non-conduct of anaerobic cul- tures, which identifies fastidious bacteria, may have led Competing interests to under-reporting of culture positivity in our study. The authors declare no competing interests. Author details 1 Conclusion Department of Medicine, Korle Bu Teaching Hospital, Accra, Ghana. 2 Depart‑ ment of Medicine & Therapeutics, University of Ghana Medical School, Accra, There is high prevalence (34.2%) of CRBSI at the KBTH Ghana. 3 West African Centre for Cell Biology of Infectious Pathogens, Univer‑ dialysis unit. The factors significantly predictive of CRBSI sity of Ghana, Accra, Ghana. 4 Greater Accra Regional Hospital, Accra, Ghana. 5 among patients include male sex, short duration of main- Department of Community Health, University of Ghana Medical School, Accra, Ghana. 6 Ghana Health Service, Accra, Ghana. 7 Department of Medical tenance dialysis using the CVCs, ESRD caused by dia- Microbiology, University of Ghana Medical School, Accra, Ghana. betes, neutrophil count, and lymphocyte count. 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