Waning of Measured Influenza Vaccine Effectiveness Over Time: The Potential Contribution of Leaky Vaccine Effect.

BACKGROUND: Several observational studies have shown decreases in measured influenza vaccine effectiveness (mVE) during influenza seasons. One study found decreases of 6-11%/month during the 2011-2012 to 2014-2015 seasons. These findings could indicate waning immunity but could also occur if vaccine effectiveness is stable and vaccine provides partial protection in all vaccinees ("leaky") rather than complete protection in a subset of vaccinees. Since it is unknown whether influenza vaccine is leaky, we simulated the 2011-2012 to 2014-2015 influenza seasons to estimate the potential contribution of leaky vaccine effect to the observed decline in mVE. METHODS: We used available data to estimate daily numbers of vaccinations and infections with A/H1N1, A/H3N2, and B viruses. We assumed that vaccine effect was leaky, calculated mVE as 1 minus the Mantel-Haenszel relative risk of vaccine on incident cases, and determined the mean mVE change per 30 days since vaccination. Because change in mVE was highly dependent on infection rates, we performed simulations using low (15%) and high (31%) total (including symptomatic and asymptomatic) seasonal infection rates. RESULTS: For the low infection rate, decreases (absolute) in mVE per 30 days after vaccination were 2% for A/H1N1 and 1% for A/H3N2and B viruses. For the high infection rate, decreases were 5% for A/H1N1, 4% for A/H3, and 3% for B viruses. CONCLUSIONS: The leaky vaccine bias could account for some, but probably not all, of the observed intraseasonal decreases in mVE. These results underscore the need for strategies to deal with intraseasonal vaccine effectiveness decline.

Seasonal Incidence of Symptomatic Influenza in the United States.

Background: The seasonal incidence of influenza is often approximated as 5%-20%. Methods: We used 2 methods to estimate the seasonal incidence of symptomatic influenza in the United States. First, we made a statistical estimate extrapolated from influenza-associated hospitalization rates for 2010-2011 to 2015-2016, collected as part of national surveillance, covering approximately 9% of the United States, and including the existing mix of vaccinated and unvaccinated persons. Second, we performed a literature search and meta-analysis of published manuscripts that followed cohorts of subjects during 1996-2016 to detect laboratory-confirmed symptomatic influenza among unvaccinated persons; we adjusted this result to the US median vaccination coverage and effectiveness during 2010-2016. Results: The statistical estimate of influenza incidence among all ages ranged from 3.0%-11.3% among seasons, with median values of 8.3% (95% confidence interval [CI], 7.3%-9.7%) for all ages, 9.3% (95% CI, 8.2%-11.1%) for children <18 years, and 8.9% (95% CI, 8.2%-9.9%) for adults 18-64 years. Corresponding values for the meta-analysis were 7.1% (95% CI, 6.1%-8.1%) for all ages, 8.7% (95% CI, 6.6%-10.5%) for children, and 5.1% (95% CI, 3.6%-6.6%) for adults. Conclusions: The 2 approaches produced comparable results for children and persons of all ages. The statistical estimates are more versatile and permit estimation of season-to-season variation. During 2010-2016, the incidence of symptomatic influenza among vaccinated and unvaccinated US residents, including both medically attended and nonattended infections, was approximately 8% and varied from 3% to 11% among seasons.

Outbreak of Middle East Respiratory Syndrome at Tertiary Care Hospital, Jeddah, Saudi Arabia, 2014.

During March-May 2014, a Middle East respiratory syndrome (MERS) outbreak occurred in Jeddah, Saudi Arabia, that included many persons who worked or received medical treatment at King Fahd General Hospital. We investigated 78 persons who had laboratory-confirmed MERS during March 2-May 10 and documented contact at this hospital. The 78 persons with MERS comprised 53 patients, 16 healthcare workers, and 9 visitors. Among the 53 patients, the most probable sites of acquisition were the emergency department (22 patients), inpatient areas (17), dialysis unit (11), and outpatient areas (3). Infection control deficiencies included limited separation of suspected MERS patients, patient crowding, and inconsistent use of infection control precautions; aggressive improvements in these deficiencies preceded a decline in cases. MERS coronavirus transmission probably was multifocal, occurring in multiple hospital settings. Continued vigilance and strict application of infection control precautions are necessary to prevent future MERS outbreaks.

Health care worker contact with MERS patient, Saudi Arabia.

To investigate potential transmission of Middle East respiratory syndrome coronavirus (MERS-CoV) to health care workers in a hospital, we serologically tested hospital contacts of the index case-patient in Saudi Arabia, 4 months after his death. None of the 48 contacts showed evidence of MERS-CoV infection.

Adverse event reports after tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines in pregnant women.

OBJECTIVE: We sought to characterize reports to the Vaccine Adverse Event Reporting System (VAERS) of pregnant women who received tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap). STUDY DESIGN: We searched VAERS for reports of pregnant women who received Tdap from Jan. 1, 2005, through June 30, 2010. We conducted a clinical review of reports and available medical records. RESULTS: We identified 132 reports of Tdap administered to pregnant women; 55 (42%) described no adverse event (AE). No maternal or infant deaths were reported. The most frequent pregnancy-specific AE was spontaneous abortion in 22 (16.7%) reports. Injection site reactions were the most frequent non-pregnancy-specific AE found in 6 (4.5%) reports. One report with a major congenital anomaly (gastroschisis) was identified. CONCLUSION: During a time when Tdap was not routinely recommended in pregnancy, review of reports to VAERS in pregnant women after Tdap did not identify any concerning patterns in maternal, infant, or fetal outcomes.

The risk of Guillain-Barré syndrome associated with influenza A (H1N1) 2009 monovalent vaccine and 2009-2010 seasonal influenza vaccines: results from self-controlled analyses.

PURPOSE: The Centers for Disease Control and Prevention Emerging Infections Program implemented active, population-based surveillance for Guillain-Barré syndrome (GBS) following H1N1 vaccines in 10 states/metropolitan areas. We report additional analyses of these data using self-controlled methods, which avoid potential confounding from person-level factors and co-morbidities. METHODS: Surveillance officers identified GBS cases with symptom onset during October 2009-April 2010 and ascertained receipt of H1N1 vaccines. We calculated self-controlled relative risks by comparing the number of cases with onset during a risk interval 1-42 days after vaccination with cases with onset during fixed (days 43-84) or variable (days 43-end of study period) control intervals. We calculated attributable risks by applying statistically significant relative risks to an independent estimate of GBS incidence. RESULTS: Fifty-nine GBS cases received H1N1 vaccine with or without seasonal vaccine. The relative risk was 2.1 (95%CI 1.2, 3.5) by the variable-window and 3.0 (95%CI 1.4, 6.4) by the fixed-window analyses. The corresponding attributable risks per million doses administered were 1.5 (95%CI 0.3, 3.4) and 2.8 (95%CI 0.6, 7.4). CONCLUSIONS: These attributable risks are similar to those of some previous formulations of seasonal influenza vaccine (about one to two cases per million doses administered), suggesting a low risk of GBS following the H1N1 vaccine that is not clearly higher than that of seasonal influenza vaccines.

Influenza Antiviral Treatment and Length of Stay.

BACKGROUND: Antiviral treatment is recommended for hospitalized patients with suspected and confirmed influenza, but evidence is limited among children. We evaluated the effect of antiviral treatment on hospital length of stay (LOS) among children hospitalized with influenza. METHODS: We included children <18 years hospitalized with laboratory-confirmed influenza in the US Influenza Hospitalization Surveillance Network. We collected data for 2 cohorts: 1 with underlying medical conditions not admitted to the ICU (n = 309, 2012-2013) and an ICU cohort (including children with and without underlying conditions; n = 299, 2010-2011 to 2012-2013). We used a Cox model with antiviral receipt as a time-dependent variable to estimate hazard of discharge and a Kaplan-Meier survival analysis to determine LOS. RESULTS: Compared with those not receiving antiviral agents, LOS was shorter for those treated ≤2 days after illness onset in both the medical conditions (adjusted hazard ratio: 1.37, P = .02) and ICU (adjusted hazard ratio: 1.46, P = .007) cohorts, corresponding to 37% and 46% increases in daily discharge probability, respectively. Treatment ≥3 days after illness onset had no significant effect in either cohort. In the medical conditions cohort, median LOS was 3 days for those not treated versus 2 days for those treated ≤2 days after symptom onset (P = .005). CONCLUSIONS: Early antiviral treatment was associated with significantly shorter hospitalizations in children with laboratory-confirmed influenza and high-risk medical conditions or children treated in the ICU. These results support Centers for Disease Control and Prevention recommendations for prompt empiric antiviral treatment in hospitalized patients with suspected or confirmed influenza.

Automated monitoring of clusters of falls associated with severe winter weather using the BioSense system.

OBJECTIVES: To identify and characterise clusters of emergency department (ED) visits for fall injuries during the 2007-2008 winter season. METHODS: Hospital ED chief complaints and diagnoses from hospitals reporting to the Centers for Disease Control and Prevention BioSense system were analysed. The authors performed descriptive analyses, used time series charts on data aggregated by metropolitan statistical areas (MSAs), and used SaTScan to find spatial-temporal clusters of visits from falls. RESULTS: In 2007-2008, 17 clusters of falls in 13 MSAs were found; the median number of excess ED visits for falls was 71 per day. SaTScan identified 11 clusters of falls, of which seven corresponded to MSA clusters found by time series and five included more than one state/district. Most clusters coincided with known periods of snowfall or freezing rain. CONCLUSION: The results show the role that a national automated system can play in tracking widespread injuries. Such a system could be harnessed to assist with prevention strategies.

Summary of data reported to CDC's national automated biosurveillance system, 2008.

BACKGROUND: BioSense is the US national automated biosurveillance system. Data regarding chief complaints and diagnoses are automatically pre-processed into 11 broader syndromes (e.g., respiratory) and 78 narrower sub-syndromes (e.g., asthma). The objectives of this report are to present the types of illness and injury that can be studied using these data and the frequency of visits for the syndromes and sub-syndromes in the various data types; this information will facilitate use of the system and comparison with other systems. METHODS: For each major data source, we summarized information on the facilities, timeliness, patient demographics, and rates of visits for each syndrome and sub-syndrome. RESULTS: In 2008, the primary data sources were the 333 US Department of Defense, 770 US Veterans Affairs, and 532 civilian hospital emergency department facilities. Median times from patient visit to record receipt at CDC were 2.2 days, 2.0 days, and 4 hours for these sources respectively. Among sub-syndromes, we summarize mean 2008 visit rates in 45 infectious disease categories, 11 injury categories, 7 chronic disease categories, and 15 other categories. CONCLUSIONS: We present a systematic summary of data that is automatically available to public health departments for monitoring and responding to emergencies.

Enhancing time-series detection algorithms for automated biosurveillance.

BioSense is a US national system that uses data from health information systems for automated disease surveillance. We studied 4 time-series algorithm modifications designed to improve sensitivity for detecting artificially added data. To test these modified algorithms, we used reports of daily syndrome visits from 308 Department of Defense (DoD) facilities and 340 hospital emergency departments (EDs). At a constant alert rate of 1%, sensitivity was improved for both datasets by using a minimum standard deviation (SD) of 1.0, a 14-28 day baseline duration for calculating mean and SD, and an adjustment for total clinic visits as a surrogate denominator. Stratifying baseline days into weekdays versus weekends to account for day-of-week effects increased sensitivity for the DoD data but not for the ED data. These enhanced methods may increase sensitivity without increasing the alert rate and may improve the ability to detect outbreaks by using automated surveillance system data.

An evaluation and update of methods for estimating the number of influenza cases averted by vaccination in the United States.

INTRODUCTION: To evaluate the public health benefit of yearly influenza vaccinations, CDC estimates the number of influenza cases and hospitalizations averted by vaccine. Available input data on cases and vaccinations is aggregated by month and the estimation model is intentionally simple, raising concerns about the accuracy of estimates. METHODS: We created a synthetic dataset with daily counts of influenza cases and vaccinations, calculated "true" averted cases using a reference model applied to the daily data, aggregated the data by month to simulate data that would actually be available, and evaluated the month-level data with seven test methods (including the current method). Methods with averted case estimates closest to the reference model were considered most accurate. To examine their performance under varying conditions, we re-evaluated the test methods when synthetic data parameters (timing of vaccination relative to cases, vaccination coverage, infection rate, and vaccine effectiveness) were varied over wide ranges. Finally, we analyzed real (i.e., collected by surveillance) data from 2010 to 2017 comparing the current method used by CDC with the best-performing test methods. RESULTS: In the synthetic dataset (population 1 million persons, vaccination uptake 55%, seasonal infection risk without vaccination 12%, vaccine effectiveness 48%) the reference model estimated 28,768 averted cases. The current method underestimated averted cases by 9%. The two best test methods estimated averted cases with <1% error. These two methods also worked well when synthetic data parameters were varied over wide ranges (≤6.2% error). With the real data, these two methods estimated numbers of averted cases that are a median 8% higher than the currently-used method. CONCLUSIONS: We identified two methods for estimating numbers of influenza cases averted by vaccine that are more accurate than the currently-used algorithm. These methods will help us to better assess the benefits of influenza vaccination.

Measurement of the impact of risk adjustment for central line-days on interpretation of central line-associated bloodstream infection rates.

OBJECTIVE: To describe methods to assess the practical impact of risk adjustment for central line-days on the interpretation of central line-associated bloodstream infection (BSI) rates, because collecting these data is often burdensome. METHODS: We analyzed data from 247 hospitals that reported to the adult and pediatric intensive care unit component of the National Nosocomial Infections Surveillance System from 1995 through 2003. For each unit each year, we calculated the percentile error as the absolute value of the difference between the percentile based on a risk-adjusted or more-sophisticated measure (eg, the central line-day rate) and the percentile based on a crude or less-sophisticated measure (eg, the patient-day rate). Using rate per central line-day as the "gold standard," we calculated performance characteristics (eg, sensitivity and predictive values) of rate per patient-day for finding central line-associated BSI rates higher or lower than the mean. Greater impact of risk adjustment is indicated by higher values for percentile error and lower values for performance characteristics. RESULTS: The median percentile error was +/-7 (i.e., the percentile based on central line-days could be 7% higher or lower than the percentile based on patient-days). This error was less than 10 percentile points for 62% of the unit-years, was between 10 and 19 percentile points for 22% of the unit-years, and was 20 percentile points or more for 15% of the unit-years. Use of the rate based on patient-days had a sensitivity of 76% and a positive predictive value of 61% for detecting a significantly high or low central line-associated BSI rate. CONCLUSIONS: We found that risk adjustment for central line-days has an important impact on the calculated central line-associated BSI percentile for some units. Similar methods can be used to evaluate the impact of other risk adjustment methods. Our results support current recommendations to use central line-days for surveillance of central line-associated BSI when comparisons are made among facilities.

Preventing catheter-associated bloodstream infections: a survey of policies for insertion and care of central venous catheters from hospitals in the prevention epicenter program.

OBJECTIVE: To determine the extent to which evidence-based practices for the prevention of central venous catheter (CVC)-associated bloodstream infections are incorporated into the policies and practices of academic intensive care units (ICUs) in the United States and to determine variations in the policies on CVC insertion, use, and care. DESIGN: A 9-page written survey of practices and policies for nontunneled CVC insertion and care. SETTING: ICUs in 10 academic tertiary-care hospitals. PARTICIPANTS: ICU medical directors and nurse managers. RESULTS: Twenty-five ICUs were surveyed (1-6 ICUs per hospital). In 80% of the units, 5 separate groups of clinicians inserted 24%-50% of all nontunneled CVCs. In 56% of the units, placement of more than two-thirds of nontunneled CVCs was performed in a single location in the hospital. Twenty units (80%) had written policies for CVC insertion. Twenty-eight percent of units had a policy requiring maximal sterile-barrier precautions when CVCs were placed, and 52% of the units had formal educational programs with regard to CVC insertion. Eighty percent of the units had a policy requiring staff to perform hand hygiene before inserting CVCs, but only 36% and 60% of the units required hand hygiene before accessing a CVC and treating the exit site, respectively. CONCLUSION: ICU policy regarding the insertion and care of CVCs varies considerably from hospital to hospital. ICUs may be able to improve patient outcome if evidence-based guidelines for CVC insertion and care are implemented.

A multicenter intervention to prevent catheter-associated bloodstream infections.

BACKGROUND: Education-based interventions can reduce the incidence of catheter-associated bloodstream infection. The generalizability of findings from single-center studies is limited. OBJECTIVE: To assess the effect of a multicenter intervention to prevent catheter-associated bloodstream infections. DESIGN: An observational study with a planned intervention. SETTING: Twelve intensive care units and 1 bone marrow transplantation unit at 6 academic medical centers. PATIENTS: Patients admitted during the study period. INTERVENTION: Updates of written policies, distribution of a 9-page self-study module with accompanying pretest and posttest, didactic lectures, and incorporation into practice of evidence-based guidelines regarding central venous catheter (CVC) insertion and care. MEASUREMENTS: Standard data collection tools and definitions were used to measure the process of care (ie, the proportion of nontunneled catheters inserted into the femoral vein and the condition of the CVC insertion site dressing for both tunneled and nontunneled catheters) and the incidence of catheter-associated bloodstream infection. RESULTS: Between the preintervention period and the postintervention period, the percentage of CVCs inserted into the femoral vein decreased from 12.9% to 9.4% (relative ratio, 0.73; 95% confidence interval [CI], 0.61-0.88); the total proportion of catheter insertion site dressings properly dated increased from 26.6% to 34.4% (relative ratio, 1.29; 95% CI, 1.17-1.42), and the overall rate of catheter-associated bloodstream infections decreased from 11.2 to 8.9 infections per 1,000 catheter-days (relative rate, 0.79; 95% CI, 0.67-0.93). The effect of the intervention varied among individual units. CONCLUSIONS: An education-based intervention that uses evidence-based practices can be successfully implemented in a diverse group of medical and surgical units and reduce catheter-associated bloodstream infection rates.

Guidance on public reporting of healthcare-associated infections: recommendations of the Healthcare Infection Control Practices Advisory Committee.

Since 2002, 4 states have enacted legislation that requires health care organizations to publicly disclose health care-associated infection (HAI) rates. Similar legislative efforts are underway in several other states. Advocates of mandatory public reporting of HAIs believe that making such information publicly available will enable consumers to make more informed choices about their health care and improve overall health care quality by reducing HAIs. Further, they believe that patients have a right to know this information. However, others have expressed concern that the reliability of public reporting systems may be compromised by institutional variability in the definitions used for HAIs, or in the methods and resources used to identify HAIs. Presently, there is insufficient evidence on the merits and limitations of an HAI public reporting system. Therefore, the Healthcare Infection Control Practices Advisory Committee (HICPAC) has not recommended for or against mandatory public reporting of HAI rates. However, HICPAC has developed this guidance document based on established principles for public health and HAI reporting systems. This document is intended to assist policymakers, program planners, consumer advocacy organizations, and others tasked with designing and implementing public reporting systems for HAIs. The document provides a framework for legislators, but does not provide model legislation. HICPAC recommends that persons who design and implement such systems 1) use established public health surveillance methods when designing and implementing mandatory HAI reporting systems; 2) create multidisciplinary advisory panels, including persons with expertise in the prevention and control of HAIs, to monitor the planning and oversight of HAI public reporting systems; 3) choose appropriate process and outcome measures based on facility type and phase in measures to allow time for facilities to adapt and to permit ongoing evaluation of data validity; and 4) provide regular and confidential feedback of performance data to healthcare providers. Specifically, HICPAC recommends that states establishing public reporting systems for HAIs select one or more of the following process or outcome measures as appropriate for hospitals or long-term care facilities in their jurisdictions: 1) central-line insertion practices; 2) surgical antimicrobial prophylaxis; 3) influenza vaccination coverage among patients and healthcare personnel; 4) central line-associated bloodstream infections; and 5) surgical site infections following selected operations. HICPAC will update these recommendations as more research and experience become available.

Why is an infection control program needed in the hemodialysis setting?

Infections account for the second leading cause of mortality among patients with end-stage renal disease. Many of these infections are due to sepsis, primarily arising from the vascular access site. Septicemia alone accounts for almost 11% of mortality in hemodialysis patients. Hemodialysis patients are also a sentinel population for the emergence of antimicrobial resistance, especially with regards to gram-positive cocci (vancomycin-resistant enterococci (VRE), methicillin resistant S. aureus (MRSA), Staphylococcus aureus with reduced susceptibility to vancomycin (VISA), and vancomycin resistant S. aureus [VRSA]). It is extremely important to follow infection control recommendations designed to prevent these types of adverse events from occurring in the hemodialysis population. The campaign to prevent antimicrobial resistance in dialysis includes four strategies: Prevent infection; diagnose and treat infection; use antimicrobials wisely; and prevent transmission. In addition, efforts to prevent infection should include avoiding use of hemodialysis catheters, whenever possible, and meticulous care of hemodialysis catheters and other vascular access sites. These efforts would improve patient outcomes and quality-of-life issues by reducing hospitalizations and mortality due to infection and vascular access complications.

Electronic reporting of infections associated with hemodialysis.

UNLABELLED: Monitoring infections and antibiotic resistance patterns in dialysis populations is an important component of efforts to improve patient safety and quality of health care. The objective of this report is to update findings from the Dialysis Surveillance Network and describe the soon-to-be-available National Healthcare Safety Network. METHODS: Volunteer dialysis centers in the DSN submitted reports of hospitalizations, outpatient intravenous antimicrobial starts, and positive blood cultures. From these reports, an online system calculated rates of important adverse events. For this report, we summarize adverse-event data submitted to the DSN from September 1999 through March 2005. RESULTS: There were 53,804 events in the 321,519 patient-months during the period of analysis. The rate of hospitalization was 13 per 100 patient-months; the rate of outpatient IV vancomycin starts was 3 per 100 patient-months. The rate of vascular access infection was 3.1 per 100 patient-months and varied from 0.6 for fistulas to 10. 1.for temporary catheters. Of the 8,359 blood isolates reported, 77% (6,427) were primary bacteremias (5,275 were catheter-associated, 1,152 were fistula- or graft-associated), 19% (1,587) were secondary bacteremias, and 4% (345) were contaminants. CONCLUSIONS: Infection-related adverse events remain lowest among patients with vascular access in the form of fistulas and grafts. In the future, adverse events in dialysis will be monitored in the NHSN. The new, Web-based, NHSN surveillance system allows centers to monitor their rates and compare with other outpatient dialysis centers. In 2006, CDC plans to open enrollment for outpatient dialysis centers not already in the DSN.

Predictive value of blood cultures positive for coagulase-negative staphylococci: implications for patient care and health care quality assurance.

Interpretation of blood cultures that are positive for coagulase-negative staphylococci (CoNS) is often difficult. Predictive values for blood cultures positive for CoNS in patients with a central vascular line in place were calculated using the following rates: true bacteremia, 3%; blood culture contamination, 2%; detection of bacteremia, 80%; and catheter colonization, 2% (for blood samples obtained through a central vascular line). Positive predictive values were 55% for 1 positive culture result of 1 culture performed, 20% for 1 positive result of 2 performed, and only 5% for 1 positive result of 3 performed. For 2 positive culture results of 2 cultures performed, the positive predictive value was 98% if both samples were obtained through the vein, 96% if one sample was obtained through a catheter and the other was obtained by vein, and only 50% if both samples were obtained through a catheter. Use of this model with institution-specific values for input parameters would assist in clinical decision-making as well as hospital quality assurance.

The changing face of surveillance for health care-associated infections.

Surveillance of health care-associated infections and antimicrobial resistance is an important aspect of prevention. In 2004, the Centers for Disease Control and Prevention had 3 national health care surveillance systems. During 2004-2005, these will be combined into a single Internet-based system, the National Healthcare Safety Network (NHSN). The NHSN will feature a number of enhancements, and ultimately, all US hospitals and other health care facilities will be encouraged to participate. Health care surveillance using standard methods has been very useful and is cited as a model for prevention. However, alternative approaches may improve health care surveillance by reducing complexity, decreasing the burden of data collection, and improving accuracy. These alternative approaches include adopting simpler methods and more-objective definitions, using sampling and estimation, substituting information in computer databases for manually collected data, and increasing surveillance for process measures with known prevention efficacy. Maintaining successful features of standard systems, adopting alternate surveillance approaches, and exploiting new technologies, such as the Internet, will make health care surveillance an even better tool for prevention.

Preventing bacterial infections and antimicrobial resistance in dialysis patients.

Antimicrobial use, in concert with patient-to-patient transmission of resistant strains, has caused a rapid increase in the prevalence of antimicrobial resistance in recent years. This increase is a particular threat to dialysis patients, who often have been in the forefront of the epidemic of resistance. In this report, which was written in collaboration between the American Society of Nephrology and the Centers for Disease Control and Prevention and has been endorsed by the Executive Council of the Infectious Diseases Society of America, we review and summarize existing clinical practice guidelines and recommendations concerning the prevention, diagnosis, and treatment of certain bacterial infections in dialysis patients and present four strategies to limit the spread of antimicrobial resistance in dialysis patients. First, preventing infection eliminates the need for antimicrobials, thereby reducing selection pressure for resistant strains. Efforts to prevent infection include avoidance of hemodialysis catheters, when possible, and meticulous care of hemodialysis and peritoneal catheters and other hemodialysis vascular access sites. Second, diagnosing and treating infections appropriately can facilitate the use of narrower spectrum agents, rapidly decrease the number of infecting organisms, and reduce the probability of resistance emerging. This entails the collection of indicated specimens for culture and avoidance of contamination of cultures with common skin microorganisms. Third, optimizing antimicrobial use helps protect the efficacy of such critical agents as vancomycin. Published guidelines for the use of vancomycin should be followed, and alternate agents should be used when infections with beta-lactam-resistant bacteria are unlikely or not documented. Fourth, preventing transmission in health care settings is important to limit the spread of resistant organisms. In this regard, such basic measures as glove use and hand hygiene are most important.