Infection Control in Dialysis Unit
Hemodialysis Symposium
Dr. Shoeb Mohammed, M.D.
Diplomate of American Boards in Nephrology and
Internal Medicine
Consultant Nephrologist, King Fahd Hospital, Madina
Objectives
• Review latest infection related mortality and hospitalization
data among dialysis patients from USRDS 2013.
• Review blood stream infections in HD.
• Learn about the CDC Collaborative for control of blood
stream infections in dialysis.
• Control of HBV/HCV/HIV and pulmonary infections.
• Vaccinations in dialysis
ESRD: Chapter Five
Mortality
United States Renal
Data System
2013 Annual Data
Report
USRDS 2013 ADR
Incident & prevalent patient counts (USRDS),
by modality
Figure 1.1 (Volume 2)
Incident & December 31 point prevalent ESRD patients; peritoneal dialysis consists of CAPD & CCPD.
USRDS 2013 ADR
Adjusted all-cause mortality rates (from day 1
and day 90), by modality & year of treatment
Figure 5.1 (continued; Volume 2)
Incident ESRD patients. Adj: age/gender/race/primary diagnosis; ref: incident ESRD patients, 2010.
USRDS 2013 ADR
ESRD: Chapter Three
Hospitalization
United States Renal
Data System
2013 Annual Data
Report
USRDS 2013 ADR
Change in adjusted all-cause & causespecific hospitalization rates, by modality
Figure 3.1 (Volume 2)
Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2010.
USRDS 2013 ADR
Adjusted cause- specific hospitalization rates,
hemodialysis
Figure 3.1 (Volume 2)
USRDS 2013 ADR
Adjusted rates of hospital admissions, by modality
& diagnosis code type: Bacteremia/Sepsis
Figure 3.5 (Volume 2)
Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2010.
USRDS 2013 ADR
Rehospitalization or death within 30 days after live
hospital discharge, by cause-specific index
hospitalization, 2011
Figure 3.16 (Volume 2)
USRDS 2013 ADR
Period prevalent hemodialysis patients, all ages, 2011; unadjusted.
Includes live hospital discharges from January 1 to December 1, 2011.
TABLE 2. Estimated annual number of central line--associated blood stream infections (CLABSIs), by
health-care setting and year --- United States, 2001, 2008, and 2009
Health-care setting
Year
No. of infections (upper and
lower bound of sensitivity
analysis)
Intensive-care units
2001
43,000 (27,000--67,000)
2009
18,000 (12,000--28,000)
Inpatient wards
2009
23,000 (15,000--37,000)
Outpatient hemodialysis*
2008
37,000 (23,000--57,000)
* Case definitions approximate current definition of CLABSI according to the National Healthcare Safety Network.
USRDS 2013 ADR
In Summary
• Blood stream infections (BSIs) remain a major cause
of morbidity and mortality in hemodialysis pts.
• The rate of hospitalizations for bacteremia / sepsis
has increased by 42.9 % since 1995. (USRDS 2013)
• More than 37000 access related BSI admissions in
2008 in USA due to dialysis catheters. (MMWR, 2011)
• BSIs lead to severe complications of endocarditis,
septic emboli, metastatic infections, readmissions
and death.
USRDS 2013 ADR
Types of infections in hemodialysis
unit
• Infections due to the process of hemodialysis:
– Catheter related Bacteremia…Infective
Endocarditis…Metastatic septic emboli
– AVF / AVG infections
– Dialysate water related infections.
• Infectious transmission between patients:
– Hepatitis B and C, HIV
– MRSA carrier state
– Respiratory infections: TB, Influenza, Pneumococcal
Epidemiology of Infections among
Hemodialysis Patients
• Infections are the 2nd leading cause of death.
• Site of infection
–57% vascular access
–23% wound
–15% lung
–5% urinary tract
USRDS 2005 Annual Data Report
• Tokars, Miller, Stein. AJIC 2002;30:288-295
Invasive Methicillin-Resistant S. aureus
(MRSA) Infections, 2005
• Incidence of invasive MRSA infections: 45.2 cases
per 1,000 dialysis population
• 100 times the rate in general population!!! (0.2 –
0.4 per 1000)
•Invasive MRSA in dialysis
• –86% were bloodstream infections (BSIs)
• –90% required hospitalization, mortality = 17%
CDC. MMWR 2007; 56(09):197-9
Reasons for high infection rates in HD
• The process of hemodialysis requires direct vascular access for
prolonged periods.
• Multiple events occur during dialysis concurrently, so multiple
opportunities exist for person-to-person transmission of
infectious agents, directly or indirectly.
• High risk of contaminated devices, equipment, supplies,
environmental surfaces, or hands of personnel.
• Immunosuppressed.
• Require frequent hospitalizations and surgery, which increases
their opportunities for exposure to nosocomial infections.
Vascular Access related Infections
Risk Factors
• Type of access
– Catheter >>
– AV graft >
– AV fistula
•Lower extremity access
•Recent access surgery
•Trauma, hematoma,
dermatitis, scratching
• Poor hygiene
• Poor needle insertion
technique
• Older age
• Diabetes
• Iron overload
• Others
Rate of Access-Related Bloodstream
Infection by Vascular Access Type
CDC Collaborative
• In April 2009, the US Centers for Disease
Control and Prevention (CDC) announced
plans for a collaborative project to prevent
BSIs in HD patients.
CDC Dialysis BSI Prevention Collaborative
Project (2009)
CDC Collaborative to BSI Prevention in Dialysis
Units (Core Interventions for Dialysis
Bloodstream Infection (BSI) Prevention)
CDC Collaborative – Core
Interventions
1. Surveillance and feedback: Conduct monthly
surveillance for BSIs and other dialysis events. Calculate your
facility rates and compare to rates in other facilities. Actively
share results with front line staff.
2. Hand hygiene observations: Perform direct
observations of hand hygiene monthly and share results
with clinical staff.
3. Catheter/Access care observations: Perform
observations of vascular access care and catheter accessing
quarterly. Assess staff adherence to aseptic technique when
connecting and disconnecting catheters and during dressing
changes. Share results with clinical staff.
CDC Collaborative - Core
Interventions
4.
5.
6.
Chlorhexidine for skin antisepsis: Use an
alcohol-based chlorhexidine (>0.5%) solution as
the first line skin antiseptic agent for central line
insertion and during dressing changes.
Catheter hub disinfection: “Scrub the hubs!” with
an appropriate antiseptic after cap is removed
and before accessing. Perform every time catheter
is accessed or disconnected.
Antimicrobial ointment: Apply antibiotic ointment
or povidone-iodine ointment to catheter exit sites
during each dressing change.
CDC Collaborative - Core
Interventions
7. Staff education and competency: Training on
infection control topics, including access care and aseptic
technique. Competency evaluation for skills such as
catheter care and accessing every 6 months.
8. Patient education/engagement.
9. Catheter reduction efforts.
Was the CDC Collaborative Effective??
Blood Stream Infections Preventive Collaborative, AJKD 2013
Blood Stream Infections Preventive Collaborative, AJKD 2013
CDC effort was very effective in
reducing BSIs.
• A 32% reduction in BSIs and 54% reduction in
access related BSIs.
• Sustained through the end of evaluation
period.
• Simple and cost effective interventions.
• This initiative helped define that it is achievable
to improve and prevent Blood stream
infections in dialysis patients through focused
efforts.
Need more info?
Current trends in Viral hepatitis in
Saudi Arabia
Hepatitis B in Saudi Arabia – A success
story!
• HBV was once considered hyper-endemic in the Kingdom
of Saudi Arabia (KSA).
• A 1988 study of Saudi children showed a hepatitis B surface
antigen (HBsAg) seroprevalence of approximately 7% and a
> 70% prevalence of at least one HBV marker*
• This study galvanized the Saudi health officials into action
and triggered a successful collaboration between scientists
and government agencies.
*Al-Faleh F. Hepatitis B infection in Saudi Arabia. Ann
Saudi Med. 1988;8:474–80.
Hepatitis B in Saudi Arabia – A success
story!
• A mass vaccination program against HBV was launched
in 1989.
• The Saudi government initiated a program in 1990
aimed at vaccinating all Saudi children at school entry.
• Mandatory vaccination of healthcare workers and
hemodialysis patients were also introduced around
1988.
• Pre-emptive strategy started: All new born children
born after October 01, 1989 be vaccinated against HBV
regardless of the mother's HBV status within the
country.
Hepatitis B in Saudi Arabia – A success
story!
Prevalence of HBsAg among the Saudi population documented before and after
introducing a nation-wide HBV vaccination program, over an 18-year period.
Saudi J Gastro Dec,2012
Is the success story complete??
• The success of low HBV infection rates is only in the
younger Saudi populations. (age < 25)
• An estimate of HBsAg+ prevalence among Saudis greater
than 40 years of age falls in the 3-6% range based on data
from community-based studies in the late 80s.
• In 2007, MOH ranked viral hepatitis as the second most
common viral disease after chickenpox, with almost 9000
new cases diagnosed in that year (52% HBV, 32% HCV, and
16% HAV).
– Saudi Arabia: Saudi Arabia Ministry of Health; Ministry of Health of Saudi
Arabia (MOH). A review of health situation. The Annual Health Statistics
Book, 2007
Hepatitis B Virus Infection in ESRD
• Leads to acute / chronic hepatitis, cirrhosis,
hepatocellular carcinoma
• Distinctly problematic in dialysis patients who are
transplant candidates:
– Life threatening complications in de novo flares post
transplant.
– Can occur in any HbsAg + patient at any time post
transplant including those who have been very
asymtomatic during dialysis.
Hepatitis B in Dialysis
• HBV is easily transmitted by percutaneous exposure.
• All HBsAg-positive persons are infectious, but those
who are also positive for HBeAg circulate HBV in high
titers and are highly infectious.
• HBV at low titers of 10²-³virions/mL can be present
on environmental surfaces in the absence of any
visible blood and still result in transmission.
Hepatitis B in Dialysis
• HBV is relatively stable and remains viable for at least
7 days on environmental surfaces at room
temperature.
• HBsAg has been detected on clamps, scissors,
dialysis machine control knobs, and even doorknobs.
• Dialysis staff members can readily transfer virus to
patients from contaminated surfaces by their hands
or gloves or through use of contaminated equipment
and supplies
Cross Contamination during dialysis was
the major route for spread of HBV
1. Environmental surfaces, supplies (e.g.,
hemostats,clamps), or equipment that were not
routinely disinfected after each use.
2. Multiple dose medication vials and IV solutions
that were not used exclusively for one pt.
3. Injections that were prepared in areas adjacent to
areas where blood samples were handled
4. Staff members who simultaneously cared for both
HBV-infected and susceptible patients
INDEPENDENT RISK FACTORS FOR HBV
INFECTION IN DIALYSIS UNITS (DOPPS Data)
• Presence of HBsAg positive patients within the same
dialysis unit
• Non segregation with dedicated hemodialysis machines
for HBsAg positive patients
• A lower than 50 percent prevalence rate of hepatitis B
vaccination among dialysis patients in the same unit.
• Absence of a protocol for HBV infected patients.
– Patterns of hepatitis B prevalence and seroconversion in
hemodialysis units from three continents: the DOPPS. Kidney
Int. 2003;63(6):2222.
Prevention of Hepatitis B in HD unit
• Segregation is the key:
– Dedicated rooms
– Dedicated machines and equipment.
– Separate staff
• Universal contact precautions
• Staff members caring for HBsAg+ pts should not care
for HBV-susceptible pts at the same time
• Ban from dialyzer reuse programs i.e. Only single use
dialyzers.
Prevention of Hepatitis B in HD unit
• Ensure full compliance of Hepatitis B vaccinations
• Make sure your unit has an updated standard
protocol for care of all HBV patients.
• Regular screening of HBsAg status in non-immune
individuals
• Antiviral treatment of HBV-infection may also
reduce the risk of other hemodialysis patients in
the same center.
HCV in HD Units worldwide
• Prevalence using 3rd generation EIA assay for
HCV worldwide shows a wide range from 5.5%
to 72%.
• DOPPS data of 308 HD facilities in 3 continents
reported a mean prevalence of 13.5%.
HCV in Saudi Arabian HD Units
• Saudi Data:
– Prevalence is variable between 15% and 80%. This
prevalence remained at almost 50% in mid 2005
– The annual rate of HCV seroconversion is 7% to
9%.
(Hepatitis C in dialysis units: the Saudi experience.
HD Intnl 2007 Karkar A.)
– However, SCOT 2012 numbers report a decline
from 69% in 1996 to 19% as of 2012
HCV Transmission in HD
• Transmission of HCV is primarily via percutaneous
exposure to infected blood.
• HCV can remain viable in the environment for at least
16 hours.
• Blood transfusions in 1980-1990s undoubtedly caused
many cases of HCV in dialysis units.
• Newer data suggest that nosocomial transmission is
the major reason contributing to the high prevalence.
• The occurrence of nosocomial transmission has been
confirmed by phylogenetic analysis in many studies.
Risk Factors for HCV Infections in
ESRD
•
•
•
•
•
Number of blood transfusions
Years on dialysis
Mode of dialysis
Prevalence of HCV in dialysis unit
Other factors:
– Previous organ transplant
– IV drug abuse
– Male sex
Unresolved issues in HCV
• Debate continues on whether transmission of
HCV in HD units may be affected by:
– Routine testing for anti-HCV antibodies,
– Patient isolation,
– Use of dedicated machines,
– Ban on dialyzer reuse.
• Recommendations for Preventing Transmission
of Infections Among Chronic Hemodialysis
Patients
– MMWR Recomm Rep. 2001;50(RR-5):1
– CDC does not recommend dedicated machines,
patient isolation, or a ban on reuse in HD patients
with HCV infection.
– However, strict adherence to "universal precautions,"
careful attention to hygiene, and strict sterilization of
dialysis machines is recommended.
The most likely cause of HCV transmission
between patients treated in the same dialysis
unit is cross-contamination from supplies and
surfaces (including gloves) as a result of failure
to follow infection-control procedures within the
unit.
VOLUME 73 | SUPPLEMENT 109 | APRIL 2008
HCV+ Care
• Hepatitis C is NOT readily transmitted across
the dialysis filter membrane
• Patient isolation is not required
• Machine isolation is not recommended
• May re-use dialyzers
Hepatitis C Surveillance
• Monitor hepatitis C surveillance laboratory test
results for negative patients:
– Antibody to hepatitis C virus (anti-HCV) and alanine
aminotransferase (ALT) on admission for all patients
– ALT monthly for anti-HCV negative patients
– Anti-HCV semiannually for all negative anti-HCV patients
– Supplemental or confirmatory testing with more specific
assays for patients with an initial positive anti-HCV
HCV Surveillance
HIV and Dialysis
• No Saudi data on HIV and dialysis.
• We have 1 HIV + patient on HD since 11 years.
• Transmission in HD is rare as per US data
(Am J Kidney Dis. 2003;41(2):279)
• CDC does not recommend routine isolation or
dedicated machines for HIV-infected patients
undergoing hemodialysis, given the low
likelihood of transmission
Standard Precautions for all Healthcare Workers
in Dialysis Settings
What is Hand Hygiene?
• Staff should wash their hands with soap or an antiseptic handwash and water, before and after contact with a patient or any
equipment at the dialysis station.
• An antiseptic alcohol gel rub may be used instead when their
hands are not visibly contaminated.
• In addition to hand washing, staff should wear disposable
gloves when caring for a patient or touching any potentially
contaminated surfaces at the dialysis station.
• Gloves should always be removed when leaving the dialysis
station.
• Where practical, patients should also clean their hands, or use
an alcohol gel rub, when arriving at and leaving the dialysis
station
A ‘potentially contaminated’ surface is any item
of equipment at the dialysis station that could
have been contaminated with blood, or fluid,
even if there is no evidence of contamination.
How to Prevent Cross Contamination
• Caregivers must wear appropriate PPE:
– Gloves, gowns and masks with face shields when accessing
AVF, AVG, catheter
• Gloves must be used for
– All patient contact
– All machine contact
– All medication preparation
• Gloves must be changed
– Between patients
– Between machines
– When moving from one area to another
Prevent Cross contamination
• When multiple dose medication vials are
used, prepare individual patient doses in a
clean (centralized) area away from dialysis
stations and deliver separately to each
patient.
Do not carry multiple dose medication
vials from station to station
Equipment management
Respiratory Infection Control
Challenges
• Host Transmission
– Tuberculosis
– Varicella
• Immunocompromised Host Susceptibility
– ESRD complicates other systemic illness
– Stem cell transplantation
– Solid organ transplantation
Respiratory Infection Control
Measures
• Isolation rooms required for all new dialysis units
– Negative pressure is required.
– Only one room required per unit
• Mask isolation
• All patients with suspected TB or VZV should be
isolated or wear masks during evaluation
• Negative pressure rooms should have at least 6 air
exchanges per hour
Tuberculosis
• Desired patient outcomes
– The patient will not convert from a negative to a
positive tuberculosis (TB) skin test
– The patient will not progress to active TB disease
– The patient with active TB will not transmit the
disease
Tuberculosis
• Monitor laboratory test results related to TB
screening, diagnosis, and treatment
– Mantoux skin test
– CXR
– Sputum smear and culture
• Assess for S/S of TB
–
–
–
–
Productive or persistent cough
Cloudy or blood-tinged sputum
Unexplained weight loss
Night sweats
• Elicit hx of exposure to TB
Tuberculosis
• Interventions:
– Provide TB screening per current CDC
recommendations
– IC policies and procedures that are consistent with
current CDC guidelines
– Coordinate care with other health care providers
and agencies, e.g. local health department, as
indicated.
Water Treatment System
Testing/Standards (AAMI)
• Testing performed monthly
• Maximal level of bacteria in water to prepare dialysis
fluid/reprocess dialyzers must NOT EXCEED 200 CFU
– AAMI action level is 50 CFU
• Maximal level of endotoxin must not exceed 2 EU/ml
– AAMI action level is 1 EU/ml
Vaccinations in HD Unit
• Hepatitis B:
•
•
•
•
•
•
– Response rate is 50-60% in ESRD patients.
– Vaccinated pts have 70% lower infection rate compared to
unvaccinated. (AJKD. 1999;33(2):356)
Tetanus vaccine.
Pneumococcal vaccine
Influenza vaccine
H1N1 vaccine is also safe and effective in ESRD patients.
Varicella zoster ……(consider if transplant candidate)
HPV vaccine for females (consider if transplant candidate)
Hepatitis B Vaccination
Hepatitis B Vaccination
HD Unit QA/QI Practices for Infection
Control
• Each unit must have ongoing assessment of current
and trend analyses of relevant infection rates:
–
–
–
–
Catheter related BSI
Catheter exit site and tunnel infections
Hospital Admissions and related mortality
Resistant Bugs: MRSA/VRE/PDRA etc.
• Regular surveillance for Hepatitis B and C virus
susceptibility status with serology and Ab titers.
• Immediate source tracking for any seroconversions.
HD Unit QA/QI Practices for Infection
Control
• Clear updated protocols and surveillance for:
– Vascular Access care.
– Equipment disinfections.
– Care of HBV/HCV and HIV patients.
– Immunizations (patients and staff)
– Water quality
Infection Control is team work!
THANK YOU!!!