Infection Control Issues
in the Dialysis Setting
Stuart L. Goldstein, MD
Associate Professor of Pediatrics
Baylor College of Medicine
Medical Director, Renal Dialysis Unit
Texas Children’s Hospital
Houston, Texas
Helen Currier, RN, BSN, CNN
Assistant Director
Renal Dialysis and Pheresis
Texas Children’s Hospital
Houston, Texas
Infections in the Dialysis Setting
Significant cause of hospitalization
 Significant cause of mortality
 Data compiled from the United States
Renal Data System (USRDS)

Change in hospital admissions
since 1993
Figure 6.3
Period prevalent
dialysis patients. Rates
adjusted for age,
gender, race, and
primary diagnosis.
ESRD patients 2005
used as reference
cohort.
Adjusted admissions for principal
diagnoses, by modality
Figure 6.5
Period prevalent ESRD
patients; adjusted for
age, gender, race, &
primary diagnosis.
ESRD patients, 2005,
used as reference
cohort.
Adjusted cause-specific
hospital admissions, by age
Figure 6.7
Dialysis patients, 2005,
used as reference
cohort. Rates adjusted
for gender, race, &
primary diagnosis.
Period prevalent
dialysis patients age 20
& older. At the end of
1998 a new ICD-9-CM
code was added for
infections due to
internal devices in
peritoneal dialysis
patients; data prior to
this date are omitted.
Infections in this
category include those
related to vascular
access devices or
peritoneal dialysis
catheters.
Percent change in hospitalization rates for
prevalent dialysis patients, 1995–2005, by
demographic characteristics & primary diagnosis
Figure 6.6
Period prevalent
dialysis patients; rates
for all patients are
adjusted for age,
gender, race, &
primary diagnosis;
rates by one factor are
adjusted for the
remaining three. Direct
comparison of adjusted
rates is appropriate
only within each graph,
not between graphs.
Dialysis patients, 2005,
used as reference
cohort. Vascular access
data include
hemodialysis patients
only.
Geographic variations in cause-specific
admissions, per 1,000 patient-years, 2005,
by state: HD, infection
Figure 6.10 (continued)
Period prevalent
hemodialysis patients,
2005. Excludes patients
residing in Puerto Rico
& the Territories.
Percent change in infectious admission
rates, 1995–2005, by state
Figure 6.11 (continued)
Period prevalent
hemodialysis patients,
1995–2005. Excludes
patients residing in
Puerto Rico & the
Territories.
All-cause mortality:
patients with major diseases, 2005
Figure 6.15
ESRD & general Medicare patients with diagnosis in 2005; adjusted for gender & race. Medicare patients, 2005, used as
reference cohort.
Survival rates after major disease diagnosis
in the ESRD & general populations
Figure 6.17
Prevalent general Medicare & ESRD patients with diagnosis between 1992 & 2004.
Medicare patients, 2005, used as reference cohort.
Adjusted cause-specific mortality:
infection
Figure 6.21
Incident dialysis
patients. Rates by age
adjusted for gender,
race, & primary
diagnosis; rates by race
adjusted for age,
gender, & primary
diagnosis. Incident
ESRD patients, 1996,
used as reference
cohort.
Outline


Review dialysis treatment procedure/logistics
Challenges for infection control
 Blood
borne pathogens
 Respiratory
 Contact contamination

Regulatory requirements
 Center
 DSHS
 CDC

QA/QI
for Medicare & Medicaid Services (CMS)
Dialysis Procedures

Hemodialysis
 Blood
cleaned directly through a closed
extracorporeal circuit
 Blood accessed via



Arterio-venous fistula (AVF)
Arterio-venous graft (AVG)
Percutaneous central venous catheter
 Can

be performed in-center or at home
Peritoneal Dialysis
 Catheter
placed percutaneously into peritoneal cavity
 Patient exchanges fluid via that catheter at various
intervals during the day or night
 Performed at home
Hemodialysis Logistics

Patients dialyze for 3-4 hours thrice weekly
 Open

ward setting
Unit schedules can run up to 4 shifts per day
depending on census
 Patients
follow each other in same chair
 Same machines
 Different disposables
 Dialyzers re-used for same patient up to 10 treatments

Nurse/Technician to patient ratio 1:1 to 1:4
depending on acuity
Disinfection Procedures

Patient station surfaces
 Any
soap
 Between each patient shift

Medical Equipment
 Hospital
disinfectant (low level)
 Between patient use

Blood spills
 Tuberculocidal/1:100
 Immediate
bleach (intermediate level)
Disinfection Procedures
Bloodborne Pathogen Challenges
Hepatitis B virus
 Hepatitis C virus
 HIV

Hepatitis B

Desired Patient Outcomes
 The
patient will not convert to HbsAg+ status
 Hepatitis B will not be transmitted in the
dialysis unit
Nephrology Nursing Standards of
Practice and Guidelines for Care (2005)
Hepatitis Susceptibility Testing
Hepatitis B Vaccination


Hep B vaccine dose
is higher for patients
with ESRD
40 mg
Hepatitis B Vaccination
HepB+ Patient Management




Hepatitis B virus is readily
transmitted across the
dialysis filter membrane
Hepatitis B+ patients
require isolation in
separate room (new
units) or a separate area
Do not re-use dialyzers
Patient education
Hepatitis C

Desired Patient Outcomes
 The
patient will not convert to a positive antiHCV status
 The patient with a positive anti-HCV will not
transmit the disease
Nephrology Nursing Standards of
Practice and Guidelines for Care (2005)
Hepatitis C

Monitor hepatitis C surveillance laboratory test
results
 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 antiHCV
Hepatitis C Surveillance
HepC+ Patient Management
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

HIV
Routine surveillance not required
 Isolation not required
 May re-use dialyzers

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 usual
 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
Nephrology Nursing Standards of
Practice and Guidelines for Care (2005)
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

Assess for risk factors that increase the risk of
development of active TB disease after
exposure
 Immunosuppression
 HIV
 Hx
of TB or + skin test without treatment or
completion of prescribed medication

Monitor adherence to home medication regimen
for patients receiving therapy
Tuberculosis

Intervention
 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
Tuberculosis

Patient Education
 Rationale
for TB surveillance
 Teach respiratory IC practices
 Reinforce importance of adherence to
prescribed medication regimen
 Teach S/S of disease progression to report to
nurse
Hand Hygiene Educational
Design

Objectives



1. Identify risk for infection in the
hospital or home
2. List one hand hygiene myth and
one hand hygiene fact.
3. Identify key steps for hand
washing:





* Soap and water
*Alcohol-based hand sanitizer
4. Demonstrate correct hand
washing techniques:



*Soap and water
*Alcohol-based hand sanitizer
5. Name four instances when hands
should be washed to limit the
transfer of bacteria, viruses and
other microbes.
6. Identify hand washing issues
unique to children.
Related Content
 I. Germs: What are they?







II. Reducing the risk of infection
III. Myths and Facts
IV. Lesson on hand washing
techniques
A. Steps for soap and
water
B. Steps for alcohol- based
hand sanitizers
V. When to wash hands
VI. Issues unique to children
Contact Contamination


Nurse/technical staff care for >1 patient at a time
Caregivers must wear appropriate personal
protective equipment
 Gloves,
gowns and masks with face shields when
accessing AVF, AVG, catheter

Gloves must be used for
 All
 All
patient contact
machine contact
 All medication preparation

Gloves must be changed
 Between patients
 Between machines
 When moving from one
area to another
Bacterial Infection

Desired Patient Outcomes
 The
patient will be free of signs and
symptoms associated with localized infection
or sepsis
 The patient’s risk for bacterial colonization or
infection due to a drug-resistant organism will
be reduced
Nephrology Nursing Standards of
Practice and Guidelines for Care (2005)
Bacterial Infection


Assessment
Intervention
 Laboratory


analyses/cultures
Avoid culturing vascular catheter tips surrounding skin or
catheter hub
Catheter exit site or wound cultures
 Collaborate
with MD/APN to avoid over use of
vancomycin
 Monitor patient response, e.g. resolution of infection,
development of sepsis
Bacterial Infection

Intervention
 Unit
infection control policies and procedures
consistent with the CDC guidelines (2001)

Patient education
 Potential
for bacterial colonization and infection of
access
 Importance of permanent vascular access placement
rather than long-term use of a hemodialysis catheter
Bacterial Infection

Patient education
 Good




Care of vascular access;
Washing prior to dialysis
Glove use when holding vascular access site to stop
bleeding
Peritoneal catheter exit site care
 Use


hygienic practices
of prophylactic antibiotic therapy
new PD catheter
Topical exit site antibiotics (mupirocin, gentamicin)
 Importance
of immunizations
Unit QA/QI Practices

Ongoing assessment of current and trend
analyses of relevant infection rates
 MRSA
 Catheter
related bacteremia
 Catheter exit site and tunnel infections
 Peritonitis

Surveillance for Hepatitis virus
susceptibility status
Facility Infection Trends
Percent of Facility Census with Infections By Type During Month
%100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
Jan
Feb
Graft/Fistula
45
40
Catheter
23
28
Wound/Limb
5
10
Sepsis/Bacteremia
2
3
HBaAg+
0
0
MRA-VRE
2
4
Other
23
15
Facility Name
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
ESRD Network of Texas
The Water Treatment System
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
Testing Sites
Testing Sites