Infection control why and how

INFECTION CONTROL IN DIALYSIS UNIT:
WHY AND HOW?
Mostafa Abdel_Salam Mohamed, MD
MUH

“You can’t tell where you’re
going unless you know where
you’ve been.” unknown

• Between 1995 and 2013, hospitalization rates
for infection rose 42%, and the rate of
hospitalization for vascular access infections in
HD patients more than doubled.
U.S. Renal Data System 2013

• Infection is reported as the second most
common cause of death in HD patients after
cardiovascular disease
U.S. Renal Data System 2013

Infections: A Major Patient Safety Problem in
Dialysis – 2nd Leading Cause Of Death
6
First cause of death is vascular disease
Approximately 15,000 dialysis patients die annually due to infections

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.

• "Body secretions of a host
organism (e.g., human
being) are contaminated by
tainted foreign organisms
that are not visible by
naked eye before the
infection."
980-1037

1632-1723
seven centuries after Ibn
Sina, the Dutch scientist
Anton van Leeuwenhoek
(also referred to as the
"Father of Microbiology")
observed microorganisms
under a microscope

Florence Nightingale
1820-1910
The very first requirement
in a hospital is that it
should do the sick no
harm

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.

• Transmission
• Blood-borne viruses are transmitted through
infected body fluids; transmission occurs by
inoculation, via sharps, broken skin or through
contact with mucous membranes. The risk of
transmission of BBVs following a single
percutaneous exposure is estimated to be:
– • HBV 1 in 3
– • HCV 1 in 30
– • HIV 1 in 300

Organisms remain viable on surfaces for prolonged periods
• Hepatitis B >1 week
• Influenza 1-2 days
• MRSA 7 days to 7 months
• VRE 5 days to 4 months
• C. difficile spore 5 months
16
Healthcare workers touch as many as 7 surfaces
after touching a contaminated one!
McLaughlin AC, Walsh F. Am J Infect Control 39(6):456-463, 2011
Kramer A, Schwebke I, Kampf G. BMC Infect Dis 6:130, 2006

Hepatitis outbreaks in
haemodialysis unit patients
and staff were reported in
the late 1960s. In 1972

1908-1972
In 1970, Lord Rosenheim
was asked on behalf of
the Department of Health
and Social Security,
Scottish Home and Health
Department and Welsh
Office to chair a
committee of experts ‘to
review the medical
problems arising in the
treatment of chronic renal
failure

The implementation of the codes of practice

• The Rosenheim report in the UK established
guidelines which included routine tests for
hepatitis B surface antigen and isolation
facilities for dialysing patients with hepatitis B
virus which resulted in a dramatic fall in cases
of hepatitis.

• However, since these guidelines were
introduced, other blood-borne viruses,
notably HCV and HIV have been discovered,
and failures of infection control practices still
lead to outbreaks of HBV in haemodialysis
units.

• The prevalence of HCV in dialysis patients
varies considerably throughout the world,
with reported prevalence ranging from 3·9%
to 71%. The number of blood transfusions and
the length of time on dialysis have consistently
been associated with HCV prevalence.

Similar guidelines were
issued by CDC in the USA
in 1977

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. 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.
5. 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.
6. 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.

Standard Precautions for all Healthcare Workers
in Dialysis Settings

An APIC Guide
• The Association for Professionals in Infection
Control and Epidemiology (APIC) is the leading
professional association for infection
preventionists (IPs) with more than 15,000
members.

• 1. Centers for Disease Control and Prevention
(CDC). Recommendations for Control of Hepatitis
B in Dialysis Centers. Atlanta, GA: Author, 1997.
• 2. CDC. Recommendations for preventing
transmission of infections among chronic
hemodialysis patients. MMWR 2001;50(RR05):1–
43.
• 3. Centers for Medicare and Medicaid Services
(CMS). 2008 Conditions for Coverage

Basic Measures—Category I Level
Evidence Supports These Measures
1. Environmental and equipment cleaning/disinfection
• Use U.S. Environmental Protection Agency (EPA)-
registered hospital disinfectants labeled tuberculocidal
or with specific label claims for HIV or HBV in
accordance with label instructions to decontaminate
spills of blood and other body fluids.

• Use standard cleaning and disinfection
protocols and EPA-registered hospital
disinfectants for confirmed or suspected
antibiotic-resistant Gram-positive cocci (e.g.,
MRSA, vancomycin intermediate–resistant S.
aureus, or vancomycin-resistant Enterococcus
[VRE]).

• Using friction, clean and disinfect high-touch
surfaces in patient-care areas (e.g., HD chairs,
HD machines, tables, carts, bedside
commodes).

• When contact precautions are indicated for
patient care, use disposable patient-care items
(e.g., blood pressurecuffs) whenever possible
to minimize cross-contamination with
multiple-resistant microorganisms.

• Items taken into a patient station should be
disposed of after use, dedicated for use on a
single patient, or cleaned and disinfected
before being taken to a common clean area or
used on another patient.

• Non disposable items that cannot be
comprehensively cleaned and disinfected
(e.g., adhesive tape, cloth covered blood
pressure cuffs) should be dedicated for use on
a single patient.

• External pressure transducer filters/protectors
should be changed after each patient
treatment. Items taken into an individual HD
patient station should be disposed of after
use, dedicated for use on a single patient, or
cleaned and disinfected before being taken to
a common clean area or used on another
patient.

• External venous and arterial pressure
transducer filters/protectors should be
changed after each patient treatment and
should not be reused. Internal transducer
filters do not need to be changed routinely
between patients.

• The internal HD machine dialysate pathway
should be subjected to heat disinfection at the
end of each treatment day.
• In the event of a blood leak, disinfection of the
internal HD machine pathway must be
performed prior to on a successive patient

Plus Measures—Level of Evidence Supporting
These Measures is Less Than Category I Level
1. Environmental and equipment
cleaning/disinfection
• Because no EPA-registered products are
specific for inactivating C. difficile spores, use
hypochlorite-based products for disinfection
of environmental surfaces in those patient-
care areas where surveillance and
epidemiology indicate ongoing transmission of
C. difficile.

• Use microfiber cloths and mops if possible
(more effective cleaning products than regular
cotton cleaning cloths).

2. Hand hygiene
• To improve hand hygiene adherence among
personnel who work in areas in which high
workloads and high intensity of patient care are
anticipated, make an alcoholbased hand rub
available at the entrance to the patient's room or
at the bedside, in other convenient locations, and
in individual pocket-sized containers to be carried
by healthcare workers (HCWs).
• Perform hand hygiene before and after contact
with patient or patient environment.

• Remove gloves after caring for a patient. Do
not wear the same pair of gloves for the
care of more than one patient, and do
not wash gloves between uses
with different patients.
• Perform hand hygiene after glove removal.

• If hands are not visibly soiled, use an alcohol-
based hand rub for routinely cleaning hands
instead of soap and water.
• Do not wear artificial fingernails or extenders
when having direct contact with patients

• Water-proof aprons or gowns should
be worn if the nurse is located within
the patient station producing any
service
• In addition to gloves, and gowns wear
face protection to protect yourself:
– During initiation and termination of
dialysis
– When cleaning dialyzers
• PPE should be changed if it becomes
dirty
Photo provided by Rosetta Jackson, used with permission

3. Immunizations and tuberculosis (TB)
screening
• Vaccine status of all patients should be
assessed at the start of dialysis. Eligible HD
patients should be immunized against HBV,
tetanus, pneumococcal disease, and influenza.
• CDC recommends one-time baseline screening
of HD patients for TB (plus anytime an
exposure is suspected).

• Employees in HD settings must receive
immunization for measles, mumps, rubella,
pertussis, diphtheria, tetanus, MMR (measles,
mumps, rubella), be offered HBV and
influenza immunization, and be screened for
TB per local regulations (usually annual).

4. Medication/injection safety:
• Single-dose vials should be dedicated to one
patient only and should not be re-entered.
• Parenteral medications should be prepared in
a designated clean area away from patient
treatment stations.
• Do not use medication carts to transport
medications to patient stations.

• Scrub the hub of intravenous (IV) tubing and
medication vials prior to accessing.
• Use aseptic technique when preparing
/handling parenteral medications/fluid.
• Never use infusion supplies such as needles,
syringes, flush solutions, administration sets,
or IV fluids on more than one patient.

Plus Measures—Level of Evidence Supporting These
Measures is Less Than Category I Level
4. Medication/injection safety:
• Avoid use of multidose vials

5. Pre- and postsurgical infection prevention
• Presurgical hair removal should be performed
with clippers instead of a razor.

5. Pre- and postsurgical infection prevention
• Antiseptic impregnated postoperative
dressings for fistulas/grafts
• Active surveillance testing for MRSA and
decolonization should be performed as
indicated (e.g., preoperatively).
• Preoperative antiseptic bathing/showering

6. Standard/transmission based precautions
• Respiratory etiquette should be employed
routinely.
• Standard Precautions should be practiced
routinely.
• Patient identified with a suspected airborne
disease should be masked immediately and
geographically separated from other patients,
preferably in a single room.
• HBV isolation should be employed routinely on all
patients known to be HBsAg positive.

6. Standard/transmission based precautions
• Contact precautions in HD facilities should be
employed in the event of known or suspected
MDRO (Multi-drug resistant organisms).

7. Vascular Access:
• Support transition from temporary (e.g., CVC)
to permanent (e.g., arteriovenous fistula or
graft vascular access whenever possible.
• Full barrier precautions and skin antisepsis
with chlorhexidine alcohol prep prior to
insertion of HD CVC.

7. Vascular access
• Routine use of chlorhexidine impregnated bathing cloths.
• Application of chlorhexidine impregnated insertion site
dressing for HD central catheters.
• Prophylactic use of antimicrobial catheter locking solution.
• Soak the hub of HD catheters in povidone-iodine solution
or wrap with gauze saturated with povidone-iodine solution
for 5 minutes prior to removing the cap.
• Application of povidone-iodine or triple antibiotic ointment
for HD catheter exit site dressings after dialysis session.

8. Water treatment
• Adhere to current Association for Advancement
of Medical Instrumentation (AAMI) standards for
quality assurance performance of devices and
equipment used to treat, store, and distribute
water in HD centers and for the preparation of
concentrates and dialysate.
• Conduct microbiological testing specific to water
in dialysis settings.
• Disinfect water distribution systems in dialysis
settings on a regular schedule.

8. Water treatment
• Ultrapure dialysate

Chapter 3: Preventing HCV Transmission
• Guideline 3.1: Hemodialysis units should ensure
implementation of, and adherence to, strict
infection-control procedures designed to prevent
transmission of blood-borne pathogens, including
HCV. (Strong)
• Isolation of HCV-infected patients is not
recommended as an alternative to strict
infection-control procedures for preventing
transmission of blood-borne pathogens. (Weak)

Chapter 3: Preventing HCV Transmission
• The use of dedicated dialysis machines for HCV
infected patients is not recommended.
(Moderate)
• Where dialyzer reuse is unavoidable, it is
suggested that the dialyzers of HCV-infected
patients can be reused provided there is
implementation of, and adherence to, strict
infection-control procedures. (Weak)

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.

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.

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.

Education, Training and Staffing

‫يقول‬ ،‫هريرة‬ ‫أبي‬ ‫وعن‬:‫قال‬
‫عليه‬ ‫هللا‬ ‫صلى‬ ‫هللا‬ ‫رسول‬
‫وسلم‬(( :‫ي‬ِ‫ط‬ ‫وال‬ ‫عدوى‬ ‫ال‬،‫رة‬
‫ر‬ِ‫ف‬‫و‬ ،‫صفر‬ ‫وال‬ ‫ة‬‫هام‬ ‫وال‬‫من‬
‫األس‬ ‫من‬ ُّ‫تفر‬ ‫كما‬ ‫المجذوم‬‫د‬))
‫ايضا‬ ‫وعنه‬(‫ور‬ُ‫ي‬ ‫ال‬ُ‫د‬
ِ‫ص‬ُ‫م‬ ‫على‬ ٌ‫ض‬ ِ‫ر‬ْ‫م‬ُ‫م‬‫ح‬)
‫صلي‬ ‫هللا‬ ‫رسول‬ ‫صدق‬
‫وسلم‬ ‫عليه‬ ‫هللا‬

Infection control why and how

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