1. 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

2. 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

3. Mortality United States Renal Data System 2013 Annual Data Report
ESRD: Chapter Five
Mortality
United States Renal Data System
2013 Annual Data Report

4. Incident & prevalent patient counts (USRDS), by modality Figure 1
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.

5. 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.

6. Hospitalization United States Renal Data System
ESRD: Chapter Three
Hospitalization
United States Renal Data System
2013 Annual Data Report

7. Change in adjusted all-cause & cause- specific hospitalization rates, by modality Figure 3.1 (Volume 2)
Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2010.

8. Adjusted cause- specific hospitalization rates, hemodialysis Figure 3
Adjusted cause- specific hospitalization rates, hemodialysis Figure 3.1 (Volume 2)

9. 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.

10. Rehospitalization or death within 30 days after live hospital discharge, by cause-specific index hospitalization, 2011 Figure 3.16 (Volume 2)
Period prevalent hemodialysis patients, all ages, 2011; unadjusted. Includes live hospital discharges from January 1 to December 1, 2011.

11. No. of infections (upper and lower bound of sensitivity analysis)
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)
2009
18,000 (12, ,000)
Inpatient wards
23,000 (15, ,000)
Outpatient hemodialysis*
2008
37,000 (23, ,000)
* Case definitions approximate current definition of CLABSI according to the National Healthcare Safety Network.

12. 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 (USRDS 2013)
More than 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.

13. 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

14. 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:

15. 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

16. 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.

17. 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

18. Rate of Access-Related Bloodstream Infection by Vascular Access Type

19. CDC Dialysis BSI Prevention Collaborative Project (2009)
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)

20. CDC Collaborative to BSI Prevention in Dialysis Units (Core Interventions for Dialysis Bloodstream Infection (BSI) Prevention)

21. CDC Collaborative – Core Interventions
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.
Hand hygiene observations: Perform direct observations of hand hygiene monthly and share results with clinical staff.
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.

22. 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.

23. 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.
Povidone-iodine (preferably with alcohol) or 70% alcohol are alternatives for patients with chlorhexidine intolerance.
** If closed needleless connector device is used, disinfect device per manufacturer’s instructions.
*** See information on selecting an antimicrobial ointment for hemodialysis catheter exit sites on CDC’s Dialysis Safety website ( Use of chlorhexidine-impregnated sponge dressing might be an alternative.

25. Was the CDC Collaborative Effective??

28. Blood Stream Infections Preventive Collaborative, AJKD 2013

29. Blood Stream Infections Preventive Collaborative, AJKD 2013

30. 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.

31. Need more info?

32. Current trends in Viral hepatitis in Saudi Arabia

33. 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.
Remember in endemic areas transfer is horizontal not vertical.

34. 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.
Despite the optimism surrounding the low HBV infection rates in the younger Saudi populations, the prevalence in older generations has not been well characterized, and remains a source of concern. A fair estimate of HBsAg prevalence among Saudis greater than 40 years of age falls in the 3-6% range based on the approximate 7% HBV prevalence rate initially documented from community-based studies in children in the late 80s. 

35. 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
Despite the optimism surrounding the low HBV infection rates in the younger Saudi populations, the prevalence in older generations has not been well characterized, and remains a source of concern. A fair estimate of HBsAg prevalence among Saudis greater than 40 years of age falls in the 3-6% range based on the approximate 7% HBV prevalence rate initially documented from community-based studies in children in the late 80s. 

36. 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
The prevalence in older generations remains a source of concern

37. 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.
Therefore, despite the relatively benign clinical disease in dialysis patients, the importance of preventing and treating HBV infection in dialysis patients must be underscored.

38. 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.

39. 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

40. Cross Contamination during dialysis was the major route for spread of HBV
Environmental surfaces, supplies (e.g., hemostats,clamps), or equipment that were not routinely disinfected after each use.
Multiple dose medication vials and IV solutions that were not used exclusively for one pt.
Injections that were prepared in areas adjacent to areas where blood samples were handled
Staff members who simultaneously cared for both HBV-infected and susceptible patients

41. 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.

42. 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.
Failure to segregate and use dedicated hemodialysis machines for HBsAg positive patients is associated with an increased incidence of HBV infection, and machine segregation is now standard practice. On the other hand, the United States national surveillance in 1997 showed no difference in the incidence of HBV infection between centers that practiced segregation of dialysis rooms and those that did not [15,38]. Dialyzer reuse was also not associated with a higher risk of HBV infection both in patients and in staff. Nevertheless, the Centers for Disease Control (CDC) recommended that dialyzers from HBsAg-positive patients be excluded from reuse programs [36].

43. 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.

44. 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%.
A Prospective Study of Hepatitis C Virus Infection in Hemodialysis Patients in Jeddah, Saudi Arabia - Of the 39 cases enrolled at KFGH, we found 22 samples to be positive for HCV RNA 15 of them were HCV-Ab positive while 7 were HCV-Ab negative (recent infection). 

45. 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

46. 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 s 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.
The occurrence of nosocomial transmission was confirmed when phylogenetic analysis identified clusters of closely related isolates of HCV, both in studies of individual units with high seroconversion rates214,215 and multicenter studies.216,217 Parts of the HCV genome (especially hypervariable region 1)
are highly variable and lend themselves to fingerprinting of each isolate or quasispecies using nucleic acid sequencing. This may be used to establish a firm basis for studies of spread and routes of infection by HCV.218,219

47. 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
In numerous studies, anti-HCV-positive hemodialysis (HD) patients had received significantly more units of blood products than anti-HCV-negative patients
The likelihood of HCV infection increases considerably after a decade of HD
Patients on peritoneal dialysis (PD) are at lower risk for HCV infection, 

48. 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.

49. 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.

50. 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

52. 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

53. 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

54. HCV Surveillance

56. 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
No cases of pt. to pt. tranmission.
One case of pt. to HCW transmission.

57. Standard Precautions for all Healthcare Workers in Dialysis Settings

58. What is Hand Hygiene?
Staff should wash their hands with soap or an antiseptic hand-wash 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

59. 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.

60. 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

61. 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

62. Equipment management

63. Respiratory Infection Control Challenges
Host Transmission
Tuberculosis
Varicella
Immunocompromised Host Susceptibility
ESRD complicates other systemic illness
Stem cell transplantation
Solid organ transplantation

64. 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

65. 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

66. 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

67. 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.

68. 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

70. 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)

71. Hepatitis B Vaccination

72. Hepatitis B Vaccination

73. 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.

74. 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

75. Infection Control is team work!

76. THANK YOU!!!