Presentation on theme: "Infection Control in Dialysis Unit Hemodialysis Symposium"— Presentation transcript:
1Infection Control in Dialysis Unit Hemodialysis Symposium Dr. Shoeb Mohammed, M.D.Diplomate of American Boards in Nephrology and Internal MedicineConsultant Nephrologist, King Fahd Hospital, Madina
2ObjectivesReview 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
3Mortality United States Renal Data System 2013 Annual Data Report ESRD: Chapter FiveMortalityUnited States Renal Data System2013 Annual Data Report
4Incident & 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.
5Adjusted 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.
6Hospitalization United States Renal Data System ESRD: Chapter ThreeHospitalizationUnited States Renal Data System2013 Annual Data Report
7Change 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.
8Adjusted cause- specific hospitalization rates, hemodialysis Figure 3 Adjusted cause- specific hospitalization rates, hemodialysis Figure 3.1 (Volume 2)
10Rehospitalization 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.
11No. 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 2009Health-care settingYearNo. of infections (upper and lower bound of sensitivity analysis)Intensive-care units200143,000 (27, ,000)200918,000 (12, ,000)Inpatient wards23,000 (15, ,000)Outpatient hemodialysis*200837,000 (23, ,000)* Case definitions approximate current definition of CLABSI according to the National Healthcare Safety Network.
12In SummaryBlood 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.
13Types of infections in hemodialysis unit Infections due to the process of hemodialysis:Catheter related Bacteremia…Infective Endocarditis…Metastatic septic emboliAVF / AVG infectionsDialysate water related infections.Infectious transmission between patients:Hepatitis B and C, HIVMRSA carrier stateRespiratory infections: TB, Influenza, Pneumococcal
14Epidemiology 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 tractUSRDS 2005 Annual Data ReportTokars, Miller, Stein. AJIC 2002;30:
15Invasive Methicillin-Resistant S. aureus (MRSA) Infections, 2005 Incidence of invasive MRSA infections: 45.2 cases per 1,000 dialysis population100 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
16Reasons 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.
17Vascular Access related Infections Risk Factors Type of access– Catheter >>– AV graft >– AV fistula•Lower extremity access•Recent access surgery•Trauma, hematoma, dermatitis, scratchingPoor hygiene• Poor needle insertion technique• Older age• Diabetes• Iron overload• Others
18Rate of Access-Related Bloodstream Infection by Vascular Access Type
19CDC Dialysis BSI Prevention Collaborative Project (2009) CDC CollaborativeIn 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)
20CDC Collaborative to BSI Prevention in Dialysis Units (Core Interventions for Dialysis Bloodstream Infection (BSI) Prevention)
21CDC 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.
22CDC 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.
23CDC 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 (http://www.cdc.gov/dialysis/prevention-tools/core-interventions.html#sites). Use of chlorhexidine-impregnated sponge dressing might be an alternative.
30CDC 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.
32Current trends in Viral hepatitis in Saudi Arabia
33Hepatitis 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.
34Hepatitis 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.
35Hepatitis 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,2012Despite 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.
36Is 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, 2007The prevalence in older generations remains a source of concern
37Hepatitis B Virus Infection in ESRD Leads to acute / chronic hepatitis, cirrhosis, hepatocellular carcinomaDistinctly 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.
38Hepatitis 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.
39Hepatitis 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
40Cross 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 handledStaff members who simultaneously cared for both HBV-infected and susceptible patients
41INDEPENDENT RISK FACTORS FOR HBV INFECTION IN DIALYSIS UNITS (DOPPS Data) Presence of HBsAg positive patients within the same dialysis unitNon segregation with dedicated hemodialysis machines for HBsAg positive patientsA 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.
42Prevention of Hepatitis B in HD unit Segregation is the key:Dedicated roomsDedicated machines and equipment.Separate staffUniversal contact precautionsStaff members caring for HBsAg+ pts should not care for HBV-susceptible pts at the same timeBan 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 .
43Prevention of Hepatitis B in HD unit Ensure full compliance of Hepatitis B vaccinationsMake sure your unit has an updated standard protocol for care of all HBV patients.Regular screening of HBsAg status in non-immune individualsAntiviral treatment of HBV-infection may also reduce the risk of other hemodialysis patients in the same center.
44HCV 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).
45HCV in Saudi Arabian HD Units Saudi Data:Prevalence is variable between 15% and 80%. This prevalence remained at almost 50% in mid 2005The 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
46HCV Transmission in HDTransmission 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
47Risk Factors for HCV Infections in ESRD Number of blood transfusionsYears on dialysisMode of dialysisPrevalence of HCV in dialysis unitOther factors:Previous organ transplantIV drug abuseMale sexIn numerous studies, anti-HCV-positive hemodialysis (HD) patients had received significantly more units of blood products than anti-HCV-negative patientsThe likelihood of HCV infection increases considerably after a decade of HDPatients on peritoneal dialysis (PD) are at lower risk for HCV infection,
48Unresolved 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.
49Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients MMWR Recomm Rep. 2001;50(RR-5):1CDC 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.
50The 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
52HCV+ CareHepatitis C is NOT readily transmitted across the dialysis filter membranePatient isolation is not requiredMachine isolation is not recommendedMay re-use dialyzers
53Hepatitis 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 patientsALT monthly for anti-HCV negative patientsAnti-HCV semiannually for all negative anti-HCV patientsSupplemental or confirmatory testing with more specific assays for patients with an initial positive anti-HCV
56HIV 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 transmissionNo cases of pt. to pt. tranmission.One case of pt. to HCW transmission.
57Standard Precautions for all Healthcare Workers in Dialysis Settings
58What 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
59A ‘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.
60How to Prevent Cross Contamination Caregivers must wear appropriate PPE:Gloves, gowns and masks with face shields when accessing AVF, AVG, catheterGloves must be used forAll patient contactAll machine contactAll medication preparationGloves must be changedBetween patientsBetween machinesWhen moving from one area to another
61Prevent 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 medicationvials from station to station
63Respiratory Infection Control Challenges Host TransmissionTuberculosisVaricellaImmunocompromised Host SusceptibilityESRD complicates other systemic illnessStem cell transplantationSolid organ transplantation
64Respiratory Infection Control Measures Isolation rooms required for all new dialysis unitsNegative pressure is required.Only one room required per unitMask isolationAll patients with suspected TB or VZV should be isolated or wear masks during evaluationNegative pressure rooms should have at least 6 air exchanges per hour
65Tuberculosis Desired patient outcomes The patient will not convert from a negative to a positive tuberculosis (TB) skin testThe patient will not progress to active TB diseaseThe patient with active TB will not transmit the disease
66TuberculosisMonitor laboratory test results related to TB screening, diagnosis, and treatmentMantoux skin testCXRSputum smear and cultureAssess for S/S of TBProductive or persistent coughCloudy or blood-tinged sputumUnexplained weight lossNight sweatsElicit hx of exposure to TB
67Tuberculosis Interventions: Provide TB screening per current CDC recommendationsIC policies and procedures that are consistent with current CDC guidelinesCoordinate care with other health care providers and agencies, e.g. local health department, as indicated.
68Water Treatment System Testing/Standards (AAMI) Testing performed monthlyMaximal level of bacteria in water to prepare dialysis fluid/reprocess dialyzers must NOT EXCEED 200 CFUAAMI action level is 50 CFUMaximal level of endotoxin must not exceed 2 EU/mlAAMI action level is 1 EU/ml
70Vaccinations 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 vaccineInfluenza vaccineH1N1 vaccine is also safe and effective in ESRD patients.Varicella zoster ……(consider if transplant candidate)HPV vaccine for females (consider if transplant candidate)
73HD Unit QA/QI Practices for Infection Control Each unit must have ongoing assessment of current and trend analyses of relevant infection rates:Catheter related BSICatheter exit site and tunnel infectionsHospital Admissions and related mortalityResistant 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.
74HD 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