Infection Control in Dialysis Units Hani A. Aziz Jokhdar, M.D. Consultant of Communicable Disease Control UQU, E & B hospital, IMC and MRQP.

Infection Control in Dialysis Units

Hani A. Aziz Jokhdar, M.D.Consultant of Communicable Disease Control

UQU, E & B hospital, IMC and MRQP

* Saudi Centre for Organ Transplantation

Introduction

The number of cases treated by maintenance hemodialysis is increasing (≈8,000 cases)*

Cases are at risk of infections: Long term vascular access Multiple patient in one environment concurrently treated

Direct (Person-to-person) Indirect (devices, equipments, surfaces or environment) Staff to patients

Immunosuppressed (frequent hospitalization)

Cont…introduction

Historically all researches used to focus on Viral Hepatitis

Vascular access infection and pyrogenic reactions

All surveillances and researches conducted over the years aim to come out with recommendations for the control of infections in hemodialysis

* Saudi Centre for Organ Transplantation ^MMWR, April 27, 2001, Vol. 50, No. RR-5

Hepatitis B Virus

Prevalence of Hep B cases among hemodialysis patient is 5.9% in 2005*

USA: 7.8% in 1976^ 0.9% in 1999^

* Shikata et al., JID. 1977; 136:571-6 ^Bond et al., Lancet. 1981;1:550-1

HBV transmission

Per-cutaneous Per-mucosal All HBsAg positive cases are infectious Cases with HBeAg titer of (108-9 virions/ml) have their body fluid

infectious* HBV at titer of (102-3 virions/ml) can contaminate surfaces without

visible blood^ HBV remains viable at least for 7 days in room temperature^;

HBsAg detected on clamps, scissors, dialysis machines, control knobs and door knobs

* CDC, MMWR 1996;45:285-9

Cont…HBV transmission

Most outbreaks related to transmission through*: Environmental surfaces supplies Multiple dose medication vials (iv solution not

dedicated for one patient) Preparation of medications in dirty areas Undedicated staff

* Alter et al., JID 1986; 153: 1149-51 MMWR, April 27, 2001, Vol. 50, No. RR-5

Control measures

Serology surveillance for patients and staff members for HBV infection

HBsAg +ve patients must be dialyzed in isolated areas* Dedication of staff for the shift duty* Assignment of dialysis equipments* Assignment of supply tray to each patient* Proper cleaning and disinfection of reusable equipments gloves Routine cleaning and disinfection of environmental surfaces

* Najem et al., JAMA 1981; 245: 153-7 ^CDC MMWR 1996; 45: 285-9

Facts for HBV

Segregation of HBV infected cases reduces the incidence among Hemodialysis HBV susceptible cases by 70-80%*

Being low incidence; outbreaks still happening^ Failure to screen patients Share of supplies Share of staff

* Saudi Centre for Organ Transplantation ^Niu et al., Am J Kidney Dis 1993; 22: 568-

73

Hepatitis C Virus

Prevalence of HCV cases among hemodialysis patient is 40% in 2005*

USA the prevalence of HCV among hemodialysis patients ranges between 10-36%^

* Moyer et al., Semin Dial 1994; 7: 124-7

HCV transmission

Mostly throuhg direct per-cutaneous exposure to infected blood

Risk factors for transmissionBlood transfusionNumber of years on dialysis*

* CDC upublished data; 1999

Cont…HCV transmission

Most HCV outbreaks are due to inadequate IC practice* Inappropriate Disinfection of equipments and supplies

between patients Use common medication carts Sharing of multiple dose medication vials Priming buckets are not routinely changed or decontaminated Machine surface not properly disinfected Blood spills not cleaned up promptly Vacutainers and sharp boxes are shared between patients

* Busch et al., Transfusion 2000; 40: 143-159 ^Larghi et al.,Hepatology 2002;36:993-

1000

Control measures Monthly ALT for all patient Serology screening (anti-HCV) every 6 months (15% false

positive) Those tested positive must undergo (recombinant immunoblot

assay) RIBA* Diagnosing cases using RT-PCR (nucleic acid test [NAT]) (not

detectable in active acute hepatitis)^ Infection control guidelines targeting factors responsible for

transmission Isolation of HCV cases has no evidence for the reduction of

transmission!!!

*CDC unpublished data; 2001 ^ Valendia et al., Lancet 1995; 345: 1417-22

Human Immunodeficiency Virus

In USA the proportion of hemodialysis cases with HIV infection is 1.4%*

Transmission is through blood and body fluid Cross-contamination have been reported in

hemodialysis units^ Control measures similar to HCV including

isolation

Bacterial infections

Epidemiology Bacterial infections is considered as the second most

common cause of mortality in hemodialysis patient 15% Infection through vascular access S. aureus, coagulase negative Staphylococci, enterococci

and fungi are the commonest in vascular access infections Infection through dialysis water Gram negative as Acinetobacter, Aeromonas,

Achromobacter, Serratia, Flavobacterium or Pseudomona are commonly found in water

Cont…bacterial infection

Transmission Exogenous

Water contamination Contaminated medication vials

Endogenous Colonization with potentially pathogenic organisms

Through cross-contamination (staff) Environmental surfaces (bed rails)

* Brady et al., Am J Kidney Dis 1998; 32: 415-8

Cont…bacterial infection

Antimicrobial resistant Severely ill cases including hemodialysis are

recognized source of multi-drug resistant organisms Vancomycin use

Cefazolin*

AAMI; 2003

Control measures

Water treatment system Softeners and deionizers are ion exchanger and do not

remove bacteria or endotoxin Carbon filters remove certain organic chemicals but increase

the growth of bacteria and do not remove endotoxin Particulate (prefilters); deep filtration for debris but do not

remove bacteria or endotoxin Absolute filters remove bacteria but easily colonized and do

not remove endotoxin Ultraviolet some water bacteria are resistant and do not

remove endotoxin

AAMI; 2003

Cont…control measures

Reverse osmosis Able to remove both bacteria and bacterial endotoxin but

not 100% Require routine disinfection

AAMI; 2003

Recommendation for water system

Recommendation would be a set of prefilter, softener, carbon filter, reverse osmosis and ultrafilters

Making the plant as close as possible to dialysis (short piping) The piping system to be small size and must not have rough

joints or dead ends Outlet taps should be at high level Storage tanks are not recommended as they serve as reservoir

other wise must be routinely disinfected Disinfection process must include all parts of the dialysis

machine that exposed to water

NKF, Am J Kidney Dis 2001.

Cont…control measures

Vascular access infection Not to use antibiotic prophylaxis prior to catheter insertion Not to replace the catheter routinely Proper sterile technique during insertion Use catheter for dialysis only and restrict manipulation and

dressing to trained personnel Change dressing with every dialysis session or when visibly

damp loose or soiled Treatment with mupirocin for carriers who have catheter-

related blood stream infection due to S. aureus.

* Saudi Centre for Organ Transplantation

Recommended general guidelines

Strict hand washing and PPEs Clear segregation between the dirty and clean areas

defining Items taken to dirty area either disposed, dedicated or

disinfected prior to taken back to clean area Unused medications or supplies taken to dirty area must be

used for that patient only Multi dose vials must be prepared in clean central area Not to use common medication carts or trays

* Saudi Centre for Organ Transplantation

Cont…guidelines

Blood samples or patient side used equipments must not be handled in clean area

Use external venous and arterial transducer filters to protect dialysis machine pressure monitor from blood

Clean and disinfect station between patients Used dialyzers and tubing must be placed in leak proof

containers for transport from station to reprocessing or disposal area

Summary

BBP, bacterial infections and pyrogenic reactions are preventable complications of dialysis

Set up a system for infection control guidelines in your dialysis unit (Policy)

Training, education and compliance will surely reduce infections in dialysis units

Surveillance for dialysis units improves the outcome BBP Bacterial infection Pyrogenic reaction