Infection Control Issues in the Dialysis Setting

Stuart L. Goldstein, MD Helen Currier, RN, BSN, CNNAssociate Professor of Pediatrics Assistant DirectorBaylor College of Medicine Renal Dialysis and PheresisMedical Director, Renal Dialysis Unit Texas Children’s HospitalTexas Children’s Hospital Houston, TexasHouston, 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 admissionssince 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: infectionFigure 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 for Medicare & Medicaid Services (CMS) DSHS CDC

QA/QI

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 bleach (intermediate level) Immediate

Disinfection Procedures

Bloodborne Pathogen Challenges

Hepatitis B virus Hepatitis C virus HIV

Nephrology Nursing Standards of Practice and Guidelines for Care (2005)

Hepatitis B

Desired Patient Outcomes The patient will not convert to HbsAg+ statusHepatitis B will not be transmitted in the

dialysis unit

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

Nephrology Nursing Standards of Practice and Guidelines for Care (2005)

Hepatitis C

Desired Patient Outcomes The patient will not convert to a positive anti-

HCV statusThe patient with a positive anti-HCV will not

transmit the disease

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 anti-HCV

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

Nephrology Nursing Standards of Practice and Guidelines for Care (2005)

Tuberculosis

Desired patient outcomesThe 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

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

InterventionProvide TB screening per current CDC

recommendations IC 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

Tuberculosis

Patient EducationRationale for TB surveillanceTeach respiratory IC practicesReinforce importance of adherence to

prescribed medication regimenTeach 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 patient contact All machine contact All medication preparation

Gloves must be changed Between patients Between machines When moving from one area to another

Nephrology Nursing Standards of Practice and Guidelines for Care (2005)

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

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 hygienic practices Care of vascular access; Washing prior to dialysis Glove use when holding vascular access site to stop

bleeding Peritoneal catheter exit site care

Use 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 ratesMRSACatheter related bacteremiaCatheter exit site and tunnel infectionsPeritonitis

Surveillance for Hepatitis virus susceptibility status

05

101520253035404550556065707580859095

100%

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

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

ESRD Network of TexasFacility Name

Facility Infection Trends

Percent of Facility Census with Infections By Type During Month

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 CFUAAMI action level is 50 CFU

Maximal level of endotoxin must not exceed 2 EU/mlAAMI action level is 1 EU/ml

Testing Sites

Testing Sites