Upload
garey-austen-dalton
View
219
Download
3
Tags:
Embed Size (px)
Citation preview
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