Big Bad Bugs in the Dialysis Unit

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Big Bad Bugs in the Dialysis Unit

• Douglas Shemin, MD
• Kidney Diseases and Hypertension Division, Rhode
  Island Hospital

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Big Bad Bugs

• MRSA
• VRE
• C. diff

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Microbiology study of microscopic living
organisms

• Algae
• Protozoans
• Fungi
• Viruses
• Bacteria one cell structure, have cell walls

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5,000,000,000,000,000,000, 000,000,000,000
bacteria in the world!
rods
cocci
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Gram staining of bacteria
Gram positive
Gram negative
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Classification of bacteria

• Gram positive cocci
• staphylococcus
• streptococcus
• enterococcus
• Gram positive rods
• clostridia

• Gram negative cocci
• Neisseria gonorrhea
• Gram negative rods
• Pseudomonas
• E. coli
• Vibrio cholera

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Staphylococcus

• Colonize skin and soft tissue
• Staph epidermidis (coagulase negative)
• Staph aureus (coagulase positive)
• 1940s treated with pencillin
• 1970s treated with methicillin
• 1990s methicillin resistant (MRSA)

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MRSA

• Introduced into health facilities from endemic
  areas (nursing homes, hospitals) or by HCWs
• Rapidly disseminates and colonizes patients
  (especially with skin diseases or breakdown) and
  HCWs. Also lives on machinery, environmental
  surfaces
• Risk of colonization highest in elderly, in ICU
  patients, HD patients

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MRSA in hemodialysis patients CDC, 2005

• 813/5287 invasive MRSA cases in 2005 in HD
  patients (15 of the total)
• 45.2 cases invasive MRSA/1000 dialysis patients
  100 times greater risk
• 70 cases in patients gt 70
• 85 cases in patients with catheters
• In hospital death rate with invasive MRSA 17

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Treatment of MRSA

• Vancomycin historically agent of choice
• Newer agents linezolid, daptomycin
• But look out for VRSA (first reported in 2002
  in a patient on long term hemodialysis

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Control of MRSA

• Screening for carriage with swabs from nares and
  skin lesions
• Isolation techniqueshandwashing, gloves, gowns,
  masks
• Eradication of the carrier state (with intranasal
  or topical mupirocin (Bactroban)

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Enterococcus

• Enterococcus are gram positive cocci
• Normally reside in gastrointestinal tract (feces,
  mouth and pharynx) and vagina
• Historically susceptible to vancomycin VRE
  (vancomycin resistant enterococcus) reported in
  1989

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VRE

• Found in stool
• Risk factors chronic illness, kidney failure,
  long hospital stays, use of antibiotics
• VRE is resistant to virtually all antibiotics
  penicillin, cephalosporins, sulfa, quinolones

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Prevention of VRE

• Avoidance of use of vancomycin
• (use of cefazolin for treatment of staph
  infections instead, or waiting for culture
  results before starting antibiotics)

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Treatment of VRE
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Control of VRE

• Screening for carriage with stool cultures
• Isolation techniqueshandwashing, gloves, gowns,
  designated equipment
• Stricter isolation with diarrhea or incontinence

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Clostridium difficile (c.diff)

• Gram positive rod
• Usually associated with membrane formation in
  colon (pseudomembranous colitis)
• Clinical manifestation diarrhea
• Always associated with previous use of
  antibiotics
• Diagnosed by c. difficile toxin in stool

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Pseudomembranous colitis due to c.diff infection
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Pathogenesis of c. diff

• Use of antibiotics that alter the intestinal
  flora in the colon
• Age or illness related susceptibility
  geriatrics, immunosuppression, poor nutrition

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Symptoms of c. diff infection

• Fever, abdominal pain and diarrhea soon after
  treatment of an infection with an antibiotic
• Toxic megacolon can occur, with colonic
  perforation

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Treatment of c.diff

• Prevention avoidance of unnecessary antibiotics
• Stopping antibiotic once diagnosis made
• Oral vancomycin or metronidazole (Flagyl)
• No anti-diarrheal agents
• Lactobacillus tablets may be helpful

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Big Bad Bugs MRSA, VRE, c. diff

• All associated with immunodeficiency, chronic
  illness, and chronic kidney disease
• All associated with antibiotic use
• Although definitive treatment is with
  antibiotics, the most effective treatment is
  prevention, with isolation techniques and
  handwashing

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What can you do to protect your patients?

• Protect yourself cooperating with isolation and
  gowning/gloving procedures
• Educate your patients isolation techniques
  decrease trasnmission
• Educate patients and families antibiotics can
  have significant negative consequences

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