There and Back Again: Relearning Infection Control

1
There and Back Again Relearning Infection
Control

• Matthew J. Arduino, M.S., Dr.P.H.
• Division of Healthcare Quality Promotion
• National Center for Preparedness, Detection and
  Control of Infectious Diseases
• Coordinating Center for Infectious Diseases

The findings and conclusions in this report are
those of the author and do not necessarily
represent the official position of the Centers
for Disease Control and Prevention
2
Outline

• Introduction
• Bloodborne Pathogens
• Hepatitis B
• Hepatitis C
• Hepatitis D
• Human Immunodeficiency Virus (HIV)
• Tuberculosis
• Drug Resistant Microorganisms (MRSA, VRE, VISA,
  VRSA)
• Dialysis Unit Precautions

3
Background

• October 20, 1972 Richard Nixon signed the Social
  Security Amendments of 1972 Extended Medicare
  coverage to patients with chronic renal failure.
• July 1973 patients became eligible for Medicare.
• Conditions of Coverage, first established in 1976
• AAMI End Stage Renal Disease and Detoxification
  Committee formed in 1981

4
Hemodialysis Numbers, 1982-2002
Number of Dialysis Facilities
Number of patients
5
So where are we today as related to infection
control?

• Infection Control added to conditions for
  coverage
• Incident transmission of hepatitis C and B
  (anti-HCV screening is not recognized by CMS as
  an infection control issue)
• Dialysis patients are sentinel population for
  antimicrobial resistance
• Prevalence of MRSA and VRE is unknown
• Dialysis patients have an extremely high
  incidence of invasive MRSA, more than 100-fold
  greater than the general U.S. population.

6
Breaks in Infection Control

• Not cleaning blood spills or splatters including
  prime buckets on side of machine
• Not cleaning or disinfecting commonly touched
  environmental surfaces between patients (e.g.
  machine, chair or station)
• Sharing equipment and supplies that were not
  disinfected shared multidose vials placed on the
  top of the machines
• Sharing a common medication cart

7
Bacterial/Fungal Infections

• Vascular access related
• Contaminated machines
• Reuse related
• Contaminated IV medications

8
Contaminated MachinesWaste Handling Option

• Several outbreaks since 1995 (U.S., Canada, and
  Israel)
• Enterobacter cloacae, Pseudomonas aeruginosa,
  Escherichia coli, Candida parapsilosis
• Recent cluster in Chicago Phialemonium curvatum
  (two patients sequentially on the same machine
  became fungemic, WHO port was removed prior to
  the investigation) Phialemonium was isolated in
  the water feeding the machine

9
Reuse Related Bacteremia/Fungemia

• Organisms Burkholderia cepacia complex,
  Ralstonia pickettii, Ralstonia mannitolytica,
  Stenotrophomonas maltophilia, Candida
  parapsilosis
• Today most reuse related infections are
  associated with header removal Header-sepsis
• In the past, most were associated with either
  poor water quality, or manual reuse

10
Drug Resistance an Emerging Infectious Disease
Emergency

• Resistance to antibiotics is becoming an
  increasing problem in healthcare delivery systems
• Organisms with major public health importance
  include
• Methicillin resistant Staphylococcus aureus
  (MRSA)
• Multiply Drug Resistant Mycobacterium
  tuberculosis
• Penicillin resistant Streptococcus pneumoniae
• Vancomycin Resistant Enterococci (VRE)
• Vancomycin Resistant Staphylococcus aureus (VISA)

11
Vancomycin Intermediate-Resistant S. aureus
(VISA)
State, Year Site PD/HD Michigan,
1997 Peritonitis Chronic PD New Jersey,
1997 Blood Recent PD New York, 1998 Blood Chronic
HD Illinois, 1999 Endocarditis Chronic
HD Minnesota, 2000 Bone Chronic HD Nevada,
2000 Liver ----- Maryland Blood ----- PDperitone
al dialysis HDhemodialysis
Fridkin Clin Infect Diseases 2001
12
First Case of Vancomycin - Resistant S. aureus
(VRSA)

• First fully vancomycin resistant clinical isolate
  of S. aureus
• Michigan, June 2002
• 40-year old black female with diabetes mellitus,
  peripheral vascular disease,on chronic
  hemodialysis
• VRSA from foot ulcer and catheter exit site
• During the 6 months preceding VRSA
• patient experienced 6 hospitalizations, totaling
  18 days
• patient received multiple antimicrobial therapy,
  including
• 5.5 weeks of vancomycin

Chang S et al, New England J of Med 2003
34814,1342-3447
13
Vancomycin Resistant S. aureus

• 9 cases of VRSA since 2002 (7 in Michigan, 1 PA,
  1 NY)
• Two were dialysis dependent (Including index
  case)
• Most patients diabetics
• Infected wounds
• MIC vancomycin gt 16µg/mL
• Acquisition of VanA gene many cases shown to
  have a VRE donor and MRSA recipient

ZhuW, et al. Vancomycin-Resistant Staphylococcus
aureus Isolates Associated with Inc18-Like vanA
Plasmids in Michigan. Antimicrob Agents
Chemother 200852(2)452-7.
14
Resurgence of HBV outbreaks in the mid 1990s

• Failure to review lab results HBsAg patients
  treated with susceptible patients
• Failure to isolate HBsAg patients
• Sharing of staff, equipment, medications, and
  supplies among patients
• Failure to vaccinate susceptible patients against
  hepatitis B

15
CDC. Hepatitis-Control measures For hepatitis B
in dialysis centers. Viral hepatitis and Control
Series, November 1977. HEW Publ No (CDC) 78-8358
16
What we have learned from our annual surveillance

• In 2002, the incidence of HBV infection was
  higher among patients in centers where injectable
  medications were prepared on a medication cart or
  medication area located in the treatment area
  compared to a dedicated medication room.
• Centers that used a disposable container versus a
  nondisposable container for priming the dialyzer
  had a significantly lower incidence of HCV.

17
Blood Contaminating a Pressure Transducer Filter
18
Have we forgotten the basics?
19
(No Transcript)
20
Bloodborne Pathogens

• Hepatitis B, C, and D Viruses
• Human Immunodeficiency Virus (HIV/AIDS)

HBV
HCV
HIV
21
Estimates of Acute and Chronic DiseaseBurden for
Viral Hepatitis, United States
HAV
HBV
HCV
HDV
Acute infections
(x 1000)/year
125-200
140-320
35-180
6-13
Fulminant
deaths/year
100
150
?
35
Chronic
0
1-1.25
3.5
infections
million
million
70,000
Chronic liver disease
deaths/year
0
5,000
8-10,000
1,000
Range based on estimated annual incidence,
1984-1994.
22
Relative Infectivity of HBV, HCV, and HIV
HBV HCV HIV
Titer/ml 108-11 105 103
Environmental Stability -
Can persist on environmental surfaces for at
least 7 days Can persist for 24 hrs (CDC
unpublished data)
23
Hepatitis B
HBV is a vaccine preventable Disease
24
Outbreaks of HBV in the Hemodialysis

• Blood leaks
• Transducer protectors
• cross-contamination of environmental surfaces,
  supplies, medications, or equipment
• simultaneous provision of care to both
  HBV-infected and susceptible patients by the same
  staff members
• multiple dose medication vials

25
Extra Precautions for HBV

• Can remain infectious on surfaces for at gt 7 days
• high titer of HBV
• Blood can be diluted to below visible levels and
  still contain enough infectious particles that
  indirect transmission can still occur
• 3.3 of centers reported gt1 patients with newly
  acquired (incident) HBV infection
• 24.1 of centers reported gt1 patients with
  chronic (prevalent) HBV infection
• 25.5 of centers reported gt1 patients with either
  acute or chronic HBV infection.

26
(No Transcript)
27
Incidence and Prevalence of Hepatitis B in the
United States, 1976-2002
1977 CDC Recommendations
2001 CDC Recommendations
Vaccine
28
Incidence of HBsAg in Hemodialysis Patients, by
use of Hepatitis B Vaccine, 1996
Plt0.05 compared with reference group
29
Hepatitis C Virus

• Most efficiently transmitted by direct
  percutaneous exposure to infectious blood
• Risk factors history of blood transfusions,
  volume of blood transfused, and years on dialysis
  (5 years)
• No significant differences in HCV incidence or
  prevalence in centers that reused dialyzers
  compared to those who did not reuse dialyzers
• Decline in prevalence may be attributable in part
  to a decline in new infections among patients as
  a result of increased awareness of the potential
  for HCV transmission in this setting.

30
HCV Prevalence by Selected Groups United States
Average Percent Anti-HCV Positive
31
Hepatitis C Virus

• Flavivirus (single stranded RNA, enveloped virus)
• Multiple HCV genotypes in addition within
  genotypes there are closely related genotypes or
  quasi species
• Antibody elicited by infection with one genotype
  fails to cross-neutralize virus of another
  genotype.
• Prior infection does not produce immunity

32
Estimated Incidence of Acute Hepatitis C United
States, 1982-2000
Source Sentinel Counties
33
Nosocomial Hepatitis C TransmissionHemodialysis
Units

• Prevalence increases with increasing years on
  dialysis
• Annual incidence is only 1-2
• Transmission probably results from poor infection
  control practices
• Prevalence in patients is approximately 10
• Prevalence in Staff members is 2

34
Tuberculosis
35
ESRD Patients With Active Tuberculosis
36
Tuberculin Skin Testing of ESRD Patients

• ESRD Patients are at increased risk for
  developing TB- A survey in New Jersey (1994)
• 7.9 of all U.S. dialysis patients treated at
  least one patient with known active TB (CDC-1995
  Survey)
• Individual dialysis centers treating a high
  proportion of minority and foreign born patients,
  have reported higher incidences of TB

37
Guidelines for Skin Testing

• Test groups with either
• high rate of TB (substance abusers residents of
  correctional facilities, nursing homes, and other
  congregate settings medically under served
  populations high risk racial or ethnic/minority
  populations children exposed to high risk
  categories)
• medical risk factors that increase risk of
  disease progression

38
Tuberculin Skin Testing in Hemodialysis Patients

• All patients with ESRD should receive at least
  one tuberculin test to identify latent infection.
• If exposure to persons with active TB is likely,
  periodic rescreening is indicated
• ESRD patients who are contacts of a person with
  infectious TB should be retested
• A recent study of anergy in patients uninfected
  patients found only 18 of ESRD patients to be
  anergic

39
General Recommendations for Tuberculosis in the
Hemodialysis Setting

• CDC. Guidelines for Preventing the Transmission
  of Mycobacterium tuberculosis in Health-Care
  Facilities, 2005. MMWR 200554 (No. RR-17).
  http//www.cdc.gov/mmwr/pdf/rr/rr5417.pdf
• Patients with ESRD who need chronic dialysis
  should have at least one test for M. tuberculosis
  infection to determine the need for treatment of
  LTBI
• Annual re-screening is indicated if ongoing
  exposure of ESRD patients to M. tuberculosis is
  probable.
• Easier to treat patients with active pulmonary
  tuberculosis in an acute setting where TB
  isolation rooms, appropriate engineering
  controls, and respiratory protection programs are
  available
• Patients can be admitted back to the unit when on
  appropriate therapy and are considered
  non-infectious.

40
Tuberculosis

• All patients with compromised immunity should be
  tested at least once for latent TB infection.
• Consider skin testing as part of patient intake
  process
• Staff should be tested at time of hire
• For patients who test positive a refer for
  medical follow up and treatment plan development
• Patients and staff with latent TB should be
  offered prophylaxis and monitored regularly for
  signs of active infection
• Patients with active pulmonary disease should be
  treated in the acute setting in an airborne
  isolation room until considered noninfectious

Haddad MB, Arduino MJ. Is tuberculosis a serious
health risk for hemodialysis patients?
Nephrology Incite 20041721-23
41
Infection Control Practices
42
CDC. Recommendations for preventing transmission
of infections among chronic hemodialysis
patients. MMWR 2001 50 (RR5)1- 43
http//www.cdc.gov/mmwr/PDF/rr/rr5005.pdf
43
(No Transcript)
44
(No Transcript)
45
Interpretation of serologic test results for
hepatitis B virus infection
46
Patients Who Might Be At Increased Risk For
Transmitting Pathogenic Bacteria

• Uncontained wound drainage, fecal incontinence or
  diarrhea uncontrolled with personal hygiene
  measures.
• a) staff members treating the patient should wear
  a separate gown over their usual clothing and
  remove the gown when finished caring for the
  patient and
• b) dialyze the patient at a station with as few
  adjacent stations as possible (e.g., at the end
  or corner of the unit).

47
Safe Injection Practices

• Use aseptic technique to avoid contamination of
  sterile injection equipment. Category IA
• Do not administer medications from a syringe to
  multiple patients, even if the needle or cannula
  on the syringe is changed. Needles, cannulae and
  syringes are sterile, single-use items they
  should not be reused for another patient nor to
  access a medication or solution that might be
  used for a subsequent patient. Category IA
• Use fluid infusion and administration sets (i.e.,
  intravenous bags, tubing and connectors) for one
  patient only and dispose appropriately after use.
  Consider a syringe or needle/cannula contaminated
  once it has been used to enter or connect to a
  patients intravenous infusion bag or
  administration set. Category IB
• Use single-dose vials for parenteral medications
  whenever possible. Category IA
• Do not administer medications from single-dose
  vials or ampoules to multiple patients or combine
  leftover contents for later use. Category IA
• If multidose vials must be used, both the needle
  or cannula and
• syringe used to access the multidose vial must be
  sterile. Category IA
• Do not keep multidose vials in the immediate
  patient treatment area
• and store in accordance with the manufacturers
  recommendations
• discard if sterility is compromised or
  questionable. Category IA
• Do not use bags or bottles of intravenous
  solution as a common source of supply for
  multiple patients. Category 1B

48
CDC Guidelines and Recommendations and the New
Conditions of Coverage

• CDC. Recommendations for preventing transmission
  of infections among chronic hemodialysis
  patients. MMWR 2001 50 (RR5)1- 43
  http//www.cdc.gov/mmwr/PDF/rr/rr5005.pdf
• Guideline for Isolation Precautions Preventing
  Transmission of Infectious Agents in Healthcare
  Settings 2007 http//www.cdc.gov/ncidod/dhqp/gl_is
  olation.html
• Guidelines for the Prevention of Intravascular
  Catheter-Related Infections, 2002
  http//www.cdc.gov/ncidod/dhqp/gl_intravascular.ht
  ml
• Guideline for Hand Hygiene in Healthcare Settings
  2002 http//www.cdc.gov/ncidod/dhqp/gl_handhyg
  iene.html

49
There and Back Again