Infection Control in Dialysis Units

1
Infection Control in Dialysis Units

• Hani A. Aziz Jokhdar, M.D.
• Consultant of Communicable Disease Control
• UQU, E B hospital, IMC and MRQP

2
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)

3
Contintroduction

• 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

4
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

5
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

6
ContHBV 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

7
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

8
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

9
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

10
HCV transmission

• Mostly throuhg direct per-cutaneous exposure to
  infected blood
• Risk factors for transmission
• Blood transfusion
• Number of years on dialysis

11
ContHCV 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

12
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!!!

13
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

14
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

15
Contbacterial infection

• Transmission
• Exogenous
• Water contamination
• Contaminated medication vials
• Endogenous
• Colonization with potentially pathogenic
  organisms
• Through cross-contamination (staff)
• Environmental surfaces (bed rails)

16
Contbacterial infection

• Antimicrobial resistant
• Severely ill cases including hemodialysis are
  recognized source of multi-drug resistant
  organisms
• Vancomycin use
• Cefazolin

17
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

18
Contcontrol measures

• Reverse osmosis
• Able to remove both bacteria and bacterial
  endotoxin but not 100
• Require routine disinfection

19
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

20
Contcontrol 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.

21
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

22
Contguidelines

• 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

23
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

24
Hand in hand for the best