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Infection Control in Dialysis Units

Infection Control in Dialysis Units. Hani A. Aziz Jokhdar, M.D. Consultant of Communicable Disease Control UQU, E & B hospital, IMC and MRQP. Introduction. The number of cases treated by maintenance hemodialysis is increasing (≈8,000 cases)* Cases are at risk of infections:

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Infection Control in Dialysis Units

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  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) * Saudi Centre for Organ Transplantation

  3. 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

  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^ * Saudi Centre for Organ Transplantation ^MMWR, April 27, 2001, Vol. 50, No. RR-5

  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 * Shikata et al., JID. 1977; 136:571-6 ^Bond et al., Lancet. 1981;1:550-1

  6. 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 * CDC, MMWR 1996;45:285-9

  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 * Alter et al., JID 1986; 153: 1149-51 MMWR, April 27, 2001, Vol. 50, No. RR-5

  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 * Najem et al., JAMA 1981; 245: 153-7 ^CDC MMWR 1996; 45: 285-9

  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%^ * Saudi Centre for Organ Transplantation ^Niu et al., Am J Kidney Dis 1993; 22: 568-73

  10. HCV transmission • Mostly throuhg direct per-cutaneous exposure to infected blood • Risk factors for transmission • Blood transfusion • Number of years on dialysis* * Moyer et al., Semin Dial 1994; 7: 124-7

  11. 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 * CDC upublished data; 1999

  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!!! * Busch et al., Transfusion 2000; 40: 143-159 ^Larghi et al.,Hepatology 2002;36:993-1000

  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 *CDC unpublished data; 2001 ^ Valendia et al., Lancet 1995; 345: 1417-22

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

  16. Cont…bacterial infection • Antimicrobial resistant • Severely ill cases including hemodialysis are recognized source of multi-drug resistant organisms • Vancomycin use • Cefazolin* * Brady et al., Am J Kidney Dis 1998; 32: 415-8

  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 AAMI; 2003

  18. Cont…control measures • Reverse osmosis • Able to remove both bacteria and bacterial endotoxin but not 100% • Require routine disinfection AAMI; 2003

  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 AAMI; 2003

  20. 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. NKF, Am J Kidney Dis 2001.

  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 * Saudi Centre for Organ Transplantation

  22. 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 * Saudi Centre for Organ Transplantation

  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

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