Infection Control in Hemodialysis Setting

1. Infection Control in Hemodialysis Setting Source: Kallen AJ, Arduino MJ, Patel PR. Preventing infections in patients undergoing hemodialysis. Expert Rev Anti Infect Ther. 2010;8(6):643–655.

2. Overview • Infections are a prime cause of morbidity and mortality in end-stage renal disease patients. • In patients on hemodialysis, infections related to hospitalizations have elevated by 26% from 1993 to 2007. • With the increase in cases transmission of bloodborne hepatitis viruses in outpatient healthcare settings, including hemodialysis centers, related to suboptimal infection control and injection safety practices, the patient safety concerns have increased. • The centers for disease control and prevention’s (CDC) study on the efficacy of nosocomial infection control (SENIC) recommends that, hospitals could reduce the occurrence of healthcare-onset infections by about one-third by adopting an infection control program. • Figure 1 depicts some of the infection control measures.

4. Current Infection Control Issues inHemodialysis Setting Preventing Transmission of Hepatitis B & C • Hepatitis B virus (HBV) infection could be prevented with vaccination, and this is recommended for all patients under chronic hemodialysis. • Complete hepatitis B serologic status of the patient should be recorded before initiating dialysis and all vulnerable patients should be vaccinated. • Other practices for controlling infection include, avoiding the exposure of vulnerable patients to infected blood, isolation of HBV-infected patients, preventing same staff members to care for HBV-infected and susceptible patients, and ensuring that specific dialysis equipment and other supplies dedicated for infected patients are not used for susceptible patients.

5. Preventing Transmission of Hepatitis B & C • The occurrence of antibody to hepatitis C virus (HCV) is seen to be higher in • hemodialysis patients (7.8%) as compared to the general population (1.6%), which may elevate depending on the duration of dialysis. • Hepatitis C virus is mainly transferred through percutaneous contact with blood; thereby posing the hemodialysis patient at a risk for infection through transmission. • Preventive steps for controlling HCV transmission in dialysis settings have been primarily focused on secure injection practices, employment of hand hygiene, and ample cleaning of environmental surfaces and equipment among patients. • In general, infection preventive steps include the restricted use of supplies and items taken into the dialysis station for individual patients, or cleaning and disinfecting them or disposing them in case they cannot be cleaned or disinfected, use of clean area far from dialysis stations for preparing medications, avoiding the usage of common medication carts for medications delivery to patients, cleaning and disinfecting of stations between patients, and proper use of hand hygiene. • The CDC also suggest that patients should be tested for the antibody to HCV during admission and then semi-annually.

6. Preventing Influenza • Vaccination is one of the prime steps used to control influenza infection in hemodialysis patients. In long-term care facilities, it has been observed that vaccination of staff members is linked with reduced influenza-like illness and the overall mortality in residents. • Educating dialysis staff on HCP vaccination, respiratory hygiene and cough etiquette, and actions to avoid the respiratory virus transmission are also important. • Staff members should not work if they are ill with contagious illnesses such as influenza.

7. Preventing Bloodstream Infections • Bloodstream infections are associated with high levels of morbidity and mortality. • The bloodstream infection (BSI) rates in patients undergoing hemodialysis differs based on the nature of vascular access that is present. • Hand hygiene, insertion practices, skin cleaning are widely recommended for preventing BSI. • The CDC and kidney disease outcomes quality initiative (KDOQI) recommends that topical antimicrobial ointments should be applied to the catheter exit site. • There also has been growing interest in the use of antimicrobial catheter locking solutions for preventing BSIs associated with catheter use.

8. Environmental Cleaning • Studies have evidenced that blood borne pathogens like HBV and HCV could be found on several surfaces within the dialysis unit. • The appropriate use of detergents and disinfectants is an important component of achieving environmental cleaning.

9. Injection Safety • Inappropriate management of shared medication vialscould lead to contamination. Some of the unsafe injection practices linked to blood borne pathogen outbreaks include preparation of parenteral medications for multiple patients in patient treatment areas and reuse of single-dose medications for multiple patients.

10. Preventing Transmission ofMultidrug-resistant Organisms • Studies have shown that the risk for invasive multidrugresistant organisms (MDRO) infections is several folds greater for dialysis patients than for the general population. • The recommended infection control practices, if followed properly could emerge out as a useful way to restrict transmission of MDROs in hemodialysis patients.

11. Decolonization • Colonization with S. aureus is a known risk factor for subsequent S. aureus infections in hemodialysis patients. • Decolonization on overall infections is not very clear, although it has been observed that decolonization reduces S. aureus infections in hemodialysis patients.

12. Conclusion • Careful surveillance and proper execution of infection control recommendations can help control infection in patients under hemodylasis. Bloodstream infections is critical, but is often ignored. Employment of CDC surveillance methods and application of surveillance data have been observed to be associated with the reduction in the incidence of BSI and other serious events. • The infection control program can be successfully implemented • with trained professionals and through evidence-based strategies. • Further issues revolving infection control in dialysis setting include the requirement for additional prevention research, a better emphasis on observation and documenting of adverse dialysis events, and the implementation of novel shared models.

13. Comprehensive Basketin Anemia Management