透析單位之感染管制

1. 透析單位之感染管制 吳丁樹醫師 感染管制委員會 內科部 感染醫學科 林口長庚紀念醫院

2. 透析病人之免疫功能 • 淋巴球等免疫細胞功能不佳 • 尿毒的影響 • 營養不良 • 透析設備的材質問題 • 視同免疫缺損病患

3. 基準體溫偏低 50% 原因 不明 感染後的體溫反應 容易不發燒 原因 發燒反應並無異常 多重其他原因 基準體溫偏低 營養不良 透析病人的體溫調節

4. 血液透析與感染 • Vascular access for prolonged periods • Multiple patients on dialysis concurrently • Person-to-person transmission • Directly • Indirectly • Devices & equipment • Supplies • Environmental surfaces • Hands of HCW • Loading with nosocomial pathogens • Antimicrobial resistance

5. 血液透析與感染 • 感染頻率高 • 感染嚴重度高

6. 感染管制 • Safety • 病患安全 • 工作人員安全

7. Infection Control Components-Study on the Efficacy of Nosocomial Infection Control (SENIC) Surveillance and control activities Infection preventionist Trained hospital epidemiologist A system Am. J. Epidemiol. 121, 182–205 (1985)

8. Comprehensive Infection Control Program in Hemodialysis Unit • Infection control practices • Infection control precautions • Bloodborne viruses • Pathogenic bacteria • Routine serologic testing for HBV & HCV • Vaccination of susceptible patients against hepatitis B. • Isolation of patients with HBsAg • Surveillance for infections • Infection control training and education CDC MMWR 2001;50:1-41

9. Dialysis Center Guidelines Prevention of vascular access infections Environmental disinfection Hand hygiene Prevention of MDR organisms Vaccinations Pevention of bloodborne viruses

10. Isolation strategies • Airborne precaution • Droplet precaution • Contact precaution

11. 透析用水作業標準及發展趨勢—國內 • 2013年血液透析及腹膜透析訪視評量標準說明「 5.1.3 細菌培養 (僅血液透析) 」 「至少每月檢測一次透析用水(RO水)細菌培養、每季一次所有機台的透析液細菌培養並做紀錄。」

12. 透析用水標準國際發展趨勢 2013 <200 (50) CFU/ml <2 EU/ml ISO 13959:2009: <100 (50) CFU/ml <0.25 EU/ml 2009 2004 AAMI RD52: 200 (50) CFU/ml, 2 (1) EU/ml 2004 USP XXVII: 100 CFU/ml, 2 EU/ml 2002 ISO 13959: 100 CFU/ml, 1 - (5) EU/ml 2002 EDTA Best Practice Guideline: <100 CFU/ml, <0.25 IU/ml (high flux:< 0.1 CFU/ml, <0.03 IU/ml) 2002 Eur Pharm 4th ed 2002:≤102 CFU/ml,<0.25 IU/ml 2001 EDTNA Guideline: <102 CFU/ml, ≤0.25 IU/ml 1998 ISO 13959: 100 CFU/ml, 5 EU/ml 1992 Eur Pharm 2nd ed 1992: ≤102 CFU/ml, ≤0.25 IU/ml 1990 Sweden LS1990: <102 CFU/ml, <0.25 IU/ml 1982 AAMI: 200 CFU/ml, - EU/ml

13. Bloodborne VirusesHEPATITIS B

14. 流行病學 • 盛行率逐漸降低 • 輸血篩檢 • Erythropoietin使得輸血減少 • 台灣全面性的疫苗施打

15. 臨床表現 • 多半無症狀 • 非特異性的疲勞 • 肝臟酵素輕微上升 • GOT/GPT 2-3X • 少有黃疸

16. 臨床表現 • 慢性B型肝炎 • 50% • 治療 • Interferon • Lamivudine 100 MG QD • Adefovir 10 MG QD

17. 預防 • Routine testing • Vaccination • Restricting exposure • Hepatitis B immune globulin

18. Routine Testing

19. Vaccination Subjects All patients on chronic hemodialysis The healthcare providers

20. Vaccination anti-HBs Testing 1-2 months after last dose <10 mIU/mL: susceptible Revaccinate with an additional 3 doses Retest anti-HBs. >10 mIU/mL: immune Retest annually. Booster dose if anti-HBs <10 mIU/mL Continue to retest annually

21. HBsAg-Positive Patients • Infection control practices as for all H/D patients • Dialysis in a separate room with separate machines, equipment, instruments, and supplies • Staff members should not care for HBV-susceptible patients at the same time • Same shift • Patient changeover

22. Outbreaks of HBV Infection • Cross-contamination to patients via • Environmental surface, supplies ( eg. hemostats, clamps), or equipment was not routinely disinfected after each use • Multiple dose medication vials and intravenous solution were not used exclusively for one pt • Medications for injection were prepared in areas adjacent to areas where blood samples were handled • Staffs simultaneously cared for both HBV-infected and susceptible pts. MMWR 2001;50:1-41

23. Other Measures General infection control practices Cleaning & disinfecting nondisposable items Using gloves when touch patients and equipments Between patients Changing gloves Cleaning & disinfection of equipment & environment Adherence Hand hygiene Safe injection and medication preparation Surveillance for HBV infection in susceptible patients HBsAg monthly

24. Bloodborne VirusesHEPATITIS C

25. 流行病學 • 比一般人要高 • 原因 • Blood transfusions • Duration of dialysis • Mode of dialysis • Lower risk in peritoneal dialysis • Previous organ transplantation • Intravenous drug abuse

26. 自然病程 • 仍不十分清楚 • 生化檢查和病理嚴重度關係不密切 • 增加肝硬化和肝癌 • 可能因此死亡率增加

27. Cross Contamination Preparation of multidose medications in the dialysis treatment station Mobile medication/supply cart to deliver supplies between patient stations Failure to clean and disinfect the dialysis station or dialysis machine Shared use of single-dose medication vials for more than one patient.

28. Infection Control Technique Safe injection practices Hand hygiene Between patients Cleaning & disinfection of equipment & environment Isolation of patients: not recommended

29. Routine Testing

30. 感染管制措施-環境 • 透析機和管路之消毒-機器維修與消毒 • 班與班透析機消毒至少有沖水，有感染之虞時應改採化學消毒模式 • 班與班之間透析機外表消毒方式，建議向廠商要求提供適當方式，以不傷害機器面板而達消毒目的 • 若廠商確認機器有二次水洗功能且有設定完成即可 • CC肝，BB肝，班與班之消毒方法採沖水；因為化消班與班間來不及，CB肝；BC肝消毒方法建議採化學消毒 資料來源：台灣腎臟醫學會一零二年度血液透析及腹膜透析評量作業說明

31. 感染管制措施-環境 • 透析機和管路之消毒-機器維修與消毒 • 每日最後一班結束後透析機消毒方式如下：(機器若未能自動監測者，應檢測消毒劑殘餘量) • 化學消毒模式順序︰ • 醋酸+化消模式順序︰ • 前水洗 → 吸酸→ 浸泡 →中水洗 →吸漂白→浸泡→後水洗 → 關閉電源 前水洗 → 吸藥 → 藥液浸泡 → 後水洗 → 關閉電源 資料來源：台灣腎臟醫學會一零二年度血液透析及腹膜透析評量作業說明

32. Bloodborne VirusesHIV

33. Routine Testing • Not recommanded • Only for: • Patients with risk factors of infection

34. 血液曝露的處理程序 • Source patient • HBsAg (+) or unknown • Hepatitis B immune globulin • Test for HIV • Inform patient; consent required • Prophylaxis • RPR for syphilis • PCN 3M u IM stat • aHCV Ab

35. 血液曝露的處理程序 • Staff • HBsAg; HBsAb; HIV Ab; RPR; aHCV Ab • Time of incident • 6 weeks later • 6 months later

36. BSI (Blood Stream Infection)CLA-BSI(Central Line Associated BSI)

37. 中央靜脈導管感染 • Pathogenesis • More common • Pathogen migration along external surface • Early (< 7days) • Hub contamination with intraluminal colonization • Late ( >10 days) • Less common • Hematogenous • Seeding from another source • Contaminated infusates

38. 中央靜脈導管感染 • Source of Infection • Contiguous skin flora • Contamination • Catheter hub or Lumen • Infusate • Hematogenous colonization • From distant, unrelated sites of infection

39. 中央靜脈導管感染 • Pathogens • Coagulase-negative staphylococci • S. aureus • Candida spp. • Gram-negative bacilli • Enterococci

40. Resistance: CLA-BSI Agents • Pathogen ICU Non ICU • Staph. coag neg – MRSE75% 65% • Staph. aureus – MRSA 50% 40% • Enterococci - Vanco R 12% 12% • Pseudomonas aeruginosa • Fluoroquinolone26% 25% • Imipenem 20% 12% • Ceftazidime 15% 8% • Piperacillin 17% 12% • Enterobacter 3rd Cef 36% 5% • E. coli 3rd Cef 36% 5%

41. 中央靜脈導管感染 • Biofilm • Attachment to intravascular catheters • Sanctuary from antimicrobial agents • Extracellular polysaccharide • esp. Staphyloccoci • Quorum-sensing" proteins • Pseudomonas • Drug resistance

42. Extraluminal Route of Infection • Cutaneous microflora • Migration between • Catheter • Cannulated vessel • Migration to • First the catheter tip • Then the bloodstream

43. Intraluminal Route of Infection • Contamination • Catheter hubs • Ports of needleless systems • Over longer periods of time • Surgically implanted catheter • Cuffed catheters

44. Intraluminal Route of Infection • Extrinsic contamination • Patient's skin • Immediate environment • Uncleaned hands of healthcare workers • Intrinsic contamination • Hematogenous colonization • Epidemic infection • Faulty manufacturing • Onsite compounding

45. Healthcare Personnel Hand Contamination Hub Contamination Contaminated Infusate Contamination of insertion site Extraluminal Contamination Hematogenous spread

46. 組合式照護(Bundle Care) • 同時施行所有實證醫學證實有效措施 • 集結這些措施的效果 • 讓介入成效最大化

47. 團結力量大

48. CLA-BSI Bundle • 確實執行手部衛生 • 全覆蓋防護 • 最大面積的覆蓋防護 • 執行者 • 病患 • 皮膚消毒 • 置放中央導管需徹底進行皮膚消毒 • 消毒液採用2% chlorhexidine為佳 • 慎選置放中央導管的位置 • 避免使用鼠蹊部為置放部位 • 每天檢討中央導管是否仍有需要 • 不再需要時立即拔除 Clin Infect Dis2011; 52:1087–99

49. 血液透析單位的相關感控措施 • Universal precautions • Staff must wear fluid-impermeable garments • Gloves for potential exposure to blood or body fluids • Gloves changed and hands washed between patients • Protective eyewear and face shields for potential splashing of blood • No recapping of contaminated needles w/ prompt disposal in appropriate container • No eating or drinking in dialysis unit

50. 血液透析單位的相關感控措施 • General precautions for staff and patients • Isolation •  HBsAg (+) •  aHCV Ab (+) •  HIV (+) • Dialyzer reuse •  HBsAg (+) •  aHCV Ab (+) •  HIV (+) • Cleansing w/ with 1% bleach • Dialysis machines • blood/body fluid contaminated areas