1 / 24

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:

jory
Download Presentation

Infection Control in Dialysis Units

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related