Dialysis by decree

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									                                        Dialysis




                                Dialysis
Introduction
Dialysis is a procedure that replaces the normal functions of the kidney by
removing metabolic waste products through diffusion and hydraulic pressure
gradients. Use of an artificial semipermeable membrane (hemodialyzer) or a
natural semipermeable membrane (peritoneum) allows passage of some
molecules while passage of other molecules is restricted. Molecules that can
move through membrane move from the area of higher concentration to the area
of lower concentration. 6 The dialysate is a combination of treated water and
electrolyte concentrates used with the dialysis machine and system. 6 Dialysis is
hazardous for the patient and for the staff that take care of the patient.
Dialysis treatment is accomplished by two primary mechanisms, hemodialysis
(HD) and peritoneal dialysis (PD). HD utilizes an artificial dialyzer for removal of
metabolic waste products and PD uses the patient’s peritoneal cavity and
membranes.
Dialysis can be hazardous for the patient as venous access and insertion of
foreign bodies can increase risk of infection. Also the patient might be exposed to
exogenous microorganisms or to endotoxin from contaminants in the water used
to prepare dialysis. Personnel that care for the patient are at risk of occupational
exposure to blood-borne pathogens as patients requiring dialysis can have a high
prevalence of blood-borne diseases. 7 Reuse of syringes and other breakdowns
in infection control resulted in transmission of HIV to 39 patients at two dialysis
centers in Egypt. 8


Infection Control in the Dialysis Setting
Dialysis is used as a life sustaining treatment for patients with renal failure.
Patients undergoing dialysis are already at risk of certain types of infections
resulting from underlying diseases or conditions such as:
        Diabetes
        Hypertension
        Cardiovascular disease
        Immunosuppressive therapy
        Other critical diseases6
Furthermore, dialysis increases the patient’s risk of infection because direct
access into normally sterile areas, including the circulatory system or peritoneal


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cavity, is required. Infection can be caused by contamination occurring at various
steps in the dialysis procedure or because of intrinsic contamination of any of the
components of the dialysis system.

The most common types of dialysis-associated infections:
   Access site infections
   Bacteremias
   Peritonitis
   Pyrogenic reactions
   Infections with blood-borne pathogens6


Reducing Dialysis-Associated Infection Risk
Infections and adverse reactions may be the result of inadequate infection control
measures. 6 Risk of infection or of adverse reactions in the dialysis unit can be
reduced by strictly adhering to aseptic technique and to procedures for
disinfection, by maintenance of equipment, and by carefully monitoring all
procedures in which bacterial or chemical contamination can occur. 6
Contact transmission is the most important route by which pathogens are
transmitted in health care settings including dialysis units. Transmission can
occur when microorganisms from a patient are transferred to the hands of health
care personnel who do not use infection control precautions and who then touch
another patient. Less often the environment around the patient, bedside tables,
countertops, etc., become contaminated and serve as a reservoir of pathogens
that can be picked up on hands of health care personnel and transferred
subsequently to a patient. For example, if health care personnel hands are
contaminated with blood-borne virus-infected blood from one patient, they can
transfer the virus to another patient’s skin or blood line access port when the skin
or port is accessed with a needle.


Hemodialysis (HD)
Hemodialysis removes toxins, electrolytes, and fluid by circulating the patients’
blood through a hemodialyzer (artificial kidney). Patients are usually scheduled to
receive hemodialysis for two to six hours three times per week. The basic
components of hemodialysis include circulatory access, water treatment system,
water distribution system, dialysate (components), dialysis machines, blood
tubing and the hemodialyzer.6




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Circulatory Access
Access to the patients’ circulatory system is gained through the establishment of
several different types of devices including external arteriovenous shunts,
internal arteriovenous fistula, graft arteriovenous fistula, and temporary vascular
access devices (e.g., dual lumen catheter in subclavian, jugular vein).6


Standard Precautions
Hand hygiene and Protective Barriers
Indications of routine handwashing in Dialysis unit
    Before and after dealing with dialysis machines
    Before and after performing non-invasive techniques
    After removal of gloves
    If hands are visibly dirty
    After leaving a particular patient dialysis station and before dealing with
      another patient’s stations

Indications for aseptic handwashing
    Before performing any invasive procedure such as inserting circulatory
      access, CV lines and peritoneal catheters.
    Before and after connecting the patient to the dialysis machine through the
      AV fistulae

Alcohol based hand rub can substitute handwashing in emergency cases or if
water source is lacking, provided that hands are visibly clean.

Gloves:
    Use non-sterile disposable gloves when performing non-invasive
     procedures, cleaning or disinfecting instruments or environment including
     the dialysis machine.
    Use sterile gloves when performing invasive procedures or connecting the
     patient to the dialysis machine
    Water-proof aprons or gowns should be worn if the nurse is located within
     the patient station producing any service.

Note:
Personnel should always have protective equipment (fluid resistant gown, mask,
and eyewear) readily available to prevent their exposure to blood in the event
that there is rupture of hemodialyzer membrane and/or a disconnection or
rupture of tubing. These events can happen if there is increased pressure in the
blood compartment of the hemodializer caused by an obstruction between the
blood outlet of the hemodialyzer and the patient.6


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Aseptic technique
Healthcare personnel can reduce the risk of infection by practicing the
following procedures:
   Hands should be washed or waterless alcohol-based handrub should be
    applied before and after each patient contact.
   Any item taken to a patient's dialysis station could become contaminated with
    blood and other body fluids and therefore could serve as a vehicle of
    transmission to other patients either directly or by contamination of the hands
    of personnel. Therefore, items taken to a patient's dialysis station, including
    those placed on top of dialysis machines, should either be disposed of,
    dedicated for use only on a single patient, or cleaned and disinfected before
    being returned to a common clean area or being used for other patients.
   HCP should prepare a sterile set of materials for each patient for insertion of
    central venous catheters.
   Heparin should be prepared just prior to use for each patient. Vials should not
    be shared between patients.
   Aseptic technique of the skin over the fistula site (creation of a sterile field,
    use of sterile barriers and gloves) is effective in preventing infection.
   Before fistula cannulation, the patient should clean the arm with soap, if
    possible. Then any antiseptic solution (e.g. alcohol, betadine) should be
    applied in an outward circular motion to the selected needle insertion site and
    allowed to dry. If betadine (povidone-iodine) is used, permit it to dry for > 2
    minutes prior to catheter insertion.
   Meticulous attention to aseptic technique should be used and the insertion
    site should not be palpated once the site has been prepared.
   A sterile gauze should be saturated with an antiseptic solution and applied to
    the ports of the central venous catheter for 5 minutes before opening the
    catheter when initiating hemodialysis and before disconnecting the blood lines
    at the termination of hemodialysis.
   Clean, non-sterile exam gloves and clean technique should be used during
    dressing changes.
   When shunts or central venous catheters are used for vascular access, a new
    sterile dressing should be applied after each dialysis treatment. Adhesive
    tape should not be applied directily to the catheter.
   Patients should be instructed in the proper way to care for the site. 6


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Equipment
Dialysis machines

Blood pump
A blood pump consists of two or more rollers and is usually necessary to pump
the patient’s blood through tubing and the hemodialyzer at stable and accurate
blood flow rates.

Fluid pathways
There are three types of hemodialysis machines:
       Recirculating machines. Recirculating machines recirculate dialysate
         repeatedly through the hemodialyzer during dialysis.6
       Recirculating single pass machines. Recirculating single pass
         machines recirculate dialysate repeatedly through the hemodialyzer
         during dialysis; however, dialysate in the recirculating reservoir is
         partially displaced by a constant flow of fresh dialysate.6
       Single pass machines. Single pass machines provide a constant flow
         of dialysate, which passes through the dialysate compartment and is
         discarded.6

Recommendations
Single-pass delivery machines are preferred. Recirculating systems permit
nutrient-rich waste products from the patient to be used as nutrients for
microorganisms and therefore may result in increased levels of bacteria during
the dialysis treatment. In contrast, contamination of single pass machines is
usually related to the quality of treated water or other dialysate components
going into the machine and the adequacy of cleaning and disinfection
procedures. 6

In a single pass machine
       Pipes and tubing of incoming water (batch system) or dialysate
         (proportioning system) as well as the internal dialysate and dialysate
         pathways must be disinfected at the end of the day
       In a single-pass machine the internal fluid pathways that supply
         dialysis fluid to the dialyzer are not subject to contamination with blood.
         If a blood leak occurs in a single-pass machine, it is not necessary to
         disinfect the internal fluid pathways because even if the fluid pathways
         that exhaust the dialysate became contaminated with blood, it would
         be unlikely that this blood contamination could reach the patient.



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       External surfaces of the machine should be cleaned and disinfected
         between patients using low level disinfectant (according to
         manufacturers’ instructions).6
In a recirculating or recirculating single pass dialysis machine
       All fluid pathways should be disinfected immediately prior to first use
         and after each patient use.
       If a blood leak occurs, then the disinfection procedures used to control
         bacterial infection in the machines are considered sufficient to reduce
         blood contamination below infectious levels.
       Waste from the dialysis machine must not be allowed to back flow into
         the machine. This is often accomplished by allowing an air gap
         between the drain hose and the drain.6

Blood tubing
To avoid bacteremia from contaminated blood tubing (e.g. gram-negative bacilli
infecting the blood from ultrafiltration waste) the following control measures
should be followed:
       Do not attach the venous tubing directly to the waste container during
         hemodialyzer priming.
       Always follow gloving and handwashing guidelines after contact with
         ultrafiltration waste.
       Decontaminate ultrafiltration waste containers daily.6
       Cleaning of dialysis machines.
       For single-pass machines perform rinsing and disinfection procedures
         at the beginning or end of the day.
       For batch recirculating machines, drain, rinse, and disinfect after each
         use. Follow the same methods for cleaning and disinfection if a blood
         leak has occurred, regardless of the type of dialysis machine used.
       Venous pressure transducer protectors should be used to cover
         pressure monitors and should be changed between patients and
         should not be reused.


Environmental Issues
       Establish written protocols for cleaning and disinfecting surfaces and
         equipment in the dialysis unit, including careful mechanical cleaning
         before any disinfection process.



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    If the manufacturer has provided instructions on sterilization or
      disinfection of the item, these instructions should be followed.
    After each patient treatment, clean and perform low level disinfection of
      the environmental surfaces at the dialysis station, including the dialysis
      bed or chair, countertops, and external surfaces of the dialysis
      machine.
    Ideally, all linens should be changed between patients.
    Between uses of medical equipment (e.g., scissors, hemostats,
      clamps, stethoscopes, blood pressure cuffs), clean and apply a
      hospital disinfectant (i.e., low-level disinfection). If the item is visibly
      contaminated with blood, use an intermediate-level disinfection.
    For a blood spill, Clean up blood spills immediately. Besides
      preventing the spread of infection, prompt removal also prevents
      accidents. When cleaning up spills, always wear gloves, such as
      disposable or heavy duty gloves. If the spill is small, wipe it with a
      disposable cloth and then disinfect the surface area of the spill with
      another disposable cloth that has been saturated with a disinfectant
      (200-500 PPM chlorine solution). If the spill is large, place a
      disposable paper or cloth towel ove the spill to soak up the fluid. Still
      wearing gloves, pick up the towel, dispose into a container and then
      soak the area with non-diluted chlorine ). Leave it for considerable
      time then dry the surface. Do not simply place a cloth over the spill for
      cleaning up later; someone could easily slip and fall on it and be
      injured.
    Housekeeping staff members in the dialysis facility should promptly
      remove soil and potentially infectious waste and should maintain an
      environment that enhances patient care.


Monitoring Water Used for Dialysis
    There should be a designated staff member who is responsible for the
      initial and routine monitoring of water and dialysate. This staff member
      should be knowledgeable of all aspects of the water treatment and
      distribution systems and have the authority to investigate and act on
      problems related to the quality of water used for hemodialysis.
    Water used to prepare dialysate and dilute germicides and reprocess
      hemodializers should meet Ministry of Health standards as defined in
      Ministerial Decree #63 for the year 1996. Microbiologic and chemical
      monitoring should be performed at least monthly in accordance with
      this decree.6




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Microbiologic monitoring
       The microbiologic monitoring of treated water should be performed at
          least monthly and more frequently if problems are identified.
       Water used to prepare dialysate should be collected at the point where
          it enters the proportioner or the dialysis machine.
       Water used to clean hemodialyzers during reprocessing or to dilute
          germicides should also be sampled.
       Dialysate samples should be collected during or at the end of dialysis
          or beyond the point where the dialysate leaves the hemodialyzer.
       Microbiologic testing of samples
           1. Total viable counts should be obtained using either spread plates or
              the membrane filter technique. A calibrated loop should not be used
              because the small amount of water sampled makes this test
              insensitive.
           2. The sample should be inoculated onto tryptic soy agar within 30
              minutes of collection or the sample should be refrigerated at 5
              degrees Celsius and processed within 24 hours.
           3. Culture plates should be incubated at 35 to 37 C for 48 hours
              before colonies are counted.
           4. Identification of organisms may be necessary to link high counts to
              cases of bacteremia.
       Total viable bacterial counts in water used to prepare dialysate or to
          reprocess hemodialyzers should not exceed 50 colony forming units
          (cfu) per milliliter.
       Total viable count for dialysate should not exceed 2000 cfu/ml. 6 If the
          count is greater than 2000 cfu/ml, dialysate equipment should be
          disinfected and culture repeated.

Water treatment
Municipal or potable water used to prepare dialysate or reprocess hemodialyzers
must be treated to remove chemical, bacterial, or endotoxin contaminants that
could be harmful to patients. When chlorine is removed from the water, as occurs
during the treatment of water for hemodialysis, there is little to impede bacterial
growth. Therefore, care must be taken at each step in the water treatment
process to minimize the risk of introducing bacteria into the system or of allowing
treated water to remain stagnant. 6




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Note:
No system should be considered 100% effective at removing bacteria and/or
endotoxin. This means that there is always a need to monitor product water for
bacterial and endotoxin contamination.6

Most hemodialysis water treatment systems consist of the following
components:
Carbon filters: Carbon filters remove chlorine, chloramines, and organic
material from the potable water. Carbon filters are prone to bacterial
contamination.
       Consider placing at least two carbon filters in series to increase their
          effectiveness and to provide redundancy in the system.
       Because of the risk of cross-contamination and inadequate
          disinfection, carbon filters should be replaced, not regenerated, when
          exhausted.6

Particulate filters: Particulate filters are used to remove sediment from water.
Bacterial growth can occur on the filter and lead to subsequent bacteremia
and/or pyrogenic reactions.

Note:
These filters should be replaced and disinfected according to the manufacturer’s
recommendations.6

Reverse Osmosis (RO): RO uses osmotic and hydrostatic pressure over a
semi-permeable membrane to remove ions and organic compounds. In theory
RO is capable of removing 90% to 99% of electrolytes and all bacteria, viruses
and endotoxins. 6

Note:
Cleaning and restoration of semipermeable membranes should be done
according to the manufacturer’s recommendations.6

Deionizers: Deionizers contain resin beds, which remove cations and anions by
binding them to the resin and releasing hydrogen and hydroxyl ions. Deionizers
do not remove bacteria and endotoxin and resin beds may contribute to
significant bacterial growth.


Note:
Deinonizers should be suspected of producing water that may contain high
numbers of bacteria and/or endotoxin, even if proceeded by RO. 6



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 Filters, ultrafilters, and ultraviolet germicidal irradiation (UVGI): Some
 dialysis centers use filters, ultrafilters, and/or UVGI to further reduce microbial
 and/or endotoxin contamination. UVGI may be ineffective in killing some bacteria
 and does not remove endotoxin. Only ultrafiltration is capable of removing
 bacteria and endotoxin.

 Water distribution and storage
         Water distribution systems should be constructed of plastic pipes
           because metal pipes could contaminate the treated water with
           chemicals such as copper, lead, or zinc.
         The minimal number of elbows and T joints should be used and outlets
           should be at the highest point of the system to allow adequate contact
           of all parts of the system with germicide.
         When possible, storage tanks should not be used because they
           increase the amount of water and surface area available for bacterial
           contamination. If a storage tank is used, it should be:
            1. The smallest tank possible.
            2. Designed to have a constant flow with no stagnant areas.
            3. Airtight using an airtight lid.
            4. Able to be cleaned, disinfected, and rinsed.
        All piping (including water lines to the dialysis machines) and storage
            tanks must be disinfected at intervals adequate to prevent bacterial
            growth in excess of 200 cfu/ml. The interval will depend on the quality
            of water entering the system and on the system’s design.6


Waste management
         All disposable items should be placed in bags thick enough to prevent
           leakage. Wastes generated by the hemodialysis facility might be
           contaminated with blood and should be considered infectious and
           handled accordingly.
         Solid medical wastes should be disposed of properly.6
         Sharps should be disposed separetly in a safety sharp disposal box
           immediately after use. Safety box should be available for each patient
           station.


 Peritoneal Dialysis (PD)
 Peritoneal dialysis removes toxins, electrolytes, and fluid by diffusion through the
 peritoneal membrane. Peritoneal dialysis requires placement of a catheter into


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the abdomen for access and repeated infusion and drainage of dialysate. Basic
components for peritoneal dialysis include:
        Abdominal access with a peritoneal catheter that can be placed either
           surgically or medically.
        Dialysate: a solution that is commercially available in glass bottles,
           polyvinyl bags, and plastic bottles. In Egypt plastic bottles are available
           in high and low concentrations.
        A schedule and system for dialysate infusion and removal.

Note:
There are three types of infections related to site of insertion for peritoneal
dialysis: exit site infection, subcutaneous tunnel infections, and peritonitis.
Sources of pathogens include the patient’s skin or nares, the dialysate, migration
from the gastrointestinal tract, and vaginal leaks. Catheter related infections are
due primarily to catheter placement and maintenance.


Aseptic Technique
Strict use of aseptic technique in the care of the operative wound and catheter
exit site should be observed. Exit site care should be performed daily and when
exit site becomes wet or soiled. Soap and water may be as effective as
povidone-iodine for exit site care. Powders, lotions, ointments, and other skin
irritating compounds should not be used. Patients and personnel should
recognize early manifestations of infectious complications.

Equipment
        Intermittent peritoneal dialysis (IPD) is performed several times a week
           (usually overnight), lasts to up to 48 hours.
        Continuous ambulatory peritoneal dialysis (CAPD) involves exchanges
           every 4 to 6 hours during the day.

Prevention of infection
   Sterile technique and sterile field should be maintained during insertion of
    peritoneal catheter.
   Aseptic techniques should always be used during exchange procedures.
   The use of a mask during connect and disconnect procedures may reduce
    risk of infection with nasally carried S. aureus.
   The catheter exit site should be kept clean and dry.




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   The catheter should be immobilized in a way that minimizes the chances of
    accidental pulling or trauma to the surrounding skin.
   Patients should be educated on proper catheter exit site care.
   Use of a disconnect system should be considered for each patient as they
    have been demonstrated to decrease the incidence of peritonitis.


Dialysis Personnel
        Training and education for all personnel at risk for occupational
          exposure should be provided on a regular basis (e.g. annually) and for
          all new employees before beginning work in the dialysis unit.
        Hepatitis B vaccine should be provided to all dialysis personnel.
        Personnel should use of protective barriers in order to protect
          themselves and in order to prevent soiling of clothing when performing
          procedures during which spurting or spattering of blood might occur
          (e.g., during initiation and termination of dialysis, cleaning of dialyzers,
          and centrifugation of blood).
        Protective clothing or gear should be changed if it becomes soiled with
          blood, body fluids, secretions, or excretions.
        Staff members should not eat, drink, or smoke in the dialysis treatment
          area or in the laboratory.
        No work restrictions for staff infected with HVC, HBV or HIV/Aids,
          however they should strictly follow dialysis specific precautions.


Environmental Factors and Design Issues for
the Dialysis Facility
Key Principles of Design
        Adequate provision of storage of clean and sterile supplies.
        At least one separate room for dialysis of patients who are HbsAg
          positive.
        Separate area of adequate size for all the water treatment equipment
          and filters.
        Separate room for disinfection of portable dialysis equipment.
        Separate area for disposable of soiled supplies and large volumes of
          body fluids.


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Patient Care Issues
Devices used in dialysis units create an access site, which requires patient
education to help minimize the risk of infection-related morbidity and mortality.
Patient education steps that should be taken include:
        Patients should be instructed to keep the access site clean and dry at
          all times. The importance of personal hygiene and its possible relation
          to access site infections should be emphasized.
        Patients should be instructed in the proper way to care for the access
          site and to recognize and report any signs and symptoms of infection
          immediately. These signs include fever, chills, pain, and redness or
          drainage around the access site.6
        Patients can be served meals or can eat food brought from home at
          their dialysis station. The glasses, dishes, and other utensils should be
          cleaned in the usual manner. No special care of these items is
          needed.6

Notes:
 HBsAg +ve patients should use be isolated in special rooms and use specific
    machines.
 Staff should be dedicated to these patients.


Prevention of Transmission of Blood-borne Pathogens
General recommendations:
   Staff members must follow Standard Precautions when exposure to blood or
    other potentially infectious materials (including peritoneal fluid) is likely.
   Dialysis clinics and centers should perform a hazard assessment to
    determine what personal protective equipment is necessary. Protective
    clothing might include fluid resistant gowns, gloves, masks, and/or protective
    eyewear.
   Times when exposure is likely to occur include initiation of dialysis,
    termination of dialysis, and during cleaning and disinfection procedures.
   Personal protective equipment should be available to dialysis personnel and
    visitors in the appropriate sizes. Use of protective equipment should be
    monitored and enforced.
   Prompt thorough cleaning and disinfection of surfaces and equipment that are
    contaminated with blood or other potentially infectious materials should be
    done with chlorine solution or with other disinfectants.


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   Disposable items contaminated with blood, peritoneal fluid, or other
    potentially infectious materials should be disposed of according to the waste
    management guidelines found in Part I “Waste Management II: Safe Sharps
    Disposal.”
   All soiled linen should be considered potentially infectious and handled
    according to procedures outlined in Part I: “Enviromental Cleaning”.
   When multiple dose medication vials are used, prepare individual patient
    doses in a clean (centralized) area away from dialysis stations and deliver
    separately to each patient. Do not carry multiple dose vials from dialysis
    station to station.
   Personnel who experience an exposure incident should follow the procedures
    outlined in their facility’s infection control plan.6, 9, 10

Prevention and management of hepatitis B virus infection
Preventing HBV transmission among chronic hemodialysis patients
requires:
        Infection control precaution recommended for all hemodialysis
          patients.
        Regular testing for HbsAg every 3 months and prompt review of
          results.
        Isolation of HBsAg-positive patients with a dedicated room, machine,
          other equipment, supplies, and staff members.
        Vaccination of all patients pending availability of resources.10


When a HBsAg-positive seroconversion occurs:
 Review all patients’ routine laboratory test results to identify additional cases.
   Investigate potential sources for infection to determine if transmission might
    have occurred within the dialysis unit. Include a review of the newly infected
    patient’s recent medical history (e.g. blood transfusion, hospitalization), of
    high-risk behaviors (e.g. injecting drug use, sexual activity), and of unit
    practices and procedures. 10
   Repeat HBsAg testing.
   Three months later repeat HBsAg testing and test for HBsAb to determine
    clinical outcome and need for counseling, medical evaluation, and vaccination
    of contacts.
   Patients who become HBsAg negative are no longer infectious and can be
    moved from isolation. 10



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Isolation of HBV-infected patients
       In order to isolate HBsAg-positive patients, designate a separate room
         for their treatment.
       Dedicate    machines, equipment, instruments, supplies,              and
         medications that will not be used by HBV susceptible patients.
       Staff members who are caring for HBsAg-positive patients should not
         care for susceptible patients at the same time. This includes the period
         when dialysis is terminated on one patient and initiated on another.
       In facilities in which a separate room is not possible, HBsAg positive
         patients should be separated from HBV-susceptible patients in an area
         removed from mainstream activity and should undergo dialysis on
         dedicated machines.
       If a machine that has been used on an HBsAg-positive patient is
         needed for an HBV-susceptible patient, internal pathways of the
         machine can be disinfected using conventional protocols and external
         surfaces can be cleaned using water and detergent and germicide.
       Dialyzers should not be reused on HBsAg-positive patients. Because
         HBV is efficiently transmitted through occupational exposure to blood,
         reprocessing dialyzers from HBsAg-positive patients might place HBV-
         susceptible staff members at increased risk for infection.
       Chronically infected patients (i.e., those who are HBsAg positive, total
         anti-HBc positive, and IgM anti-HBc negative) are infectious to others
         and are at risk for chronic liver disease. They should be counseled
         regarding preventing transmission to others and their household and
         sexual partners should receive hepatitis B vaccine. They should be
         evaluated (by consultation or referral, if appropriate) for the presence
         or development of chronic liver disease according to current medical
         practice guidelines. Persons with chronic liver disease should be
         vaccinated against hepatitis A, if susceptible.
       Chronically infected patients do not require any routine follow-up
         testing for purposes of infection control. However, annual testing for
         HBsAg is reasonable to detect the small percentage of HBV-infected
         patients who might lose their HBsAg. 10

Vaccination
       Ideally, Hepatitis B vaccine should be administered for all susceptible
         hemodialysis patients and staff. Vaccination is recommended for all
         pre-end-stage renal disease patients before they become dialysis-
         dependent. The hepatitis B vaccine should administered through the




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          intramuscular route and only in the deltoid muscle for both adults and
          children.
        Because antibody response is poorer in hemodialysis patients than in
          healthy controls, larger vaccine doses or an increased number of
          doses are required. In addition, vaccine induced protection is less
          complete in dialysis patients and necessitates administration of booster
          doses if antibody levels decline below 10 miu by enzyme
          immunoassay.
        If an adult patient begins the vaccine series with a standard dose
          before beginning hemodialysis treatment and then moves to
          hemodialysis treatment before completing the series, complete the
          series using the higher dose recommended for hemodialysis patients.10

Post-vaccination testing and revaccination of nonresponders
   Test all vaccinated patients for antibody to surface antigen (anti-HBs) one to
    two months after the last primary vaccine dose to determine if the response to
    the vaccine is adequate (an adequate response is defined as > 10 mIU/ml).
   Patients and staff who do not respond to the primary vaccine series should be
    revaccinated with three additional doses and retested for response.
   No additional doses of vaccine are warranted for those who do not respond to
    the second series.
   Evaluate personnel who do not respond to revaccination to determine if they
    are HBsAg positive. Persons who are HBsAg positive should be counseled
    accordingly (e.g. the need for medical evaluation, vaccination of sexual and
    household contacts).
   Primary nonresponders who are HBsAg negative should be considered
    susceptible to HBV infection and counseled regarding precautions to prevent
    HBV infection and the need to obtain postexposure prophylaxis with hepatitis
    B immune globulin for any know or probable percutaneous or mucosal
    exposure to HBsAg-positive blood.10

Prevention and management of hepatitis C virus infection
HCV transmission within the dialysis environment can be prevented by strict
adherence to infection control precautions recommended for all hemodialysis
patients. Although isolation of HCV-infected patients is not recommended,
routine testing for ALT and anti-HCV is important for monitoring transmission
within centers and for ensuring that appropriate precautions are being properly
and consistently used.10




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                                        Dialysis


HCV-negative patients
        Testing for anti-HCV every 3 months should be sufficient to monitor the
           occurrence of new HCV infections.
        Monthly ALT testing will facilitate timely detection of new infections and
           will provide a pattern from which to determine when exposure or
           infection might have occurred.
        If unexplained ALT elevations are observed in patients who are anti-
           HCV negative, repeat anti-HCV testing is warranted.
        If unexplained ALT elevations persist in patients who repeatedly test
           anti-HCV negative, testing for HCV RNA should be considered.10

Anti-HCV seroconversions

When a seroconversion occurs:
   Review all other patients' routine laboratory test results to identify additional
    cases.
   Perform additional testing as indicated later in this section.
   Investigate potential sources for infection to determine if transmission might
    have occurred within the dialysis unit. Include a review of the newly infected
    patient’s recent medical history (e.g., blood transfusion, hospitalization), of the
    patient’s high-risk behaviors (e.g., injecting-drug use, sexual activity), and of
    unit practices and procedures.
   If ongoing HCV transmission among patients is identified, implement control
    measures based on results of investigation of potential sources for
    transmission and monitor their effectiveness.
HCV-positive patients
        Patients who are anti-HCV positive (or HCV RNA positive) have to be
           isolated from other patients or dialyzed separately on dedicated
           machines. Unlike HBV, HCV is not transmitted efficiently through
           occupational exposures.
        HCV-positive persons should be evaluated (by consultation or referral,
           if appropriate) for the presence or development of chronic liver disease
           according to current medical practice guidelines.
        They also should receive information concerning how they can prevent
           further harm to their liver and prevent transmitting HCV to others.
           Persons with chronic liver disease should be vaccinated against
           hepatitis A, and B if susceptible.10




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                                     Dialysis




Prevention and management of hepatitis D infection
transmission
Because of the low prevalence of HDV infection, routine testing of hemodialysis
patients is not necessary or recommended. However, if a patient is known to be
infected with HDV or if evidence exists of transmission of HDV in a dialysis
center, screening for delta antibody is warranted. Because HDV depends on an
HBV-infected host for replication, prevention of HBV infection will prevent HDV
infection in a person susceptible to HBV. Patients who are known to be infected
with HDV should be isolated from all other dialysis patients, especially those who
are HBsAg-positive.10

Prevention and management of HIV infection
       Routine testing of hemodialysis patients for HIV infection every 3
          months for infection control purposes is recommended. If infected, they
          can receive proper medical care and counseling regarding preventing
          transmission of the virus.
       Infection control precautions recommended for all hemodialysis
          patients are sufficient to prevent HIV transmission between patients.
          HIV-infected patients do not have to be isolated from other patients or
          dialyzed separately on dedicated machines.
Prevention and management of bacterial Infection
       Follow published guidelines for judicious use of antimicrobials,
          particularly vancomycin, to reduce selection for antimicrobial-resistant
          pathogens.
       Infection control precautions recommended for all hemodialysis
          patients are adequate to prevent transmission for most patients
          infected or colonized with pathogenic bacteria, including antimicrobial-
          resistant strains. However, additional infection control precautions
          should be considered for treatment of patients who might be at
          increased risk for transmitting pathogenic bacteria. Such patients
          include those with either:
          1.    An infected skin wound with drainage that is not contained by
               dressings (the drainage does not have to be culture positive for
               VRE, MRSA, or any specific pathogen).
          2. Fecal incontinence or diarrhea uncontrolled with personal hygiene
             measures.

   For these patients, consider using the following additional precautions:




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                             Dialysis


1. Staff members treating the patient should wear a separate gown over
   their usual clothing and should remove the gown when finished caring
   for the patient.
2. Dialyze the patient at a station with as few adjacent stations as
   possible. (e.g., at the end or corner of the unit).10




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