Infection Control in the Dialysis Setting

Infection Control in the Dialysis Setting Part 4 of 4 Danilo B. Concepcion CCHT, CHT Manager, Renal Technology Services Email: danilo.concepcion@stjoe.org Phone: 714.771.8944 The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of St. Joseph Hospital Prevent Infection: Get the catheters out Fact: Indwelling catheters are the single most important factor contributing to bloodstream infection in hemodialysis patients. Actions: Hemodialysis:  Use catheters only when essential  Maximize use of fistulas  Remove catheters when they are no longer essential Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2002 • Dressing changes or skin prep: – 2 % chlorhexidine – 10 % povidone-iodine – 70 % alcohol • Catheter exit site: – Povidone-iodine ointment compatible with catheter material – Mupirocin ointment: not recommended Guidelines for the Prevention of Intravascular Catheter-Related Infections • Changing the catheter exit-site dressing at each HD treatment, using either a transparent dressing or gauze and tape. • Using aseptic technique to prevent contamination of the catheter or port catheter system, including the use of a surgical mask for staff and patient and clean gloves for all catheter or port catheter system connect, disconnect, and dressing procedures. Sources for Bloodborne Virus Infections in Hemodialysis Patients • External to the dialysis unit – Transfusion from unscreened blood or infected donor in the window where testing fails to detect the agent – Non-dialysis related healthcare procedures – Household/sex with infected contact – Illegal injection drug use (more common in western countries) • Internal to the dialysis unit – Patient-equipment-patient (HBV contamination on devices, tubing, supplies, surfaces) – Patient-equipment-staff-patient (HBV contaminated surfaces touched by staff and transmitted with contaminated gloves or hands) – Patient-staff-patient (direct contamination of staff members’ hands/gloves with blood) Potential Modes of Bloodborne Virus Transmission in Hemodialysis Settings • Direct contact with blood/body fluids  Percutaneous  Permucosal  Non-intact skin • Indirect contact with blood or body fluids  Equipment, supplies, medication vials  Hands of personnel  Environmental surfaces Environmental Reservoirs in the Hemodialysis Setting • Water • Dialysate • Surfaces (high touched surfaces, medical devices or instruments) • Intrinsically contaminated products (eg, antimicrobial soaps, mouth wash, saline, povidone iodine, antiseptic wipes, etc) • Extrinsically contaminated products (Saline, flushes, refillable soap containers, Erythropoietin, etc) Blood Contaminating a Pressure Transducer Filter Outbreaks of HBV in the Hemodialysis • Cross-contamination of environmental surfaces, supplies, medications, or equipment • Simultaneous provision of care to both HBV-infected and susceptible patients by the same staff members • Multiple dose medication vials Preparation of Injectable Medications • In 2002, 52.8% of centers reported that medications from multi-dose vials were prepared for patient administration in a dedicated medication room or an area separate from the treatment area • 24.6% reported that medications were prepared on a medication cart or a medication area within the treatment area, 3.7% at the dialysis station, and 18.9% in other areas • the incidence of HBV infection was significantly higher among patients in centers where injectable medications were prepared on a medication cart or medication area located in the treatment area Breaks in Infection Control • Not cleaning blood spills or splatters; including prime buckets on side of machine • Not cleaning or disinfecting commonly touched environmental surfaces between patients (e.g. machine, chair or station) • Sharing equipment and supplies that were not disinfected; shared multidose vials placed on the top of the machines • Sharing a common medication cart Reuse Related Bacteremia/Fungemia • Organisms: Burkholderia cepacia complex, Ralstonia pickettii, Ralstonia mannitolytica, Stenotrophomonas maltophilia, Candida parapsilosis • Today most reuse related infections are associated with header removal “Headersepsis” • In the past, most were associated with either poor water quality, or manual reuse Published Recommendations • CDC. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR 2001; 50(RR05):1-43 • http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm Infection Control Precautions for All Patients • Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station; remove gloves and wash hands between each patient or station. • Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. • When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Infection Control Precautions for All Patients • Do not use common medication carts to deliver medications to patients. Do not carry medication vials, syringes, alcohol swabs, or supplies in pockets. If trays are used to deliver medications to individual patients, they must be cleaned between patients. • Clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to where used equipment or blood samples are handled. Infection Control Precautions for All Patients • Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. • Clean and disinfect the dialysis station (e.g., chairs, beds, tables, machines) between patients. Infection Control Precautions for All Patients • For dialyzers and blood tubing that will be reprocessed, cap dialyzer ports and clamp tubing. Place all used dialyzers and tubing in leak-proof containers for transport from station to reprocessing or disposal area. Management of HBsAg-Positive Patients • Infection control practices for hemodialysis units for all patients. – Dialyze HBsAg-positive patients in a separate room using separate machines, equipment, instruments, and supplies. – Staff members caring for HBsAg-positive patients should not care for HBV susceptible patients at the same time (e.g., during the same shift or during patient changeover). Additional Precautions for Individuals Co-infected with HBV and HDV • Patient needs to be isolated from ALL other dialysis patients • Staff should not treat any other patients • Screening for anti-HDV may be warranted • Uncontained wound drainage, fecal incontinence or diarrhea uncontrolled with personal hygiene measures. Patients Who Might Be At Increased Risk For Transmitting Pathogenic Bacteria – a) staff members treating the patient should wear a separate gown over their usual clothing and remove the gown when finished caring for the patient and – b) dialyze the patient at a station with as few adjacent stations as possible (e.g., at the end or corner of the unit). Other CDC Guidelines and Recommendations http://www.cdc.gov/ncidod/dhqp/guidelines.html • HICPAC Guideline for Infection Control in Healthcare Personnel, 1998 • HICPAC Guideline for Intravascular Device Related Infections, 2002 • HICPAC Guideline for Isolation Precautions in Hospitals, • HICPAC Guideline for Hand Hygiene in Healthcare Settings, 2002 • CDC Guideline for Environmental Infection Control in Healthcare Facilities, 2003 • Guidelines for Vaccinating Kidney Dialysis Patients and Patients with Chronic Kidney Disease, 2006 (http://www.cdc.gov/nip/publications/dialysis_guide.pdf) Bottom Line • All patients with the exception of those who are HBsAg positive can participate in a dialyzer reuse program – HIV, HCV, and those with bacterial blood stream infections may participate in a reuse program • Isolation is recommended only for HBsAg positive • Use enhanced precautions for those who have an uncontained wound drainage or are incontinent • If treating patients with active TB additional facility design issues and separate isolation area need to be in place (not cost effective). Send to hospital for treatment. Protect patients, Protect healthcare personnel, Protect quality healthcare Prevention Is Primary!