INFECTION CONTROL IN

1
INFECTION CONTROL IN HEMODIALYSIS UNITS
Hyun Chul Kim, MD. Dept. of Internal Medicine
Keimyung University Dongsan
Medical Center, Daegu, Korea.
2
OVERVIEW OF HEMODIALYSIS-ASSOCIATED INFECTIONS
Infections problems remain a significant cause
of morbidity and mortality in
patients on HD. In addition, financial cost,
impaired health, and a reduction in quality
of life.
3
(No Transcript)
4
(No Transcript)
5
Cause of Death (1993 1995, USRDS )
6
Distribution of Specific Infectious Deaths
Septicemia
71.9
Pul. infection
16.7 Viral infection
0.8 AIDS

7.0 Other infection
3.5

100
7
Parimary Kidney Disease
Immuno- Suppressive Rx
Systemic Disease
ESRD
Uremic Toxins
Comorbid Conditions
inadequate
Dialysis
Malnutrition
dialysis
Procedure
Access
Loss of Skin Barrier
Impaired Immune System
Infection
Morbidity
Mortality
8
Relationship of Incidence of Infectious
Complications and Dialyzer Biocompatibility
Renal Failure Chronic Chronic Chronic Chronic
Variable Sepsis Mortal/inf Admiss/inf IV AB days
BICM() 3/8(37) 40/438(9) 0.024 10.7
BCM() 0/7(0) 5/548(1) 0.011 5.8
P value .07 lt.0001 ? lt.05
Reference Vanholder et al6 Levin et
al15 Hornberger et al16 Hakim et al17
BICM, bioincompatible membrane, BCM,
biocompateble membrane
9
Topics includes
Access-related infection Viral Other
infections Prevention of infection
Infections due to contaminated water
10
Hemodialysis Access Infection
Chronic HD pts using permanent catheter
increased from 12.7 (1995) to 24 (
2000 )
( Surveillance Study Sponsored by CDC ) Access
infection may increase in the near future.
Approximately a 30 incidence of metastatic
infection ( osteomyelitis, endocarditis,
septic arthritis )
11
Incidence of Access Related Bacteremia
100 pts-months Native fistula
0.25 Synthetic graft 0.53
Cuffed catheter 4.8 Non
cuffed catheter 8.7
( Surveillance Study Sponsored by CDC )
12
Factors Predisposing Hemoaccess Infection ( ? )
AV conduits Postsurgical complications
Skin erosion, wound dehiscence Seroma
Hematoma Graft manipulation Needle
puncture Direct contamination ( break
in aseptic technique ) Poor needle
placement or hemostasis Perigraft
hematoma formation Pseudoaneurysm
Secondary procedures
Thrombectomy, revision Indirect contamination
IV drug use Poor hygiene Overlying
dermatitis, cellulitis Nasal colonization
with Staph. aureus
13
Cuffed hemodialysis catheters  
Break in aseptic technique ( direct
contamination ) Poor exit site care
Secondary seeding during bacteremia IV drug
use Nasal colonization with Staph. aureus
14
Signs and Symptoms of Access Infection ( ? )
Definite infection AV graft Perigraft
purulence Perigraft fluctuance
Herald bleed Segmental induration or
erythema with tenderness Cuffed venous
catheter Tenderness and erythema along
tunnel Fluctuance along tunnel Loss
of adhesion of anchoring cuff Purulence at
exit site
15
Signs and Symptoms of Access Infection ( ? ) 
Probable infection Sepsis without definite
alternate source Fever gt 38? 
Rigors ( especially on dialysis ) Suggestive of
infection Low grade fever
Leukocytosis
16
Comparison of Cuffed Tunneled HD Catheter Survival

• 182 Cuffed catheter during 16 mos period
• Exit site infection 41 cases
• Tunnel infection 11 cases
• Catheter related bacteremia 28 cases
• 88 of exit site infections were managed by
  antibiotic Tx only
• 25 of 174 catheters were removed because of
  infection

Rocklin MA, et al. AJKD 2001
17
Organisms Isolated From 28 Episodes of Catheter
Acquired Bacteremia
No. of Episodes 10 9 3
1 1 1 1 1
Frequency ( ) 35.7 32.1 10.7 3.6 3.6 3.6 3.6 3.6
Organism Coagulase negative Staphylococcus Methi
cillin sensitive Staphylococcus Methicillin
resistant S. aureus Enterococcus
spp Corynebacterium jeikeium Nocardia
asteroides Enterobacter cloacae Klebsiella
pneumonia
18
T R E A T M E N T (1)

• Antibiotic Tx
• Staph. aureus and epidermidis (70)
• Vancomycin ( 20mg / kg ) iv weekly
• gentamicin 1- 2 mg / kg after each
  dialysis
• Cefazolin mono Tx after each dialysis
  initial Tx
• Duration 3 wks ( ? )

19
T R E A T M E N T (2)
2. Catheter removal ? Catheters can be
salvaged in case of functioning
properly exit site ( tunnel ) are not
infected Only 25- 32 of catheters being
salvaged with systemic antibiotic alone
( Moss A AJKD 1990 ) Only 32 of catheter
left in place were salvaged
( Marr KA, Ann Int Med 1997
)
20
T R E A T M E N T (3)
3. Catheter exchange ? Selection criteria
? Afebrile after 48 hrs of antibiotic Tx
? Clinically stable ? No evidence of
tunnel or exit site infection 50 of
initial enrolled patients require
catheter removal within 48 hours.
21
Table. Recommendations for the Prevention of AV
Fistula and Graft Infection
Wash the area to be punctured with antibacterial
soap or scrub ( eg, 2 chlorhexidine ) and
treat the area with tincture of chlorhexidine,
70 alcohol, or Povidone iodine before
cannulation ( NOTE Alcohol should be applied
in a rubbing motion for 1 minute immediately
before cannulation. Povidone iodine should
be applied for 2 to 3 minutes and allowed to dry
before cannulation. ) Use clean gloves for
access puncture, with new gloves used for each
patient. Gloves should be changed if
contaminated. Ensure that dialysis personnel
receive adequate training and follow
recommended access puncture techniques.
22
Infection Control Measures, Skin Preparation
Technique for Permanent AV Accesses
CLINICAL PRACTICE GUIDELINES FOR VASCULAR
ACCESS

• GUIDELINE 13
• Staff and patient education should include
  instruction on infection control
• measures for all hemodialysis access sites.
  (Opinion)
• 
  
  
• GUIDELINE 14
• A clean technique for needle cannulation
  should be used for all cannulation procedures.
  (Evidence) (See proposed skin preparation
  technique in Table III-8 and cannulation
  technique in Table III-9.)
• 
  
  

23
Skin Preparation Technique for Permanent AV
Accesses
CLINICAL PRACTICE GUIDELINES FOR VASCULAR
ACCESS

• Table III-8
• 1. Locate and palpate the needle cannulation
  sites prior to skin preparation.
• 2. Wash access site using an antibacterial soap
  or scrub (eg, 2 chlorhexidine) and water.
• 3. Cleanse the skin by applying 70 alcohol
  and/or 10 povidone iodine using a circular
  rubbing motion.
• Notes
• Alcohol has a short bacteriostatic action
  time and should be applied in a rubbing motion
  for 1 minute immediately prior to needle
  cannulation.
• Povidone iodine needs to be applied for 2
  to 3 minutes for its full bacteriostatic action
  to take effect and must be allowed to dry prior
  to needle cannulation.
• Clean gloves should be worn by the dialysis
  staff for cannulation. Gloves should be changed
  if contaminated at any time during the
  cannulation procedure.
• New, clean gloves should be worn by the
  dialysis staff for each patient.
  
  

24
GUIDELINE 15 Catheter Care and Accessing the
Patients Circulation
Catheter care and accessing the patients
circulation should be clean procedures. A.
Hemodialysis catheter dressing changes and
catheter manipulations that access the
patients bloodstream should only be
performed by trained dialysis staff. ( Evidence /
Opinion ) B. The catheter exit site should be
examined at each hemodialysis treatment for
signs of infection. ( Opinion ) C. Catheter exit
site dressings should be changed at each
hemodialysis treatment. ( Opinion )
25
D. Use of dry gauze dressing combined with skin
disinfection, using either chlorhexidine or
povidone iodine solution, followed by
povidone idine ointment or mupirocin ointment at
the catheter exit site are recommended
after catheter placement and at the end of
each dialysis session. ( Evidence ) E.
Manipulating a catheter and accessing the
patients bloodstream should be performed in
a manner that minimizes contamination ( see
Table lll 10 ). ( Evidence ) F. During catheter
connect and disconnect procedures, nurses and
patients should wear a surgical mask or face
shield. Nurses should wear gloves during all
connect and disconnect procedures. ( Opinion
)
26
Table lll 10. Considerations for Accessing the
Bloodstream Using Catheters

• The catheter hub caps or bloodline connectors
  should be soaked for 3 to 5
• minutes in povidone iodine and then allowed to
  dry prior to separation.
• Catheter lumens should be kept sterile.
• To prevent contamination, the lumen and tip
  should never remain open to
• the air.
• A cap or syringe should be placed on or within
  the catheter lumen, while
• maintaining a clean field under the catheter
  connectors.
• Patients should wear a surgical mask for all
  catheter procedures that remove
• the catheter caps and access the patients
  bloodstream.
• Dialysis staff should wear gloves and a
  surgical mask or face shield for all
• procedures that remove catheter caps and
  access the patients bloodstream.
• A surgical mask for the patient and mask or
  face shield for the dialysis staff
• should be worn for all catheter dressing
  changes.

27
Treatment of Infection of Dialysis AV Grafts
CLINICAL PRACTICE GUIDELINES FOR VASCULAR
ACCESS

• GUIDELINE 24
• Local infection of a dialysis AV graft should be
  treated with appropriate antibiotics based on
  culture results and by incision/resection of the
  infected portion of the graft. (Evidence)
• Extensive infection of a dialysis AV graft should
  be treated with antibiotics and total resection
  of the graft. (Evidence)
• Infection of a newly placed graft (ie, within 1
  month) should be treated with antibiotics and by
  removing the graft, regardless of the extent of
  the infection. (Opinion)
• Initial antibiotic treatment should cover both
  Gram-negative and Gram-positive organisms and
  should cover Enterococcus. (Opinion)
  
  

28
Treatment of Infection of Primary AV Fistulae
CLINICAL PRACTICE GUIDELINES FOR VASCULAR
ACCESS

• GUIDELINE 25
• Infections of primary AV fistulae are rare
  and should be treated as subacute bacterial
  endocarditis with 6 weeks of antibiotic therapy.
  Fistula take-down is required in cases of septic
  emboli. (Opinion)

29
Treatment of Infection of Tunneled Cuffed
Catheters ( I )
CLINICAL PRACTICE GUIDELINES FOR VASCULAR
ACCESS

• GUIDELINE 26
• A. Catheter exit site infectionscharacterized by
  redness, crusting, and exudate at
• the exit site in the absence of systemic
  symptoms and negative blood cultures
• should be treated as follows
• 1. Apply topical antibiotics, ensuring
  proper local exit site care do not remove
• the catheter. (Opinion)
• 2. If there is tunnel drainage, treat
  with parenteral antibiotics (anti- staph. anti-
• streptococcal therapy pending exit
  site cultures) in addition to following
• appropriate local measures.
  Definitive therapy should be based on culture
• results. Do not remove the catheter
  unless the infection fails to respond to
• therapy. If the infection fails to
  respond to therapy, remove the catheter and
• replace it using a different tunnel
  and exit site. (Evidence/Opinion)
  
  

30
Treatment of Infection of Tunneled Cuffed
Catheters (II)
CLINICAL PRACTICE GUIDELINES FOR VASCULAR
ACCESS

• GUIDELINE 26
• B. Catheter-related bacteremia, with or
  without systemic signs or symptoms of illness,
  should be treated by initiating parenteral
  treatment with an antibiotic(s) appropriate for
  the organism(s) suspected, usually Staphylococcus
  and Streptococcus. (Evidence)
• Definitive therapy should be based on the
  organism(s) isolated. (Evidence) The catheter
  should be removed in all instances if the patient
  remains symptomatic more than 36 hours.
  (Evidence) The catheter should also be removed in
  any clinically unstable patient. (Opinion)

31

• GUIDELINE 26 ( cont )
• Preliminary reports suggest that after obtaining
  a bactericidal
• level of the antibiotic in the blood, in a stable
  asymptomatic
• patient without exit site or catheter tunnel
  tract involvement
• may be treated by changing the catheter over a
  guidewire plus
• a minimum of 3 weeks of systemic antibiotic
  therapy.
• Blood cultures should be repeated periodically
  during and
• immediately after this treatment to monitor its
  effectiveness.
• A new permanent access should not be placed until
  blood
• cultures, performed after cessation of antibiotic
  treatment,
• have been negative for at least 48 hours.
  (Opinion)

32
R E C O M M E N D A T I O N S
Catheters should be removed in case of catheter
associated bacteremia. Catheters should be
removed in case of exit site or tunnel
infection. In case of alternative access is not
available, a trial of catheter salvage can be
attempted. Patients who remain febrile or have
positive culture after catheter removal, should
undergo a study for metastatic complications (
endocarditis, vertebral abscess, and
oteomyelitis )
33
? Patients should be instructed in good personal
hygiene and hand washing technique, the
role of patient in care of vascular access,
how to recognize signs of infection, and
the need for immunizations.
34
Non Access Related Infections
Recent evidence suggests that non access
related infection are less common and not
devastating, accounting for an overall mortality
less than 3.
T U R E R C U L O S I S
a 12 year study of 110 HD patients found an
incidence of 24 ( 70 pulmonary )
propensity to acquire new or reactivate old Tbc
infections.
35
Hepatitis B virus Infection
U.S nationwide incidence had decreased from
6.2 ( 1974 ) to 0.06 ( 1999 ) according
CDC. Due to implementation of infection
control precautions vaccination against
HBV dedicated hemodialysis machines for HBs
Ag ( ) patients avoidance of
dialyzer reuse in patients for HBs Ag (
) practice of screening donor blood for HBV
markers
36
HBV in transmitted by percutaneous or
permucosal exposure to infectious blood or
body fluids that contain blood. The virus can
be present on epuipment and environemental
surface. HBV in relatively stable in the
environment and viable for at 7 days on
environmental surface at room temperature.
Dialysis staff members can transfer the virus to
the patients. Outbreaks of HBV infection in
dialysis unit have occurred through
contamination of multidose vials and failure to
identify and separate patients ( ) for HBs
Ag.
37
HBV Serologic Testing and Vaccination ( ? )
Immune patients who are positive for anti
HBs (10 mIU/mL) and negative for anti
HBc should receive follow up test.
Immune patients positive for both anti HBs and
anti HBc, no further testing. 
Vaccination in recommended for all susceptible
patients with HD and for staff members. Non
- responder after last primary vaccine dose
should receive 3 additional doses and
retest for response. For patients ( staffs )
who are non - responder to the 2nd series, no
additional doses are warranted.
38
( ?  )
Patients who respond to vaccine should be
retested annually for anti HBs. If anti
HBs drops lt 10 mIU/mL, a booster dose should
be given. Staff members who respond to
vaccination do not require further vaccination
or serologic screening. Staff members who do
not respond to vaccine should be retested for
HBs Ag. Staff who are positive for HBs Ag
should be counseled and medically evaluated.
39
Additional Measures for HBs Ag () Patients
HBs Ag () patients, should be dialyzed in a
separate room using separate machines,
equipment, instruments, and medications.
Staff members who care for HBs Ag () patients
should not care for HBV susceptible patients.
Dialyzer should not be reused for HBs Ag (
) patients to protect susceptible staff
members.
40
Attemps to Enhance the Immune Response to HBV
Vaccine
Doubling the dose Giving booster dose
Changing the mode of injection Begin the
vaccine as soon as CRF is recognized.
41
Despite the availability of vaccine, the most
important factor in preventing the spread of HBV
infection in a homodialysis unit is isolating Ag
( ) patients and prohibiting the use of
shared medications. ( common heparin vials )
42
Hepatitis C virus Infection
Major cause of parenterally transmitted NANB
H Higher incidence in dialysis pt than in
healthy people ELISA 2 has been found to be 1.2
to 3.8 times higher than that by ELISA ?
Dialysis unit staff 1.6 ( 0 6 )
Transmission by needle-stick injury 2.7 ( 67
in HBV ) - - - - - - - - - - - - - Kiyosawa
et al Ann Int Med 1991
43
The incidence of HCV infection in steadily
declining
EDTA 21 (1992 ) 12.5 (1999 ) U S A
NANBH 1.7 (1982 ) 0.3 (
1995 ) Due to reduction in post transfusion HCV
subsequently it has reflected the
implementation of infection control measure.
More recently, a multi-center prospective study
from Belgium unequivocally demonstrated that
universal precautions alone fully prevent
transmission of HCV in HD units
44
P r e v e n t i o n
In high prevalent areas, isolation of patient
is the most effective way to prevent HCV
transmission. However, in low prevalent HD
units, isolation is not if necessary strict
precautions are implemented. The high
prevalence of de novo HCV infection in Asian HD
units may reflect the consequences of multiple
reuse of tubings and dialyzer without strict
infection control.
45
HBsAg() Anti-HCV()
( )
HS HD
HS HD
Data from KMUH. ( HS health screening, HD
Hemodialysis )
46
Risk Factors for HCV Infections in Dialysis
patient
Number of blood transfusions Duration of
hemodialysis In center hemodialysis ( vs. home
HD or CAPD ) Previous organ
transplantation Intravenous drug use
47
Prevalence of HCV-Ab using 1st and 2nd
Generation of ELISAs
ELISA 1 ( )
ELISA 2 ( )
Study Population
North America 8-36
25-36
South America
39
Europe
1-54 3.3-55 Asia

17-51
22-55.5 Australia and New Zealand
1.2-10 Europe, North
Africa, and Middle East ( EDTA 69,321
patient survey )
8 Europe, North Africa, and Middle
East ( EDTA survey )
17.7
(2-44) United States ( CDC 27,086 patient
survey )
8.1 (0-51)
48
Prevention of HCV Infection
All patients should be tested for anti HCV
and alanine aminotransaminase ( ALT )
Anti-HCV negative patients should be retested
monthly for ALT and 6 months for anti-HCV
HCV infected patients do not have to be isolated
from other patients or dialyzed separately on
dedicated machines. Futhermore, they may
participate in reuse program Unlike HBV,
HCV is not transmitted through occupational
exposure, therefore reprocessing dialyzers from
HCV ( ) patients should not place staff
members at increased risk for infection
49
HIV Infection
1 2 of all HD patients in U.S
Transmitted by blood and other body fluids
that contain blood Risk of
occupational exposure 0.5 ( vs 3 30
in HBV)
50
HIV Infection
Routine test of HD patients for HIV infection
is neither necessary nor recommended .
Patients with risk factors for HIV infection
should be tested. HIV infected patients
do not have to isolated from other patients
or dialyzed separately on dedicated
machines. In addition, they may participate in
dialyzer reuse programs. HIV is not
transmitted through occupational exposures.
51
Immunizations in patients with ESRD

• Reduced efficacy of the vaccine?
• Only 50 60 of response rate compared to
• a 90 of patients without renal failure.
• The lower rate of HBV infection
• Vaccination protocol should be depend upon
  the
• local prevalence of HBV infection ( 0.1
  among
• hemodialysis patients in U.S )
• High cost of the vaccine
• 70 lower risk for infection compared with
• nonvaccinated patients.

52
(No Transcript)
53

 
54
Preventing Infections Due to Contaminated Water
and Equipment
1. Water Treatment Systems
In exchangers, activated carbon adsorption
media do not remove endotoxin or bacteria
Reverese osmosis can remove both endotoxin and
bacteria, however must be disinfected routinely
to prevent colonization of downstream
portion
55
Table. AAMI Standards for Dialysis Fluid
Type of fluid Bacteria
Endotoxin
Water lt200
cfu/mL No standard Dialysate
lt200 cfu/mL No
standard Water used to rinse and reprocess
dialyzers lt200 cfu/mL or lt1
ng/mL Water used to prepare dialyzer
disinfectant lt200 cfu/mL or lt1
ng/mL
American Association for the Advancement of
Medical Instrument
56
Ultrafilter in needed to make ultra - pure
water for the treatment of
hemodiafiltration ( on line HDF ). Ultra
pure dialysate Bacteria lt 0.1 cfu/mL
or Endotoxin lt 5 pg/mL
57
2. Water Distribution Systems Gram ( - )
bacteria can multiply rapidly and colonize
the wet surfaces of pipes, which results
the biofilm formation. Routine disinfection
of the dialysate distribution system should
be performed at least weekly. The system
should be free of rough joints, dead end
pipes. Storage tanks should be drained,
cleaned and disinfected frequently. 3.
Dialysis Machine
58
Conclusion
Infectious complications are a source of
substantial morbidity and mortality among
dialysis patients. Strict adherence to
universal precautions and standard infection
control measures would help prevent
transmission of infection and control the
infections in dialysis unit