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. * Saudi Centre for Organ Transplantation 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)

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. * Saudi Centre for Organ Transplantation ^MMWR, April 27, 2001, Vol. 50, No. RR-5 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^

5. * Shikata et al., JID. 1977; 136:571-6 ^Bond et al., Lancet. 1981;1:550-1 HBV transmission  Per-cutaneous  Per-mucosal  All HBsAg positive cases are infectious  Cases with HBeAg titer of (10 8-9 virions/ml) have their body fluid infectious*  HBV at titer of (10 2-3 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

6. * CDC, MMWR 1996;45:285-9 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

7. * Alter et al., JID 1986; 153: 1149-51 MMWR, April 27, 2001, Vol. 50, No. RR-5 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

8. * Najem et al., JAMA 1981; 245: 153-7 ^CDC MMWR 1996; 45: 285-9 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

9. * Saudi Centre for Organ Transplantation ^Niu et al., Am J Kidney Dis 1993; 22: 568-73 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%^

10. * Moyer et al., Semin Dial 1994; 7: 124-7 HCV transmission  Mostly throuhg direct per-cutaneous exposure to infected blood  Risk factors for transmission  Blood transfusion  Number of years on dialysis*

11. * CDC upublished data; 1999 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

12. * Busch et al., Transfusion 2000; 40: 143-159 ^Larghi et al.,Hepatology 2002;36:993-1000 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!!!

13. *CDC unpublished data; 2001 ^ Valendia et al., Lancet 1995; 345: 1417-22 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

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. * Brady et al., Am J Kidney Dis 1998; 32: 415-8 Cont…bacterial infection  Antimicrobial resistant  Severely ill cases including hemodialysis are recognized source of multi-drug resistant organisms  Vancomycin use  Cefazolin*

17. AAMI; 2003 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

18. AAMI; 2003 Cont…control measures  Reverse osmosis  Able to remove both bacteria and bacterial endotoxin but not 100%  Require routine disinfection

19. AAMI; 2003 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

20. NKF, Am J Kidney Dis 2001. 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.

21. * Saudi Centre for Organ Transplantation 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

22. * Saudi Centre for Organ Transplantation 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

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