Infection Control in Dialysis Unit Hemodialysis Symposium

1. Infection Control in Dialysis Unit Hemodialysis Symposium Dr. Shoeb Mohammed, M.D. Diplomate of American Boards in Nephrology and Internal Medicine Consultant Nephrologist, King Fahd Hospital, Madina

2. Objectives Review latest infection related mortality and hospitalization data among dialysis patients from USRDS 2013. Review blood stream infections in HD. Learn about the CDC Collaborative for control of blood stream infections in dialysis. Control of HBV/HCV/HIV and pulmonary infections. Vaccinations in dialysis

3. USRDS 2013 ADR United States Renal Data System 2013 Annual Data Report ESRD: Chapter Five Mortality

4. USRDS 2013 ADR Incident & prevalent patient counts (USRDS), by modality Figure 1.1 (Volume 2) Incident & December 31 point prevalent ESRD patients; peritoneal dialysis consists of CAPD & CCPD.

5. USRDS 2013 ADR Adjusted all-cause mortality rates (from day 1 and day 90), by modality & year of treatment Figure 5.1 (continued; Volume 2) Incident ESRD patients. Adj: age/gender/race/primary diagnosis; ref: incident ESRD patients, 2010.

6. USRDS 2013 ADR United States Renal Data System 2013 Annual Data Report ESRD: Chapter Three Hospitalization

7. USRDS 2013 ADR Change in adjusted all-cause & cause- specific hospitalization rates, by modality Figure 3.1 (Volume 2) Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2010.

8. USRDS 2013 ADR Adjusted cause- specific hospitalization rates, hemodialysis Figure 3.1 (Volume 2)

9. USRDS 2013 ADR Adjusted rates of hospital admissions, by modality & diagnosis code type: Bacteremia/Sepsis Figure 3.5 (Volume 2) Period prevalent ESRD patients. Adj: age/gender/race/primary diagnosis; ref: ESRD patients, 2010.

10. USRDS 2013 ADR Rehospitalization or death within 30 days after live hospital discharge, by cause-specific index hospitalization, 2011 Figure 3.16 (Volume 2) Period prevalent hemodialysis patients, all ages, 2011; unadjusted. Includes live hospital discharges from January 1 to December 1, 2011.

11. USRDS 2013 ADR TABLE 2. Estimated annual number of central line--associated blood stream infections (CLABSIs), by health-care setting and year --- United States, 2001, 2008, and 2009 Health-care setting Year No. of infections (upper and lower bound of sensitivity analysis) Intensive-care units 2001 43,000 (27,000--67,000) 2009 18,000 (12,000--28,000) Inpatient wards 2009 23,000 (15,000--37,000) Outpatient hemodialysis* 2008 37,000 (23,000--57,000) * Case definitions approximate current definition of CLABSI according to the National Healthcare Safety Network.

12. USRDS 2013 ADR In Summary Blood stream infections (BSIs) remain a major cause of morbidity and mortality in hemodialysis pts. The rate of hospitalizations for bacteremia / sepsis has increased by 42.9 % since 1995. (USRDS 2013) More than 37000 access related BSI admissions in 2008 in USA due to dialysis catheters. (MMWR, 2011) BSIs lead to severe complications of endocarditis, septic emboli, metastatic infections, readmissions and death.

13. Types of infections in hemodialysis unit Infections due to the process of hemodialysis: Catheter related BacteremiaInfective EndocarditisMetastatic septic emboli AVF / AVG infections Dialysate water related infections. Infectious transmission between patients: Hepatitis B and C, HIV MRSA carrier state Respiratory infections: TB, Influenza, Pneumococcal

14. Epidemiology of Infections among Hemodialysis Patients Infections are the 2 nd leading cause of death. Site of infection 57% vascular access 23% wound 15% lung 5% urinary tract USRDS 2005 Annual Data Report Tokars, Miller, Stein. AJIC 2002;30:288-295

15. Invasive Methicillin-Resistant S. aureus (MRSA) Infections, 2005 Incidence of invasive MRSA infections: 45.2 cases per 1,000 dialysis population 100 times the rate in general population!!! (0.2 0.4 per 1000) Invasive MRSA in dialysis 86% were bloodstream infections (BSIs) 90% required hospitalization, mortality = 17% CDC. MMWR 2007; 56(09):197-9

16. Reasons for high infection rates in HD The process of hemodialysis requires direct vascular access for prolonged periods. Multiple events occur during dialysis concurrently, so multiple opportunities exist for person-to-person transmission of infectious agents, directly or indirectly. High risk of contaminated devices, equipment, supplies, environmental surfaces, or hands of personnel. Immunosuppressed. Require frequent hospitalizations and surgery, which increases their opportunities for exposure to nosocomial infections .

17. Vascular Access related Infections Risk Factors Type of access Catheter >> AV graft > AV fistula Lower extremity access Recent access surgery Trauma, hematoma, dermatitis, scratching Poor hygiene Poor needle insertion technique Older age Diabetes Iron overload Others

18. Rate of Access-Related Bloodstream Infection by Vascular Access Type

19. CDC Collaborative In April 2009, the US Centers for Disease Control and Prevention (CDC) announced plans for a collaborative project to prevent BSIs in HD patients. CDC Dialysis BSI Prevention Collaborative Project (2009)

20. CDC Collaborative to BSI Prevention in Dialysis Units (Core Interventions for Dialysis Bloodstream Infection (BSI) Prevention)

21. CDC Collaborative Core Interventions 1. Surveillance and feedback: Conduct monthly surveillance for BSIs and other dialysis events. Calculate your facility rates and compare to rates in other facilities. Actively share results with front line staff. 2. Hand hygiene observations: Perform direct observations of hand hygiene monthly and share results with clinical staff. 3. Catheter/Access care observations: Perform observations of vascular access care and catheter accessing quarterly. Assess staff adherence to aseptic technique when connecting and disconnecting catheters and during dressing changes. Share results with clinical staff.

22. CDC Collaborative - Core Interventions 4. Chlorhexidine for skin antisepsis: Use an alcohol-based chlorhexidine (>0.5%) solution as the first line skin antiseptic agent for central line insertion and during dressing changes. 5. Catheter hub disinfection: Scrub the hubs! with an appropriate antiseptic after cap is removed and before accessing. Perform every time catheter is accessed or disconnected. 6. Antimicrobial ointment : Apply antibiotic ointment or povidone-iodine ointment to catheter exit sites during each dressing change.

23. CDC Collaborative - Core Interventions 7. Staff education and competency: Training on infection control topics, including access care and aseptic technique. Competency evaluation for skills such as catheter care and accessing every 6 months. 8. Patient education/engagement. 9. Catheter reduction efforts.

25. Was the CDC Collaborative Effective??

28. Blood Stream Infections Preventive Collaborative, AJKD 2013

29. Blood Stream Infections Preventive Collaborative, AJKD 2013

30. CDC effort was very effective in reducing BSIs. A 32% reduction in BSIs and 54% reduction in access related BSIs. Sustained through the end of evaluation period. Simple and cost effective interventions. This initiative helped define that it is achievable to improve and prevent Blood stream infections in dialysis patients through focused efforts.

31. Need more info?

32. Current trends in Viral hepatitis in Saudi Arabia

33. Hepatitis B in Saudi Arabia A success story! HBV was once considered hyper-endemic in the Kingdom of Saudi Arabia (KSA). A 1988 study of Saudi children showed a hepatitis B surface antigen (HBsAg) seroprevalence of approximately 7% and a > 70% prevalence of at least one HBV marker* This study galvanized the Saudi health officials into action and triggered a successful collaboration between scientists and government agencies. *Al-Faleh F. Hepatitis B infection in Saudi Arabia. Ann Saudi Med. 1988;8:47480 .

34. Hepatitis B in Saudi Arabia A success story! A mass vaccination program against HBV was launched in 1989. The Saudi government initiated a program in 1990 aimed at vaccinating all Saudi children at school entry. Mandatory vaccination of healthcare workers and hemodialysis patients were also introduced around 1988. Pre-emptive strategy started : All new born children born after October 01, 1989 be vaccinated against HBV regardless of the mother's HBV status within the country.

35. Hepatitis B in Saudi Arabia A success story! Prevalence of HBsAg among the Saudi population documented before and after introducing a nation-wide HBV vaccination program, over an 18-year period. Saudi J Gastro Dec,2012

36. Is the success story complete?? The success of low HBV infection rates is only in the younger Saudi populations. (age < 25) An estimate of HBsAg+ prevalence among Saudis greater than 40 years of age falls in the 3-6% range based on data from community-based studies in the late 80s. In 2007, MOH ranked viral hepatitis as the second most common viral disease after chickenpox, with almost 9000 new cases diagnosed in that year (52% HBV, 32% HCV, and 16% HAV). Saudi Arabia: Saudi Arabia Ministry of Health; Ministry of Health of Saudi Arabia (MOH). A review of health situation. The Annual Health Statistics Book, 2007

37. Hepatitis B Virus Infection in ESRD Leads to acute / chronic hepatitis, cirrhosis, hepatocellular carcinoma Distinctly problematic in dialysis patients who are transplant candidates: Life threatening complications in de novo flares post transplant. Can occur in any HbsAg + patient at any time post transplant including those who have been very asymtomatic during dialysis.

38. Hepatitis B in Dialysis HBV is easily transmitted by percutaneous exposure. All HBsAg-positive persons are infectious, but those who are also positive for HBeAg circulate HBV in high titers and are highly infectious. HBV at low titers of 10-virions/mL can be present on environmental surfaces in the absence of any visible blood and still result in transmission.

39. Hepatitis B in Dialysis HBV is relatively stable and remains viable for at least 7 days on environmental surfaces at room temperature. HBsAg has been detected on clamps, scissors, dialysis machine control knobs, and even doorknobs. Dialysis staff members can readily transfer virus to patients from contaminated surfaces by their hands or gloves or through use of contaminated equipment and supplies

40. Cross Contamination during dialysis was the major route for spread of HBV 1. Environmental surfaces, supplies (e.g., hemostats, clamps), or equipment that were not routinely disinfected after each use. 2. Multiple dose medication vials and IV solutions that were not used exclusively for one pt. 3. Injections that were prepared in areas adjacent to areas where blood samples were handled 4. Staff members who simultaneously cared for both HBV-infected and susceptible patients

41. INDEPENDENT RISK FACTORS FOR HBV INFECTION IN DIALYSIS UNITS (DOPPS Data) Presence of HBsAg positive patients within the same dialysis unit Non segregation with dedicated hemodialysis machines for HBsAg positive patients A lower than 50 percent prevalence rate of hepatitis B vaccination among dialysis patients in the same unit. Absence of a protocol for HBV infected patients. Patterns of hepatitis B prevalence and seroconversion in hemodialysis units from three continents: the DOPPS. Kidney Int. 2003;63(6):2222.

42. Prevention of Hepatitis B in HD unit Segregation is the key: Dedicated rooms Dedicated machines and equipment. Separate staff Universal contact precautions Staff members caring for HBsAg+ pts should not care for HBV-susceptible pts at the same time Ban from dialyzer reuse programs i.e. Only single use dialyzers.

43. Prevention of Hepatitis B in HD unit Ensure full compliance of Hepatitis B vaccinations Make sure your unit has an updated standard protocol for care of all HBV patients. Regular screening of HBsAg status in non-immune individuals Antiviral treatment of HBV-infection may also reduce the risk of other hemodialysis patients in the same center .

44. HCV in HD Units worldwide Prevalence using 3 rd generation EIA assay for HCV worldwide shows a wide range from 5.5% to 72%. DOPPS data of 308 HD facilities in 3 continents reported a mean prevalence of 13.5%.

45. HCV in Saudi Arabian HD Units Saudi Data: Prevalence is variable between 15% and 80%. This prevalence remained at almost 50% in mid 2005 The annual rate of HCV seroconversion is 7% to 9%. ( Hepatitis C in dialysis units: the Saudi experience. HD Intnl 2007 Karkar A.) However, SCOT 2012 numbers report a decline from 69% in 1996 to 19% as of 2012

46. HCV Transmission in HD Transmission of HCV is primarily via percutaneous exposure to infected blood. HCV can remain viable in the environment for at least 16 hours. Blood transfusions in 1980-1990s undoubtedly caused many cases of HCV in dialysis units. Newer data suggest that nosocomial transmission is the major reason contributing to the high prevalence. The occurrence of nosocomial transmission has been confirmed by phylogenetic analysis in many studies.

47. Risk Factors for HCV Infections in ESRD Number of blood transfusions Years on dialysis Mode of dialysis Prevalence of HCV in dialysis unit Other factors: Previous organ transplant IV drug abuse Male sex

48. Unresolved issues in HCV Debate continues on whether transmission of HCV in HD units may be affected by: Routine testing for anti-HCV antibodies, Patient isolation, Use of dedicated machines, Ban on dialyzer reuse.

49. Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients MMWR Recomm Rep. 2001;50(RR-5):1 CDC does not recommend dedicated machines, patient isolation, or a ban on reuse in HD patients with HCV infection. However, strict adherence to "universal precautions," careful attention to hygiene, and strict sterilization of dialysis machines is recommended.

50. The most likely cause of HCV transmission between patients treated in the same dialysis unit is cross-contamination from supplies and surfaces (including gloves) as a result of failure to follow infection-control procedures within the unit. VOLUME 73 | SUPPLEMENT 109 | APRIL 2008

52. HCV+ Care Hepatitis C is NOT readily transmitted across the dialysis filter membrane Patient isolation is not required Machine isolation is not recommended May re-use dialyzers

53. Hepatitis C Surveillance Monitor hepatitis C surveillance laboratory test results for negative patients: Antibody to hepatitis C virus (anti-HCV) and alanine aminotransferase (ALT) on admission for all patients ALT monthly for anti-HCV negative patients Anti-HCV semiannually for all negative anti-HCV patients Supplemental or confirmatory testing with more specific assays for patients with an initial positive anti-HCV

54. HCV Surveillance

56. HIV and Dialysis No Saudi data on HIV and dialysis. We have 1 HIV + patient on HD since 11 years. Transmission in HD is rare as per US data ( Am J Kidney Dis. 2003;41(2):279) CDC does not recommend routine isolation or dedicated machines for HIV-infected patients undergoing hemodialysis, given the low likelihood of transmission

57. Standard Precautions for all Healthcare Workers in Dialysis Settings

58. What is Hand Hygiene? Staff should wash their hands with soap or an antiseptic hand- wash and water, before and after contact with a patient or any equipment at the dialysis station. An antiseptic alcohol gel rub may be used instead when their hands are not visibly contaminated. In addition to hand washing, staff should wear disposable gloves when caring for a patient or touching any potentially contaminated surfaces at the dialysis station. Gloves should always be removed when leaving the dialysis station. Where practical, patients should also clean their hands, or use an alcohol gel rub, when arriving at and leaving the dialysis station

59. A potentially contaminated surface is any item of equipment at the dialysis station that could have been contaminated with blood, or fluid, even if there is no evidence of contamination.

60. How to Prevent Cross Contamination Caregivers must wear appropriate PPE: Gloves, gowns and masks with face shields when accessing AVF, AVG, catheter Gloves must be used for All patient contact All machine contact All medication preparation Gloves must be changed Between patients Between machines When moving from one area to another

61. Prevent Cross contamination 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 medication vials from station to station

62. Equipment management

63. Respiratory Infection Control Challenges Host Transmission Tuberculosis Varicella Immunocompromised Host Susceptibility ESRD complicates other systemic illness Stem cell transplantation Solid organ transplantation

64. Respiratory Infection Control Measures Isolation rooms required for all new dialysis units Negative pressure is required. Only one room required per unit Mask isolation All patients with suspected TB or VZV should be isolated or wear masks during evaluation Negative pressure rooms should have at least 6 air exchanges per hour

65. Tuberculosis Desired patient outcomes The patient will not convert from a negative to a positive tuberculosis (TB) skin test The patient will not progress to active TB disease The patient with active TB will not transmit the disease

66. Tuberculosis Monitor laboratory test results related to TB screening, diagnosis, and treatment Mantoux skin test CXR Sputum smear and culture Assess for S/S of TB Productive or persistent cough Cloudy or blood-tinged sputum Unexplained weight loss Night sweats Elicit hx of exposure to TB

67. Tuberculosis Interventions: Provide TB screening per current CDC recommendations IC policies and procedures that are consistent with current CDC guidelines Coordinate care with other health care providers and agencies, e.g. local health department, as indicated.

68. Water Treatment System Testing/Standards (AAMI) Testing performed monthly Maximal level of bacteria in water to prepare dialysis fluid/reprocess dialyzers must NOT EXCEED 200 CFU AAMI action level is 50 CFU Maximal level of endotoxin must not exceed 2 EU/ml AAMI action level is 1 EU/ml

70. Vaccinations in HD Unit Hepatitis B : Response rate is 50-60% in ESRD patients. Vaccinated pts have 70% lower infection rate compared to unvaccinated. ( AJKD. 1999;33(2):356) Tetanus vaccine. Pneumococcal vaccine Influenza vaccine H1N1 vaccine is also safe and effective in ESRD patients. Varicella zoster (consider if transplant candidate) HPV vaccine for females (consider if transplant candidate)

71. Hepatitis B Vaccination

72. Hepatitis B Vaccination

73. HD Unit QA/QI Practices for Infection Control Each unit must have ongoing assessment of current and trend analyses of relevant infection rates: Catheter related BSI Catheter exit site and tunnel infections Hospital Admissions and related mortality Resistant Bugs: MRSA/VRE/PDRA etc. Regular surveillance for Hepatitis B and C virus susceptibility status with serology and Ab titers. Immediate source tracking for any seroconversions .

74. HD Unit QA/QI Practices for Infection Control Clear updated protocols and surveillance for: Vascular Access care. Equipment disinfections. Care of HBV/HCV and HIV patients. Immunizations (patients and staff) Water quality

75. Infection Control is team work!

76. THANK YOU!!!