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INFECTIONS IN

DIALYSIS PATIENTS
basis & prevention
Dr.T.V.Rao MD

3/2/16

Dr.T.V.Rao MD

Renal Failure and Technology


for Survival

3/2/16

Dr.T.V.Rao MD

3/2/16

Dr.T.V.Rao MD

INFECTIONS IN
HEMODIALYSIS UNIT
Patients
are
at
risk
with
Bacterial
infections
Viral infections
like Hepatitis B
and C
Other
prevailing

Dr.T.V.Rao MD

Why Infections in Dialysis Patients

Patients who undergo dialysis


treatment have an increased
risk for getting a healthcareassociated infection (HAI).
Hemodialysis patients are at a
high risk for infection because
the process of hemodialysis
requires frequent use of
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Dr.T.V.Rao MD

Reduced Immunity plays a


Role in Infections
Haemodialysis
patients have
weakened immune
systems, which
increase their risk for
infection, and they
require frequent
hospitalizations and
surgery where they
might acquire an
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Dr.T.V.Rao MD

Renal failure Patients are susceptible


to Infections
Patients with renal failure are
susceptible to infection. In the
predialysis era, 60% of patients with
chronic renal failure requiring
hospitalization were infected and 39%
died from infectious causes. It was
assumed that the debility caused by
the uremic state increased the risk of
infection, and the reversal of uremia
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Dr.T.V.Rao MD

Basic Principles of Medical Asepsis


as in Critical Areas
Clean Technique used to prevent the spread of
microorganisms
Hand washing AGAIN
Carry soiled items away from body
Do not place soiled items on floor
Client instructed not to cough, sneeze, breathe on
anyone; expectorate into tissues; cover mouth
and nose when coughing and sneezing; (Airborne)
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Dr.T.V.Rao MD

Microbiology
Common Bacterial Infections

Staphylococcus aureus,
coagulase negative
staphylococci (CONS), P.
aeruginosa, E. coli,
Klebsiella, and
Enterobacter were the
most frequent isolates .
From infections of the
HVAD, S. aureus and CONS
were the most commonly
isolated bacteria.
Unexpectedly, gramnegative
bacteria were Dr.T.V.Rao MD
3/2/16

Gram Negative bacteria too play


the part
*Fifty-five percent (55 %) of 113 patient episodes with positive
sputum cultures grew gram-negative bacteria, including 23 isolates
of P. aeruginosa. Although outpatient hemodialysis facilities are
free-standing and separate from the hospital, the cohorting of
patients into large room(s) with multiple dialysis stations, the
pervasive and widespread use of antibiotics, and frequency with
which patients are in/out of the hospital all contribute to a resident
microbiological flora historically associated with nosocomial
infections. Infections in these patients are more accurately classified
as Health Care Associated (HCA) rather than community acquired.
*Infections in Patients Undergoing Chronic Dialysis
Authors: Steven Berman, M.D.

3/2/16

Dr.T.V.Rao MD

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Infections Associated
With
Peritoneal
Dial
ysis
Continuous ambulatory
peritoneal dialysis
(CAPD) is the most
frequently utilized
technique. The
advantages of
peritoneal dialyses
include more
independence as they
can be done at home
or work and do not
require incapacitation

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Dr.T.V.Rao MD

11

Infections are common in


peritoneal
Dialysis
Peritoneal
dialysis
is labour intensive
and infection is a
common
complication
averaging 1
episode/ 10 patient
months. The
bacteria, which
cause peritonitis,
may come from the
skin, water, or the

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Dr.T.V.Rao MD

12

Water Sources can


be cause
of
Waterborne
organisms
Infections
as Stenotrophomonas

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maltophilia and
pseudomonas species
are associated with
contamination of the
exit site with tap water
during body wash, and
mixed flora often
implicates the
gastrointestinal tract
as the source of

Dr.T.V.Rao MD

13

Bacterial
Infections

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Dr.T.V.Rao MD

14

Gram positive bacteria


play
a
Major
Role
Gram-positive
organisms,
especially S.
epidermidis, are
responsible for 70%
of cases of
peritonitis in chronic
dialysis patients,
gram-negative
bacteria for 25%.
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Dr.T.V.Rao MD

15

Pneumonia
Pneumonia is a
common infection in
patients with end
stage renal disease..
The causative bacterial
pathogens of
community-acquired
pneumonia (CAP) in
the dialysis population
include pneumococcus
and Haemophilus

3/2/16

Dr.T.V.Rao MD

16

Urinary Tract Infection


Asymptomatic pyuria and bacturia are
present in about 30% of patients with end
stage renal disease and, in the absence of
symptoms, is not a significant clinical
problem and does not require treatment.
Yet, the urine may be the origin of the
majority of cases of gram-negative
bacteraemia. A urine culture is advisable in
the presence of gram-negative
bacteraemia if the source of infection is not
obvious. When the isolate from the urine is
the same as the blood culture, a genital
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Dr.T.V.Rao MD

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Host Dysfunction And Infection


Other infectious problems
of chronic renal failure
and uraemia persist
despite maintenance
dialysis. Reactivation of
tuberculosis and leprosy
is a danger. Delayed
hypersensitivity and cell
mediated immunity is
impaired. Yersinia and
Listeria infections have
been
associated with
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Dr.T.V.Rao MD
elevated serum ferritin

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Many drug resistant bacteria


hamper the Survival ..
Methicillin Resistant
Staphylococcus aureus
(MRSA)
Vancomycin Resistant
Enterococci (VRE),
Extended Spectrum lactamase (ESBL)producing Klebsiella
pneumonia,
Carbapenem-resistant
Acinetobacter
Dr.T.V.Rao MD
baumannii (CRAB) and

19

Greater Risk with Hepatitis


Virus Infections
Dialysis patients are at
risk of getting Hepatitis B
and C infections and
bloodstream infections. Of
particular concern in the
dialysis setting is the fact
that Hepatitis B and C
viruses can live on
surfaces like dialysis
chairs and machines and
can be spread even with
no visible blood.
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Dr.T.V.Rao MD

20

During dialysis
Infections like
Hepatitis B and C
and bloodstream
infections are
spread from
patient to patient
most commonly
by the hands of
healthcare
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Dr.T.V.Rao MD

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Do not Forget Hand Hygiene


Unwashed hands of healthcare
workers are the major route of
transmission of microorganisms in
healthcare settings.
Hand hygiene is includes hand
washing with soap and water, and/or
applying an alcohol- based hand rub )
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Dr.T.V.Rao MD

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Hand washing continues to


be most basic care in dialysis
patient

Clean
hands
before and
after every
patient
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Dr.T.V.Rao MD

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Clinicians follow the basics of


infection control as a routine

Promote fistula use


Get catheters out
when not needed
Improve catheter
care
Talk to patients
about good
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Dr.T.V.Rao MD

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Investigating Fever During


Hemodialysis And Antibiotic
Administration

Fever that occurs only during dialysis


should be aggressively evaluated. The first
manifestation of an indolent vascular
access infection may be fever and
bacteraemia during hemodialysis. Blood
cultures should be drawn from any patient
with fever during hemodialysis. During the
initial period of hemodialysis, a profound
neutropenia and the sudden high flow
through a colonized vascular access device
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Dr.T.V.Rao MD

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Hemodialysis machines can


be source of Infection
Hemodialysis machines may also
be the source of fever and
bacteraemia. Contamination of the
blood by waterborne organisms
may occur in several ways: a leak
in the system, contamination of
the water source, rapid growth of
bacteria in dialysate, or by
colonization of the patient through
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Dr.T.V.Rao MD

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Uncommon and Emerging


Infections in Dialysis patients
If cultures are positive for
Burkholderia cepacia,
Stenotrophomonas
maltophilia, Pseudomonas
stutzeri, Pseudomonas
aeruginosa or Aeromonas
sp., consider a break in
sterility. Fever may be
non-infectious, caused by
endotoxin absorption,
activation of interleukin,
or leukocyte pyrogen from
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Dr.T.V.Rao MD
the dialysis coil.

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Proper Documentation of Infection


Medical and administrative
records should
demonstrate recognition of
any potential infection and
actions taken to decrease
the transmission of
infection within the
dialysis facility.
Dr.T.V.Rao MD

28

Dialysis Infection Prevention


Strategies
Performed monthly
hand hygiene
observations;
Performed regular
observations of
vascular access
care and catheter
accessing;
Trained staff on
infection control
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Dr.T.V.Rao MD

29

Prevention Of Infection
Prevention of infection
is one of the few
avenues available to
reduce
hospitalizations,
control costs, and
improve quality of life
for these patients.
Common pyogenic
bacteria from the
patients endogenous
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Dr.T.V.Rao MD

30

MRSA Nasal Carriage


The carriage rate of S. aureus in patients with end
stage renal disease may approach 70%. Vascular
access is the risk factor in more than 50% of the
infections and S. aureus on the skin the most
common pathogen. A previous episode of
bacteraemia is the most predictive risk factor for
subsequent bacteremia, suggesting that the same
patients have repeated infections and may be
chronic carriers of staphylococcus. Mupirocin
applied to the nares significantly reduces the
carriage rate as well as subsequent rate of
bacteraemia.
3/2/16

Dr.T.V.Rao MD

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Mupirocin resistance is a growing


concern
Unfortunately,

clinical experience
demonstrates that
universal use will
ultimately lead to
mupirocin
resistance. Other
strategies may have
better results
including limiting
mupirocin

3/2/16

Dr.T.V.Rao MD

32

Dialysis Infection Prevention


Strategies
Provided standardized education to their patients on
infection prevention strategies;
Worked to identify and address barriers to permanent
vascular access placement and catheter removal;
Used chlorhexidine for catheter exit-site skin antisepsis
during dressing changes;
Scrubbed catheter hubs with an appropriate antiseptic
before accessing the lines; and
Applied an antibiotic ointment or povidone-iodine
ointment to catheter exit sites during dressing changes
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Dr.T.V.Rao MD

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Practising

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Face protection
(eyewear/goggles,
masks)
is required
Universal
Precautions
to protect the
mucous membranes
of the eyes, nose
and mouth when
performing
procedures that
may generate
splashes or sprays
of blood or body
fluids (e.g. during
initiation and
Dr.T.V.Rao MD

34

Blood Borne Virus Screening and


Management
All patients should be tested
for HBV, HCV and HIV on
admission to the dialysis unit
including after transfer from
another unit
Recheck time ???
All maintenance dialysis
patients should be retested at
regular every 6 months for
HBV, HCV and HIV infection.
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Dr.T.V.Rao MD

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Hepatitis B vaccination
Hepatitis:

Recommendations for
Preventing Transmission
of Infections Among
Chronic Hemodialysis
Patients, (precautions,
testing, immunization,
isolation, surveillance,
response, training
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Dr.T.V.Rao MD

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HBV+ Isolation Room/Area


New regulations

Effective Feb 9, 2009, every new facility


MUST include an isolation room for
treatment of HBV+ patients, unless the
facility is granted a waiver of this
requirement

For existing units in which a separate


room is not possible, there must be a
separate area for HBsAg positive
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Dr.T.V.Rao MD

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Hepatitis C an Emerging Problem


HCV has become apparent in dialysis
populations as a growing concern as there
is no vaccine available for this strain. The
increase in spread of the infection is mostly
attributed to the cross-contamination of
patients due to inadequately trained staff
and the reuse of disposables. HIV infection
is not a major concern of the dialysis
population in developing countries, even in
Africa where high HIV rates predominate.
3/2/16

Dr.T.V.Rao MD

38

Cleaning of dialysis machines and


chairs/beds
Dialysis machines should be internally disinfected,
externally cleaned (and disinfected if indicated), and
dried after each patient.
The exterior of the machine should be effectively cleaned
using protocols following manufacturers instructions.
Special attention should be given to cleaning control
panels on the dialysis machines and other surfaces that
are frequently touched and potentially contaminated with
patients blood.
3/2/16

Dr.T.V.Rao MD

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Cleaning of dialysis machines and


chairs/beds
Cleaning of non-critical
surfaces (e.g. dialysis bed or
chair, countertops, external
surfaces of dialysis machines
and equipment) should be
done with neutral detergent
and warm water.
Do not waste on chemicals
they are counterproductive
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Dr.T.V.Rao MD

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Care of Environment
Additional Specifics:
splash zone nothing considered clean in it
Medication prep: no delivery carts, clean prep
Isolation Room or agreement, two station separation
for pre-reg facilities
Catheter reduction and Precautions
Water and Dialysate Cultures
Documentation of audits, breaks action
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Dr.T.V.Rao MD

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Active Surveillance Component


The infection prevention and control
program must include an active surveillance
component that covers both hospital
patients and personnel working in the
hospital.
Surveillance includes infection
detection,
data collection and analysis,

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Dr.T.V.Rao MD

42

Staff training a MUST


All staff in dialysis units should be trained in infection
prevention and control practices including
Proper hand hygiene technique
Appropriate use of personal protection equipment
Modes of transmission for BBV, pathogenic bacteria,
and other microorganisms Infection Control
Precautions for Dialysis Units
Rationale for segregating patients
Correct techniques for initiation, care, and
maintenance of dialysis access sites.
3/2/16

Dr.T.V.Rao MD

43

Have a self audit


Medical and administrative records should
demonstrate recognition of any potential infection
and actions taken to decrease the transmission of
infection within the dialysis facility.
If deficient practices noted in infection control,
techniques are multiple, pervasive, or of an extent
to present a risk to patient health and safety,
Condition level non-compliance should be
considered.
3/2/16

Dr.T.V.Rao MD

44

Vaccination in Dialysis Patients


Patients on dialysis
mount reduced immune
responses compared with
the general population.
The Department of Health
advises that these
patients receive influenza
and pneumococcal
vaccinations at regular
intervalsonce yearly
and every five years,
respectively
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Dr.T.V.Rao MD

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Trends in Pneumococcal Vaccine


The 13-valent Pneumococcal Conjugate Vaccine
(PCV13) is recommended for use in children <2
years of age as it is more immunogenic in this
population but it protects against less
pneumococcal strains than the PPV23. Recent
studies on immunogenicity of PCV13 in
immunocompetent adults have led to a change in
recommendation by the Centre for Disease Control
to vaccinate immunocompromised adults with
PCV13 in addition to PPV23
3/2/16

Dr.T.V.Rao MD

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