Module No: 09_
Module Title: INFECTION CONTROL IN HEMODIALYSIS
Learning Outcomes:
1. Review the infectious disease process.
2. Review the international guidelines for the ff:
i. Equipment cleaning / disinfection
ii. Hand hygiene
iii. Immunization and screening for patients and employees
iv. Medication / Injection safety
v. Standard / Transmission based precautions
vi. Vascular access – infection prevention and care
vii. Water treatment / testing
3. Learn the outcome and process metrics of infection surveillance for a hemodialysis
facility.
Outline:
1. The infectious disease process
2. Equipment cleaning / disinfection
3. Hand hygiene
4. Immunization and screening for patients and employees
5. Medication / Injection safety
6. Standard / Transmission based precautions
7. Vascular access – infection prevention and care
8. Water treatment / testing
9. Infection surveillance
10. Quality improvement program
Definition of terms
APIC – Association for Professionals in Infection Control and Epidemiology
AAMI – Association for Advancement of Medical Instrumentation
CDC – Center for Disease Control and Prevention
CMS – Center for Medicare and Medicaid Services
Recommendations for infection control are rated according to the following categories:
Category IA
o Strongly recommended for implementation and strongly supported by well-
designed experimental, clinical, or epidemiologic studies.
Category IB
o Strongly recommended for implementation and supported by certain
experimental, clinical, or epidemiologic studies and a strong theoretic rationale.
Category IC
o Required by state or federal regulation, or representing an established
association standard.
Category II
o Suggested for implementation and supported by suggestive clinical or
epidemiologic studies, or a theoretic rationale.
Unresolved issue
o No recommendation is offered. No consensus or insufficient evidence exists
regarding efficacy
The Infectious Disease Process
Common Pathogens in a Dialysis Facility
• Viruses
– Hepatitis B Virus (HBV)
– Hepatitis C Virus (HCV)
– Human Immune Deficiency (HIV)
– Cytomegalovirus (CMV)
• Bacteria
– Coagulase Negative Staphylococcus (CNS)
– Methicillin – Resistant Staphylococcus Aureus (MRSA)
– Vancomycin – Resistant Staphylococcus Aureu (VRSA)
Gram Negative Microorganisms commonly found in Hemodialysis water Supply:
- Pseudomonas
- Serratia
- Acinetobacter
- Flavobacteria
What are the possible sources of infection in a hemodialysis facility?
1. Machine
2. Dialyzer
3. Dialysate solution
4. Surfaces
5. Extracorporeal circuit
6. Water treatment
7. Vascular access
8. Personnel
9. Patients
Environmental and Equipment cleaning / disinfection
Basic Measures (Category I)
o Use Environmental Protection Agency (EPA)-registered hospital disinfectants to
decontaminate blood spills and other body fluids.
o MRSA, VIRSA and VRE – use standard cleaning + EPA registered disinfectants
o Using friction, clean and disinfect high – touch surfaces in patient care areas
o Contact precaution patients – use disposable items
o Items taken into patient station – dispose after use or disinfect before taking
into a common clean area or using to another patient.
o Items that cannot be comprehensively cleaned or disinfected – should be
dedicated for use on a single patient.
o Adhesive tape, Cloth – covered BP cuffs
o External pressure transducer filters/protectors – should be changed after each
treatment.
o Internal HD machine dialysate pathway – should be subjected for heat
disinfection
Heat disinfection is an auto cycle that subjects the pathway to an >= 80
deg C water temperature for approximately 30 minutes exposure time.
Heat disinfection for internal HD machine dialysate pathway shall be done
every after each TREATMENT DAY.
However, in the event of BLOOD LEAK (dialysate side), heat disinfection is
must be performed prior to successive patient treatments.
Chemical disinfection on the other hand uses variety of chemicals such as
bleach or peroxyacetic acid, and is recommended for machines that are
inactive for a long period.
Plus Measures (Below Category I)
o Because no EPA – registered disinfectants that are known to be specific against C.
difficile spores - use hypochlorite based solutions for areas with known C.
difficile transmission
Surfaces that need to be disinfected:
o Machine
o Treatment chair
o Patient care stations
o Areas outside the patient zone
Auxiliary equipment
o Jugs for acid concentrate
o Sodium bicarbonate concentrate
o Priming bucket
o Transducer protector
Hand Hygiene
Basic Measures (Category I)
o Use of alcohol based hand rub
o Perform hand hygiene before and after contact with patient or patient’s
environment. (5 moments)
o Remove gloves after caring for a patient
o Perform hand hygiene after glove removal
o If hands are not visibly soiled, use alcohol based hand rub instead of soap and
water.
o Do not wear artificial fingernails or extenders when having direct contact with
patients.
Immunizations and Tuberculosis Screening
Basic Measures (Category I)
o Vaccine status of all patients shall be assessed at the start of dialysis.
o Eligible HD patients should be immunized against:
Hepatitis B Virus (HBV)
Tetanus
Pneumococcal disease
Influenza
o One-time TB screening for all HD patients (plus anytime exposure is suspected) -
CDC
o Employees in HD setting must receive immunizations for the following:
MMR
HBV
DPT
Influenza immunization
TB screening (per local regulations) – usually annual
Medication / Injection Safety
Basic Measures (Category I)
o Single dose vials – should be dedicated to one patient only
o Avoid using multidose vials (PLUS Measures)
o Parenteral medications – should be prepared in a clean area away from patient
care stations
o Do not use carts to transport medications to patient stations.
o Scrub the hub of IV tubing and vials prior accessing, use ASEPTIC technique.
o Never use infusion supplies on more than ONE patient!
Pre and Post Surgical Infection Prevention
Basic Measures (Category I)
o Clippers instead of Razors for pre-surgical hair removal
Plus Measures
o Antiseptic impregnated dressings for post-surgical fistulas/grafts
o Active surveillance testing for MRSA and decolonization – as indicated (pre-op)
o Pre-op bath / shower
Standard and Transmission Based Precautions
Standard Precautions
o Formerly Universal precautions (1987)
o Refers to the practices that are designed to prevent the transmission of infection
by contact with bodily fluids.
o Concept: all blood, body fluids, secretions and excretions may contain infectious
transmissible agents.
Basic Measures (Category I)
o Respiratory etiquette should be employed routinely.
o Standard Precautions should be practiced routinely.
o Patient with Airborne disease – should be masked immediately , separate from
other patients (SINGLE room)
Varicella, TB, measles
Mircoorganism can remain airborne for 2 hours
Negative airflow room
Patients – masked immediately and separate from other patients.
o Droplets
Pertusis, influenza, mumps, rubella, diphtheria, adenovirus, neisseria
meningitidis, Acute respiratory infections with MRSA, VRE, or other
MDRO, mycoplasma pneumonia
6 feet rule
Mask the patient
Vaccine preventable diseases – assign immune staff.
o Contact Precautions
C. difficile, adenovirus, rotavirus, impetigo, scabies, pediculosis, and
MDROs – VRE, MRSE, MRSA
Incidence: Most common in in-patient settings
HbsAg positive (HBV) – isolation should be employed
Plus Measures (Below Category I)
o Contact precautions should be employed in cases of known or suspected MDRO.
PPE Guidelines for Standard Precautions in HD Settings
Patients
o Wear mask during initiation and discontinuation of dialysis treatment if the
vascular access is a catheter.
o Wear mask in a Hemodialysis facility when experiencing symptoms of upper
respiratory illness.
Employees
o Lab style cover coats:
Regular cotton non-fluid resistant lab coats
Fluid resistant lab coats
o Masks:
Must be worn if experiencing mild cold or cough
Must be worn when initiating and terminating treatment (catheter
access)
o Gloves:
Worn whenever caring for a patient
Worn whenever touching patient’s medical equipment, handling lab
specimens and used dialyzers.
Worn when cleaning stations, machines, wiping up blood or other body
fluid spills.
Changed when moving from dirty to clean site/task on the same patient.
Changed after cannulation.
Removal of gloves is always followed by hand hygiene
o Face Protection (mask with eye protection/goggles)
Worn during initiation and termination of treatment
Worn during reprocessing or cleaning equipment in sink
Worn when within 6 feet of an unmasked coughing patient.
Discarded between patient care, or if reusable - disinfect between uses.
HBV Isolation / Precautions
Isolation of HbsAg positive patients is standard of practice in HD facilities for 2 reasons:
1. Environmental stability
2. High Viral titer
Risk Comparison of Blood – borne viruses for Health Care Workers:
o HIV infection from an exposure occurs at a rate of 0.2% to 0.4%.
o HCV infection from an exposure occurs at a rate of less than 1%.
o HBV infection from an exposure occurs at a rate of up to 30%.
Patients are placed in a private room or segregated area.
Dedicated HD machine is provided for HBV positive patients.
Dialyzers
o Dialyzers SHOULD NOT BE REUSED! - CDC
Gown, gloves are required when caring for HBV positive patients.
Mask with eye protection (face shield) is required during cannulation and
decannulation.
Staff caring for HBV patients cannot care for susceptible patients at the same time.
Staff caring for HBV should be HBV –immune.
Required when surface antigen is positive and not required when the surface antigen is
not detectable.
HCV Positive Patients
HCV RNA positive
Same Standard Precautions
Seroconversion of known negative patients is 0.34% (less than 1%)
Case series based studies
Dialyzer
• Dialyzers CAN BE REUSED
HIV Positive Patients
Same Standard Precautions
Isolation:
o Not required
Need for dedicated machine:
o No need
Dialyzer:
o Can be REUSED (CDC)
Vascular Access
Basic Measures (Category I)
o Support transition from temporary (CVC) to permanent (AVF or AVG) vascular
access whenever possible.
o Full barrier precautions and skin antisepsis with chlorhexidine (CHG) alcohol prep
prior to insertion of HD catheter.
Plus Measures (Below Category I)
o Application of CHG impregnated insertion site dressing for HD CVCs.
o Prophylactic antimicrobial catheter locking solution.
AVF / AVG
o Wash access site with soap and water
o Skin prep: CHG greater than 0.5% / 70% alcohol / 10% povidone iodine (KDOQI)
o Alcohol – should be applied in a rubbing motion for 1 minute
o Povidone-iodine – should be applied 2-3 minutes prior cannulation
CVC
o Catheter manipulation :
kept to absolute minimum
o Exit site care:
Povidone-iodine antiseptic ointment (CDC), triple antibiotic ointment
(neomycin, polymyxin B, bacitracin)
o Mupirocin use
Mupirocin use should be limited due to increasing cases of mupirocin
resistant [Link] and is said to be not effective with gram negative
organisms (CDC 2002)
o Gauze and tape or transparent dressing.
Frequency of changing dressing: gauze and tape every 3 days (every HD
session) for 3x a week HD patient, every 7 days for transparent dressings.
Water treatment system and loop distribution
Basic Measures (Category I)
o Adhere to AAMI standards for quality assurance performance of devices and equipment
used to treat, store and distribute water in a HD facility and for the preparation of
concentrates and dialysate.
o Conduct microbiological testing specific to water in dialysis settings
o Disinfect water distribution system on dialysis settings on a regular schedule.
Plus Measures (Below Category I)
o Ultrapure dialysate – unresolved issue
o Unresolved issue on HD vs HDF
OUTCOME and PROCESS METRICS of Infection Control in HD
Reference
1. CDC and HICPAC. Guidelines for Environmental Infection Control in
Healthcare Facilities. Available at
[Link] .
[PDF - 1.4 mb].
