Dialysis-Associated Infections

 
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Slide 1
Infection Control in Dialysis Settings
Priti R. Patel, MD, MPH
Division of Healthcare Quality Promotion
Centers for Disease Control and Prevention
July 20, 2008
Disclaimer: The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Slide 2
Important Trends

  • Growing dialysis population; ~340,000
  • Mortality, increasing morbidity from infections
  • Antimicrobial resistant infections, new forms of resistance

Slide 3
What else is new?

  • New CMS Conditions for Coverage
  • Includes by reference CDC guidelines:
    • Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients, 2001
    • Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2002


Slide 4
Mortality and Survival on Dialysis

Graph: Annual death rate: 23%
Adjusted five-year survival, by modality and primary diagnosis: 1994-1998
~36% alive at 5 years

Slide 5
Epidemiology of Infections among Hemodialysis Patients

  • Infections are the 2nd leading cause of death (15% of deaths)
  • Site of infection
    • 57% vascular access
    • 23% wound
    • 15% lung
    • 5% urinary tract

Slide 6
Vascular Access & Bloodstream Infections (BSI)

  • Vascular access infections
    • Local access site infection or bloodstream infection (BSI)
  • Catheter-related BSI:
    2.5 – 5.5 episodes per 1000 patient-days
    0.9 – 2.0 episodes per patient-year

Slide 7
Hospitalization Rates

  • Cause-specific hospitalization rates among hemodialysis patients, 2004-05:
    • Vascular access infection = 132 admissions / 1000 pt-yrs
    • Bloodstream infection = 102 admissions / 1000 pt-yrs
    • Pneumonia = 86.3 admissions / 1000 pt-yrs
  • Since 1993, rates have increased for:
    Bloodstream infection (+29%)
    Cellulitis (+24%)
    Pneumonia (+19%)

Slide 8
Outcomes of S. aureus BSI
Among hemodialysis patients admitted with S. aureus bacteremia1:

  • Avg. length of stay: 13 days
  • Cost of hospital admission = $20,685
  • 31% had complications
  • 21% had to be readmitted
  • Within 12 weeks,
    • 19% died from any cause
    • 11% died due to S. aureus


1. Engemann. ICHE 2005(26):534-9
2. Nissenson. AJKD 2005(46):301-8

 

Slide 9
MRSA = Methicillin-Resistant S. aureus

  • Dialysis patients:
    • 0.1% of the U.S. population
    • 15% of all invasive MRSA infections
  • Rate of invasive MRSA is 100x greater than in general population

Slide 10
Antimicrobial Resistance
Cartoon: MRSA superbug

Slide 11
Emergence of Antimicrobial Resistance
Resistant Bacteria
Resistance Gene Transfer
Mutations
Susceptible Bacteria
New Resistant Bacteria

Slide 12
Selection for Antimicrobial-resistant Strains
Resistant Strains Rare
Antimicrobial Exposure
Resistant Strains Dominant

Slide 13
Evolution of Drug Resistance in S. aureus
S. aureus Penicillin [1944]
Penicillin-resistant S. aureus Methicillin [1962]
Methicillin-resistantS. aureus (MRSA)
Vancomycin [1990]
Vancomycin-resistant enterococci (VRE) [1997]
Vancomycin intermediate S. aureus (VISA) [2002]
Vancomycin-resistant S. aureus
 
CDC, MMWR 2002;51(26):565-567

Slide 14
New Resistance – Staph. aureus
Vancomycin- Intermediate S. aureus (VISA)

State, Year Site PD/HD*
Michigan, 1997 Peritonitis  Chronic PD 
New Jersey, 1997 Blood  Recent PD 
New York, 1998 Blood  Chronic HD 
Illinois, 1999 Endocarditis Chronic HD
Minnesota, 2000 Bone  Chronic HD 
Nevada, 2000 Liver  ----- 
PD=peritoneal dialysis , HD=hemodialysis

Fridkin, Clin Infect Dis 2001;32:111

 

Slide 15
Vancomycin Resistant S. aureus (VRSA) -- Case #1

  • First case of S. aureus fully vancomycin resistant
  • Michigan, June 2002
  • 40 year old with diabetes mellitus, peripheral vascular disease, hemodialysis
  • VRSA from foot ulcer and catheter exit site

Slide 16
VRSA – Case #1
image of infected foot

Slide 17
But what can I do?
Infections happen

Slide 18
Key Prevention Strategies

  • Prevent infection *
  • Diagnose and treat infection effectively
  • Use antimicrobials wisely
  • Prevent transmission *

Clinicians hold the solution!

Slide 19
Infection Prevention: A few moments from history

Slide 20
The Origins of Infection Control: the Story of Semmelweis

  • 1847: Vienna General Hospital, Austria
    • “Childbed fever” or puerperal fever is a severe febrile condition following childbirth, claimed many women’s lives
    • Dr. Ignaz Semmelweis, director of obstetrics on 2 wards noticed that childbed fever deaths onWard #1 much greater than Ward # 2
    • Ward #1 staffed by interns; Ward #2 midwives only
    • Different activities: interns would often perform autopsies and then go to the ward and examine patients in labor

Slide 21
Cadaveric ‘Poisoning’

  • Solving the mystery
    • At the time, the medical establishment thought that ailments were caused by imbalances in humors or from “bad air”
    • Semmelweis observed friend who died after an accidental stick from a scalpel during an autopsy; the friend appeared to have a condition similar to puerperal fever
    • Determined that there were “cadaveric particles” carried on the hands of interns to the obstetric ward that caused childbed fever

Slide 22
The “Savior of Mothers”

  • Getting results
    • Instituted hand washing with a chlorinated lime solution and saw an immediate decrease in childbed fever deaths
    • Documented all of these changes
    • Consistently, Semmelweis demonstrated dramatic results in several hospitals
    • In some cases, was able to eliminate childbed fever altogether

Slide 23
Fame and Fortune?

  • Sadly, no
    • Unfortunately, the medical establishment rejected his evidence
    • One scientist:
      “it seems improbable that enough infective matter or vapor could be secluded around the fingernails to kill a patient”
    • Wasn’t until Louis Pasteur developed the germ theory (~20 years later) that the medical establishment finally began to appreciate his work
    • Semmelweis was sent to an insane asylum, where he was severely beaten and died within 2 weeks

Slide 24
A Brief History of Infection Control

  • 1889: Invention of surgical gloves by American surgeon, Dr. W.S. Halsted
  • Came about by accident
  • The head nurse, also Halsted’s future wife, had irritated skin from antiseptic agents
  • Halsted commissioned Goodyear to make gloves that could be worn during surgery

Slide 25
A Brief History of Infection Control

  • Determined later…
    • Reduction in bacteria on hands if gloves were used during surgery

Slide 26
Infection Control in the 21st Century

  • Many of the practices recommended today are still based on important findings from the 19th century
  • We now have more advanced tools, but the principles are the same
  • These concepts seem fairly obvious but how well are we doing?
  • Would we make Semmelweis proud?

Slide 27
Infection Control
Making the Invisible Visible
Microbes are sneaky and invisible. Goal is to try to make them visible so we don’t forget about them.

Slide 28
Basic Concepts of Microbiology

  • Germs colonize the human body during birth or shortly thereafter and do not cause disease
  • Normal flora can be found in many sites of the human body
    • The skin (especially moist areas)
    • The respiratory tract
    • The urinary tract
    • The digestive tract
  • Other areas such as the brain, the bloodstream and the lungs are intended to be “microbe free” and are considered sterile sites

Slide 29
Difference between Colonization and Infection

  • Sometimes a microbe will enter, survive, and multiply in its host and cause clinical signs and symptoms such as inflammation, tissue damage and/or tissue death. This is known as an INFECTION and usually requires treatment.
  • Microbes that cause infection are known as infectious agents.
  • Infectious agents interfere with the normal functioning of the host and can lead to acute illness, shock, and even death.

Slide 30
Steps in the Spread of Disease
To cause an infection, an infectious agent must
Leave original host
Survive in transit (air, water, surfaces, hands)
Be delivered to a susceptible host
Reach a susceptible part of the host
Escape host defenses
Multiply and cause infection

Slide 31
Most Common Route of Spread
Bacteria
Workers’ Hands
Infected or colonized
Patients
Becomes colonized

Slide 32
Standard Precautions
Set of tasks designed to . . .
Protect staff and patients (WHO),
From contact with infectious agents (WHAT),
Wherever healthcare is delivered (WHERE),
To be used all the time, whether infection is known or not (WHEN),
In order to reduce infectious risks!! (WHY)
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. http://www.cdc.gov/ncidod/dhqp/gl_isolation.html

Slide 33
Essentials of Standard Precautions

  • HAND HYGIENE
  • PERSONAL PROTECTIVE EQUIPMENT
  • COUGH ETIQUETTE AND RESPIRATORY COHORTING
  • BLOODBORNE PATHOGEN SAFETY
    • Injection safety

Slide 34
Putting Standard Precautions into Use
Who? All healthcare workers with direct or face-to-face contact with patients should use Standard Precautions
When? Standard Precautions should be used at all times!
Protect yourself from contact with:

  • Blood
  • Body fluids
  • Non-intact skin
  • Mucous membranes of others

How? Use of hand hygiene measures, protective barriers, and cough etiquette/respiratory cohorting

Slide 35
Hand Hygiene

  • Cornerstone to infection control
  • Single most effective method to prevent the spread of many communicable diseases
  • Includes
    • Hand washing: use of plain soap & water to mechanically remove bacteria and viruses and debris
    • Hand antisepsis: use of antimicrobial soap & water, or waterless hand gel to kill bacteria and viruses on hands

Slide 36
Compliance with Hand Hygiene

  • While a simple task, getting healthcare workers to improve hand hygiene is challenging
  • On average, only 30-50% of healthcare workers perform hand hygiene when they should
  • Some of the reasons people do not wash their hands:
  1. Inconvenient placement or lack of sinks
  2. Lack of soap or paper towels
  3. Too busy; not enough time
  4. Causes skin irritation or dryness
  5. Think the risk of transmitting disease is low
  6. Understaffed or overcrowded wards
  7. Lack of knowledge about the value of hand hygiene

Slide 37
Hand Hygiene:
(It’s not just handwashing anymore)

  • Alcohol-based handrubs can be used when hands are not visibly soiled
  • Benefits:
    • Rapid and effective antimicrobial action
    • More accessible than sinks
    • Reduced time for hand disinfection
    • Improved skin condition

Slide 38
Why is Hand Hygiene Important?
Practicing good hand hygiene has been shown to

  • Terminate outbreaks of diseases spread by person-to- person contact
  • Reduce the spread of multidrug-resistant organisms like MDR-TB
  • Reduce overall infection rates
  • Reduce staff illness and absenteeism

Single most effective way to reduce the risk of spreading or acquiring infections!

Slide 39
When to Perform Hand Hygiene

  • Before caring for patients
  • Before placement of an invasive device
  • Before administering medications
  • After every contact with a patient or a potentially contaminated surface or object
  • After touching blood or body fluids
  • After removing gloves
  • Between tasks on the same patient
  • When hands are visibly soiled
  • After using the restroom
  • Before preparing or handling food

Slide 40
How to Perform Hand Hygiene

  • Apply soap (plain or antimicrobial) and water to entire surface of hands
  • Rub fingers back and forth, and wash around the fingernail beds (about 15-30 seconds)
  • Rinse hands until all soap is gone
  • Dry hands with a clean towel (preferably a disposable paper towel)
  • Use towel to turn water off

Slide 41
Areas Commonly Missed after Performing Hand Hygiene
image of hands

Slide 42
So What’s Growing around You?
Example of bacterial growth from swabs taken from a kitchen sink in a North American household

Slide 43
A Pair of Hospital Hands…
Image showing bacteria growth

Slide 44
And after Hand Hygiene…
AFTER HANDWASHING WITH ANTIMICROBIAL SOAP

Slide 45
Hand Hygiene Works!
HANDWASHING WITH ANTIMICROBIAL SOAP
Hand print before washing
Hand print after washing

Slide 46
Vancomycin-Resistant Enterococci (VRE) on Hands and Environmental Surfaces

  • Up to 41% of healthcare worker hands sampled (after patient care and before hand hygiene) were positive for VRE1
  • VRE were recovered from a number of environmental surfaces in patient rooms
  • VRE survived on a countertop for up to 7 days2

Slide 47
The Inanimate Environment Can Facilitate Transmission
~ Contaminated surfaces increase cross-transmission ~
Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

Slide 48
Personal Protective Equipment

  • Types of personal protective equipment (PPE)
    • Gloves: sterile, non-sterile, utility
    • Gowns and aprons
    • Masks
    • Goggles

Slide 49
Why Should We Wear PPE?

  • Use gowns and/or gloves to
    • Protect your skin from blood and body fluid exposure
    • Prevent contamination of your clothing
    • Prevent spread of pathogens to other patients
  • Use masks, goggles or face shields to
    • Protect yourself from exposure to potentially infectious material by blocking droplets, splashes or sprays to mucous membranes such as the eyes and mouth

Slide 50
When is PPE Appropriate?

  • Gloves:
    • Before you anticipate contact with blood and body fluids or contaminated surfaces or objects
    • When performing direct patient care with those on contact isolation
    • Remember to perform hand hygiene after removal
  • Gowns:
    • If you anticipate splashes and sprays to the body or face
  • Masks and/or eye protection:
    • Before going to care for a patient who is coughing
    • Before performing bronchoscopy / intubation

Slide 51
Gloves

  • Protect you from patients
  • Also protect your patients from you! (and stuff you picked up from the environment)
  • Must be changed when moving between:
    • Patients or Patient stations
    • Machine and Patient
    • Clean and contaminated sites of same patient
  • Not doing so spreads the contamination on your gloves to everything else you touch

Slide 52
Vascular Access

Slide 53
Differences in Event Rates: Fistula vs. Catheter

Slide 54
Rate of Access-Related Bloodstream Infection by Vascular Access Type
Graph: Dialysis Surveillance Network 1999-2005

Slide 55
Image of Non-Cuffed Catheter

Slide 56
Types of Vascular Access, U.S. Hemodialysis Patients, by Year
Graph: Finelli, Miller, Tokars. Semin Dial 2005;18:52-61

Slide 57
Prevent Infection: Get the catheters out
Fact: Indwelling catheters are the single most important factor contributing to bloodstream infection in hemodialysis patients.
Actions:

  • Hemodialysis:
  • Use catheters only when essential
  • Maximize use of fistulas
  • Remove catheters when they are no longer essential

Slide 58
Prevent Infection Optimize access care
Fact: Careful infection control can prevent dialysis-related infections.
Actions:

  • Follow established guidelines for access care
  • Use proper insertion and catheter-care protocols
  • Remove access device when infected

Slide 59
Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2002
Dressing changes or skin prep:

  • 2 % chlorhexidine (preferred)
  • 10 % povidone-iodine
  • 70 % alcohol

Slide 60
KDOQI Clinical Practice Guidelines, 2006 – Catheter Care

  • Catheter access & cleansing exit site:
    • Chlorhexidine 2% is preferred
  • Use aseptic technique:
    • Correct hand hygiene
    • Masks for patient & staff
    • Disposable clean gloves

Slide 61
Catheter Dressings & Exit site Care

  • Change catheter dressing at each HD treatment using:
    • Transparent dressing, or
    • Gauze and tape
  • Catheter exit site:
    • Povidone-iodine ointment compatible with catheter material
    • Mupirocin ointment: not recommended

Slide 62
KDOQI Clinical Practice Guidelines, 2006 – Fistula / Graft Care

  • Wash site using antibacterial soap or scrub and water
  • Cleanse with:
    • 2% chlorhexidine
    • 70% alcohol
    • 10% povidone iodine
  • Wear new, clean gloves
  • Follow proper infection control procedures

Slide 63
Skin Antisepsis

  • 2% chlorhexidine
    • Has rapid (30 sec) and persistent (upto 48 hrs) action
    • Apply for 30 seconds, allow to dry
  • 70% alcohol
    • Apply for 1 minute prior to cannulation
  • 10% povidone iodine
    • Apply for 2-3 minutes, and allow to dry before cannulation

Slide 64
Access Care

  • Patient Education
    • Proper access care
    • Signs of access infection
    • Encourage patients to report any changes in access site or discomfort
  • Gloves & Hand Hygiene

Slide 65
Prevent Transmission Partner with your patients
Fact: Dialysis patients share in the responsibility for preventing access-related infections.
Actions:

  • Educate patients about proper access care and infection control measures
  • Re-educate regularly

Slide 66
Reducing BSI Rates in ICUs
Figure: MMWR 2005;54:1013-6

Slide 67
Bringing This All Together

  • Good Infection Control Can Make a Difference
    • Hand Hygiene
    • Environmental cleaning and disinfection
  • Vascular Access Care
    • Fistula First, Catheter Removal
    • Vascular Access Site Care
    • Staff Training & Patient Education
    • Follow recommended practices, ensure policies reflect best practices
      • Chlorhexidine antisepsis
  • Monitoring Infections

Slide 68
Thanks!!
NHSN Support:
Email: nhsn@cdc.gov
Phone:
800-893-0485
404-639-4225
http://www.cdc.gov/nhsn/

 

 

Date last modified: April 20, 2009
Division of Healthcare Quality Promotion (DHQP)
National Center for Preparedness, Detection, and Control of Infectious Diseases