Renal patients: IP&C in haemodialysis

Transcription

1 Renal patients: IP&C in haemodialysis Dr J Richards Formerly, Cons Med Micro & DIPC, N&N Univ. Hosp. NHS Trust Hon Sr. Lecturer, Med School, UEA CHAIR, IFIC

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3 Background Healthy kidneys clean the blood and remove bodily fluids by producing urine Patients who require dialysis have an increased risk of infection

4 Background: Infection Risks in Dialysis patients Pts. who require dialysis are at increased risk due to : Repeated and prolonged catheterization procedures Underlying disease co-morbidities ( diabetes, etc.) Immunosuppression from end stage renal failure

5 Presentation outline What is dialysis, different types Infection associated risks IP&C measures/general guidance Patient, staff, environment Organizational issues BSI/MRSA Background UK and local ( Norwich) experience Guidance

6 Dialysis Haemodialysis Peritoneal dialysis

7 Hemodialysis (HD) Dialysis machine and a dialyzer clean the blood The patient s blood enters the machine from access point A fistula, vascular graft, or a temporary central line Blood and dialysis fluids do not mix Blood passes over a semi-permeable membrane which allows some molecules to pass through. Can take up to 3-6 hours, usually 3 times per week Either as inpatient, or outpatient by trained staff

8 Hemodialysis

9 Potential Adverse Events Bacteraemia Sepsis Loss of vascular access

10 Peritoneal dialysis (PD) Instillation of dialysis fluids into the peritoneal space via a surgically-inserted catheter Most catheters are silicone Fluid is removed to take out toxins Most common types include: Chronic ambulatory PD Continuous cyclical PD Chronic intermittent PD

11 Peritoneal Dialysis

12 Potential Adverse Events Peritonitis Due to contamination at time of exchange or infection of the exit site Loss of access site Due to infection and fibrosis Death If sepsis develops

13 Infection Risks Hepatitis B Hepatitis C HIV Bacterial blood stream infections Fungal Mycobacteria

14 Modes of transmission of infection Transmission can take place through contact with: Blood or body fluids Contaminated equipment or surfaces Infected\colonised patients Staff may inadvertently spread infections from patient to patient Via direct or indirect contact with contaminated surfaces or equipment or colonised\infected patients

15 Infection Associated Risks -1 Hepatitis B HBV has been detected on: clamps and scissors used in HD external surfaces and parts of dialysis machines Can be transmitted on gloves or unwashed hands of staff HB vaccine for patients and for staff is essential component of infection prevention and control (IPC). Although low incidence of HBV in many HD populations, outbreaks do occur

16 Infection Associated Risks -2 Outbreaks of HCV are associated with: Receiving HD treatment immediately after an HCV infected patient Inadequately disinfected shared equipment and supplies including: Common medication carts Shared multi-dose vials Contaminated HD machines and related equipment Blood spills which were not cleaned

17 Infection Associated Risks -3 Acquired Immune Deficiency Syndrome (AIDS) Human immunodeficiency virus (HIV) is transmitted via blood or blood-containing body fluids Transmission has resulted from inadequate disinfection of equipment (e.g., access needles)

18 Infection Associated Risks Bacterial diseases Dialysis patients are at increased risk of infection and colonisation with multi-drug resistant organisms (MDRO) (e.g., methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). This is a result of : Frequent health care facility contact Frequent use of antibiotics Use of invasive devices

19 Infection Associated Risks MRSA Outbreaks of MRSA have occurred in dialysis units MRSA may contribute up to 30% of all MRSA BSIs in a Hospital Vancomycin resistant S. aureus (VRSA) reported among HD patients Other MDRO: Pseudomonas aeruginosa, Stenotrophomonas maltophilia and Acinetobacter spp. some are resistant to all current antibiotics

20 Infection Associated Risks -6 Mycobacteria Mycobacterial infections have occurred from contaminated water used for dialysis Patients with ESRD are at high risk for progression from latent tuberculosis (TB) to active TB disease. Frequent hospitalisation of dialysis patients increases risk of transmission of TB to other patients or staff Fungi Dialysis patients are susceptible to fungal infections such as Aspergillus spp. Strict adherence to IPC precautions for construction and renovation is critical Prompt clean up of water or other spills prevents mould contamination in environment Risk of Candida bacteraemia and peritonitis (patient s skin source)

21 IPC measures - 1 Preventing access site infections and blood stream infections (BSI) Proper hand hygiene During site access: Staff must wear mask and gloves Patient must wear mask Locate, inspect and palpate access site prior to skin preparation.

22 IPC measures -2 Standard and transmission-based precautions: All staff must use Standard Precautions, Staff must follow Contact precautions for multidrug resistant organisms HBsAg-positive patients and their equipment and supplies must be segregated from those from non HBV infected pts. Isolation of HCV patients is not recommended

23 IPC measures -3 Environmental cleaning and disinfection Regularly maintained, cleaned and disinfected dialysis equipment, machines and reusable supplies Policies and procedures (including care and maintenance) for dialysis systems including: Water treatment system Distribution system Dialysis machines

24 IPC measures -4 Safe medication and injection practices Avoid contamination of multi-dose vials Single-use vials are preferred Disinfect stopper with alcohol before accessing Use single-use sterile needle and syringe for each access Do not recap needles Discard used sharps in designated container at point of care Use safety engineered medical devices when possible

25 IPC measures -5 Patient immunization, post vaccine testing and screening Essential for HBV and HCV Screen for HBV prior to start of HD treatment Immunize for HBV-assess need for booster Screen for HCV prior to HD and every 6 months Pneumococcal vaccine: < 65 years of age dose every 5 years > 65 only one dose MRSA and VRE Screen only during outbreaks or suspected transmission Special precautions in high endemicity areas

26 IPC measures -6 Patient and staff education Staff- initial and ongoing on: Principles and practices of dialysis Infectious risks Potential adverse events IPC practices, including NTT Patient Access site and dressing care Signs and symptoms of infection Importance of reporting potential infections

27 IPC measures -7 Water treatment and testing: Perform testing of dialysis water and dialysate at least monthly US Association for the Advance of Medical Instrumentation (AAMI) guidelines Dialysis water standards: < 200 CFU/ml viable microbial count < 2 EU/ml endotoxin concentration If viable microbial count reaches 50 CFU/ml or endotoxin concentration reaches 1 EU/ml, take immediate corrective action Policies and procedures in place for testing and follow-up

28 Basic IPC Principles: documentation Dialysis surveillance program components: Routine testing and documentation of HBV and HCV for chronic dialysis patients. Documentation of patient s vaccination status On-going regular and documented surveillance of bacteraemia, access site infections and peritonitis Regular on-going surveillance of patients pre and during H/D programme if MRSA endemic

29 Active surveillance: VRE not advisable unless outbreak MRSA pre-dialysis, and regularly only if MRSA endemic or outbreaks present Mycobacteria: if high levels of HIV/MDRTb HCV and HBV regularly

30 IPC measures - 1 Wash access site with antibacterial soap\scrub and water. HD access lines must not be used for other purposes.

31 IPC measures -3 Environmental cleaning and disinfection Hospital grade disinfectant for all patient areas Special attention to high touch items or surfaces likely to be contaminated by blood or body fluids Procedures for containment and clean up of blood or body fluid spills Procedures to prevent mould contamination from water damage or wetting of permeable surfaces Safe disposal of used supplies and dialysers

32 IPC measures - 6 Environmental cleaning and disinfection Clean, high level disinfect, thoroughly rinse, dry and safely store safely dialysers before reuse Adequately clean dialysis machines and equipment and reusable supplies

33 Low resource issues Main priorities are: Safe reprocessing and reuse of dialysers Use, maintenance and testing of safe reliable water supply Spatial separation for patients with HBV, MDRO and their supplies Access to reliable methods for cleaning and disinfection of supplies and equipment Access to lab testing for patients for HBV\HCV and detection of other infections Access to HBV vaccine for patients and staff

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35 BSIs in Dialysis, the MRSA story The UK experience

36 Background: MRSA in Dialysis pts. USA, 2005: cases per 1000 population UK, : 321 deaths attributable to MRSA Hong Kong 2003, 44.6% ptscolonized with MRSA

37 N&N: Local situation MRSA BSI % contribution from RH/DU MRSA colonization increases risk of BSIs Davis et al. CID Von iffc et al. NEJM 2001 Root cause analysis : No pre H/D programme screening No decolonisation programme Use of IV shunts vshd via catheters

38 MRSA-other centres Addenbrookes Hosp, Cambridge ave.: over 120 cases/year; No renal problems, but IV line related- ICUs Dr N Brown, personal comm. Over 30-40% related to renal H/D lines Dr A Holmes, Hammersmith Hosp. Personal comm. Majority of cases seen in Cardiac ICU Prof G French, Guys & St Thomas s Hosp, Personal comm.

39 Benchmarking: Direct comparisons with Hospital A Further comparison with Hospital B Results: N&N Hospital: H/D performed via temporary IV line in 75% cases vs32% vs approx. 60% Temporary IV access used for 6 to 18 months IV access site continuously changed, but initially femoral ( emergency/temporary )

40 Multi modal Action Plan Prevention of MRSA BSIs: Training programme- implementation of NTTs Screening programme implemented Mupirocin decolonization Marshall et al J HospInfect 2004 Boelaertet al, NephrolDial Transplant.1993;8(3):235-9 Discussions with vascular surgeons Central line insertion : adherence to bundle Appointment of dedicated vascular nurse

41 Other Actions & Measures Focus on Organizational aspects Intention to dialyse referrals Pre dialysis A-V shunt preparation Best practice suggests this should be six months before starting dialysis! The National Service Framework for Renal Services, UK Dept of Health, 2004 Operating theatre access Vascular surgeon/trained operator access Dedicated vascular nurse/technician Early detection of shunt failure Care of line: Prevention of HD CRBSIs: European Renal Best Practice statement, NDTplus, 2010

42 Results : 30% of all MRSABSIsin hospital 32 H/D patients colonised : no MRSA BSI in 20 months, (last case in previously colonised patient, poor personal hygiene, no home care/support) only 2 patients colonised

43 Key points Dialysis patients are at high risk of infection due to underlying illness and other environmental and procedural factors A comprehensive infection prevention and control (IPC) program for dialysis settings reduces infection risk for patients and staff The patient plays an important part in IPC and requires education. Strict adherence to basic IP&C measures essential Organizational issues may get in the way, and need to be resolved.

44 Acknowledgements Thank you for permission to use slides: Pat Piaskowski, author, chapter on renal H/D, Basics Concepts of Infect. Control 2 nd Ed, revised 2011 Smilja Kalenski, author, PPs presentation, e-learning course, Renal Medicine, based on above, in preparation.

45 Thank you Any questions?