ol & Monitoring Infection Contro MD, MPH Priti R. Patel, Control and Prevention.

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1 Infection Contro ol & Monitoring Priti R. Patel, MD, MPH Division of Healthcaree Quality Promotion Centers for Disease Control and Prevention March 10, 2009 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.

2 Outline Infections in dialysis settings HCV, HBV, bacterial infections Vaccines Describe an infection surveillance program Basic elements Role in prevention and QAPI BSI prevention initiative NEW CMS REQUIREMENTS

3 Recent News

4 Hepatitis C Virus (HCV) Transmission: A Failure of Surveillance Identified 9 cases of HCV seroconversion (patients who tested anti-hcv negative and subsequently anti-hcv positive) Documented transmission occurring at the facility over 8 years Uncovered multiple infection control breaches Facility surrendered its operating certificate and paid $300K civil penalty

5 Additional Problems No management of HC CV-positive test results Health department was not notified of seroconversions Patients themselves were not informed that they tested positive No follow-up o studies or medical edca evaluation auato Did anyone even look at the results??

6 What Should Ha ave Happened? Review results, identif fy seroconversions Properly manage & report seroconversions Investigate possibility of transmission occurring in the unit Identify and correct infection control lapses to prevent additional cases Recognize & act upon patterns

7 What is Surveillance Doing For You? In your facility How many patients are fu ully vaccinated against hepatitis B? What percent of your staf ff have been vaccinated against influenza? How does your facility s bloodstream infection (BSI) rate compare to the national average? What are the most common organisms that cause BSIs in your facility? Is this information reviewed at your QAPI meetings?

8 Req. Quality Improvement: Monitoring Facility Data Conduct surveillance to det termine infection rates, monitor trends in those rates, and assist in identifying lapses in infection control practices A log or other tracking mechanism, such as the Dialysis Module of the National Healthcare Safety Network (NHSN) should be used Surveillance data Bloodstream infection rates Culture and susceptibility Hepatitis B & C testing Water testing Immunization rates

9 Hepatitis C

10 Hepatitis C Vi rus Infections in Hemodialysis Prevalence: 8-10% (1.6% in general popul lation) Majority of infections are asymptomatic; majority develop chron nic infection Isolation is not recommended, no vaccine Prevention requires strict attention to infection control practices

11 Schedule for Routine HBV & HC CV Testing All patients Anti-HBs 10, anti-hbc (-) Anti-HBs (+), anti-hbc (+) On admission HBsAg Anti-HBs Total-anti-HBcanti Anti-HCV ALT Monthly H BsAg No additional HBV testing needed ALT Source: MMWR 2001;50(No. RR-5) HBVsusceptible HCVsusceptible Semi- annual Anti-HCV Annual Anti-HBs

12 HCV Transmission in Dialysis Centers Mechanism of Transmission Blood contamination of the environment, medication vials, and medical devices Implicated practices Not routinely cleaning dialysis machines / station between patients Use of mobile medication or supply carts Preparation of injected medications in potentially ti contaminated areas Re-entry and re-use of medication vials N. Thompson. NKF Spring Meeting. Grapevine, TX. April 3rd, 2008

13 HCV Testing Diagnostic testing E.g., for symptoms or ALT elevation Screening Recommended by CDC & KDOQI Not required or reimbursed by CMS Only realistic way to identify transmission and rectify incorrect practices If not currently screening, consider testing on admission, and at least annually Must review and act upon results in a timely manner

14 Hepatitis B

15 HBV Infection among Hemodialysis Patients Prevalence has declined dramatically due to: Infection control & isolation Vaccination Extra precautions practices Infected persons can have high viral concentrations in blood HBV can survive at room temperature on surfaces for at least 7 days Hepatitis B surface antigen detected on clamps, scissors, machine control knobs Can be transferred to patients via contaminated hands (gloved or ungloved), medications, equipment, and supplies

16 Prevention of HBV Transmission in Recommendations Dialysis i Isolate HBsAg positive patients in separate room Dedicated staff Dedicated d equipment Dialyzers should not be re-used Setting Conduct surveillance for HBV infection Separate supplies for each patient (regardless of status) Cleaning/disinfection of non-disposable items Glove use Routine cleaning/disinfection of equipment and surfaces

17 Req. New in the Conditions Hepatitis B isolation New facilities must have a room Existing facilities may have an area: must be separated by at least width of 1 dialysis station from adjacent stations No patient buffer Patients that require a booster dose of Hep B vaccine not eligible to be cared for by HCW treating HBsAg+ patient

18 Schedule for Routine HBV & HC CV Testing All patients Anti-HBs 10, anti-hbc (-) Anti-HBs (+), anti-hbc (+) On admission HBsAg Anti-HBs Total-anti-HBcanti Anti-HCV ALT Monthly H BsAg No additional HBV testing needed ALT Source: MMWR 2001;50(No. RR-5) HBVsusceptible HCVsusceptible Semi- annual Anti-HCV Annual Anti-HBs

19 Isolation an nd anti-hbc Patient has the following hepatitis serology: Total anti-hbc positive IgM anti-hbc negative Anti-HBs negative HBsAg nega ative HBV DNA was ordered and is positive Isolated total t core positive Q1. Should this patient be isolated?

20 Q1. An nswer No isolation is neededd HBsAg status is the determinant of whether or not a patient needs isolation, not HBV DNA Q2. What to do for isolated total anti-hbc?

21 Management of iso lated total anti-hbc Repeat total anti-hbc test on a separate sample (and IgM anti-hbc if positive) If anti-hbc negative, vaccinate If anti-hbc positive, IgM anti-hbc negative, vaccinate (if no response to 2 vaccine series, then check HBV DNA) If anti-hbc positive, IgM anti-hbc positive, consider recently infected (check anti-hbs in 4-6 mos) Source: MMWR 2001;50(No. RR-5), p.28

22 Management Issues: Possible HBV transmission and/or exposure Real Scenarios 1) Patient develops new HBV infection, unclear if acquired in unit 2) Patient traveled abroad, returns to unit. Identified as surface antigen positive through screening 3) New admit, unknown HBsAg status Problem: facilities with low hepatitis B vaccination rates Essential: ensure all patients are fully immunized as soon as possible, whether or not your facility treats HBV-positive patie ents

23 Vaccination

24 Vaccinations Recommended Patients Hepatitis B Influenza yearly * Pneumococcal * Staff Hepatitis B Influenza yearly * * Pulmonary infections are the second leading cause of infectious mortality in ESRD

25 Immunizationn Guidelines

26 Influenza & Pneum mococcal ldisease Influenza 114,000 hospitalizations & 20,000 deaths per year in U.S. Highest mortality in persons 65 yrs and those with medical conditions Pneumococcal Disease 3,000 meningitis; 50,000 bacteremia; 500,000 pneumonia cases; 12,500 deaths per year in U.S. Case-fatality rate for bacteremia 15%-20% among adults 18 yrs; as high as 40% in persons 65 yrs

27 12 Steps to Prevent Antimicrobial Resistance: Dialysis Patients Step 1: Vaccinate staff and patients Vaccination Rates of Dialysis Patients, * * Unpublished data, Dialysis Surveillance Network 2001 Influenza Vaccine Pneumococcal Vaccine Healthy People 2010 Goal Link to: Influenza recommendations...cdc,, MMWR 2003; 52 (RR08):1-36

28 Need for Healthcare Personnel Immunization Programs: Influenza Vaccination Rates ( ) % Vaccinated Healthcare personnel at highh risk All healthcare personnel 38% 34% Source: 1997 National Health Interview Survey Walker FJ, et al., Infect Control Hosp Epidemiol 2000; 21:113

29 Influenza Vaccination Patients Reduces hospitalizations Reduces deaths Staff Reduces influenza illness Fewer missed days of work Improves patient outcomes Gilbertson, Unruh, McBean. Kidney CDC. MMWR 2006;55:1-16 Int 2003;63:738-43

30 Strategies to Imp prove Vaccination Rates Have a procedure for ordering vaccine from the manufacturer in a timely manner Have a system to record vaccination status of patients and staff Consider standing orders to allow nurses to administer the vaccine Educate patients and staff members Address concerns and myths

31 Other Immunization Resources

32 Vascular Access Infections

33 Bloodstream Infections (BSI) Major cause of morbidity Catheter-related related BSI 1 : episodes per patient-year Among patients hospitaliz zed with S. aureus BSI 2 : Avg. length of stay: 13 days Cost of hospital admission 31% had complications, 21% had to be readmitted Within 12 weeks, 19% died from any cause 11% died due to S. aureus and mortality = $20,685 (1) Allon. AJKD 2004; 44: (2) Engemann. ICHE 2005(26):534-9

34 Invasive Methicillin-Resistant S. aureus (MRSA) Infections, 2005 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 Dialysis cases: 86% were bloodstream infections 90% required hospitalization, mortality = 17% CDC. MMWR 2007; 56(09):197-9

35 Types of Vascul lar Access, U.S. Hemodialysis Patients, by Year % of Pa atients D ialyzed Through Graft Fistula Catheter Year Finelli, Miller, Tokars. Semin Dial 2005;18:52-61

36 Prevalent HD Patients with Catheter USRDS 2007 Annual Data Report

37 Incident Patient ts with Catheter at HD Initiation USRDS 2007 Annual Data Report

38 Concernin ng Trends Catheter t usage among both incident id and prevalent HD patients is increasing Since 1993, hospitalization rates for BSI have increased 29% Current process / outcome measures may not be sufficient USRDS 2007 Annual Data Report

39 Surveillance CDC s Dialysi is surveillance in the National Healthcare Safety Network (NHSN) is open for enrollment.

40 What can surveillance do for outpatient dialysis centers? Identify areas for follow-up and prevention Report to stakeholders Data available for an nalysis Routine and custom reports Compare data with other centers Uniform system of measurement CMS expectation

41 NHSN uses the CDC Secure Data Network

42 Dialysis Proto col Brief Population Denominator Chro nic hemodialysis outpatients Number of dialysis outpatients on the first 2 working days of the month Stratified by 5 types of vascular acces ss Complete this informat tion once per month

43 Dialysis Proto col Brief Population Numerator Chronic hemodialysis outpatients Complete form for each dialysis event Hospitalization Outpatient IV antimicrobial start Positive blood culture This information is more detailed, but is collected less frequently (only when there is an event)

44 Real-time Analyses Line listings Rate tables Infections stratified by vascular access type Hospital incidents Antibiotic starts t Control charts Analysis training available

45 Standard Analysis Option Screen for Dialysis Event Surveillance

46 Rates of Bacteremia by Access Type - Dialysis Surveillance Network, Sep Mar 2005 patient-m months Rate per Fistula 0.7 Graft 4.6 Cuffed Catheter Noncuffed Catheter Klevens, Tokars, Andrus. Nephrology News & Issues 2005; June:37-43.

47 Do we really need data to tell us what s happening right around us? - Many benefits - Is not as hard as you might think

48 UK Expe erience Busy London dialysis unit: 112 patients Implemented CDC dialysis surveillance; described their experience over 18 months After initial set up, required 2 hours per month Maintained compliance with surveillance Outcomes: Reductions in Access related bacteremiaa Antibiotic usage Hospital admissions George A, Tokars JI, Clutterbuck EJ, et al. Reducing dialysis associated bacteraemia, and recommendations for surveillance in the United Kingdom: prospective study. BMJ 2006; 332:

49 Reducing BSI rates in ICUs Collaborative project Uniform system of measurement Evidencebased practices Data feedback MMWR 2005;54:

50 BSI Prevention Collaboratives Collaboratives in a num mber of settings have had success in preventing BSIs Role for this approach in outpatient dialysis BSIs common and preventable Collaborative approach leads to dissemination of good ideas between stakeholders

51 Requirements Collaborativ ve Approach Willingness to think about and help develop approaches to BSI pre vention that work in your setting Interventions not dictated Willingness to uniformly collect outcomes in NHSN Identifying partners & stakeholders Stay tuned!

52 Summary Infection Monitoring in Dialysis Required by CMS Essential for identifying and correcting problems Facilitates facility-led quality improvement efforts NHSN monitor BSI rates patient and staff vaccination hepatitis seroconversio ons

53 Use data to Summary Know your rates! Know your fistula and catheter rates Know your vascular access infection rates* Compare rates with other facilities Assist quality improvement efforts First step in collaborat tive prevention initiatives

54 Than nks!! NHSN Support: