infections in dialysis patientsbasis & prevention
TRANSCRIPT
02/05/2023 Dr.T.V.Rao MD 1
INFECTIONS IN DIALYSIS PATIENTSbasis & prevention
Dr.T.V.Rao MD
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Renal Failure and Technology for Survival
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Dr.T.V.Rao MD 4
INFECTIONS IN HEMODIALYSIS UNIT
Patients are at risk with •Bacterial infections •Viral infections like Hepatitis B and C•Other prevailing infections as per the circumstances
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Why Infections in Dialysis Patients
•Patients who undergo dialysis treatment have an increased risk for getting a healthcare-associated infection (HAI). Hemodialysis patients are at a high risk for infection because the process of hemodialysis requires frequent use of catheters or insertion of needles to access the bloodstream.
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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 infection
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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 would reduce the risk of infection.
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Basic Principles of Medical Asepsisas 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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MicrobiologyCommon 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, gram-negative bacteria were commonly isolated from the initial sputum cultures of patients with community-onset pneumonia.
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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.
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Infections Associated With Peritoneal Dialysis
• 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 of 3 to 6 hours, three times a week
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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 gastrointestinal tract. S. epidermidis suggests problem with hygiene of the skin,
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Water Sources can be cause of Infections
•Waterborne organisms as Stenotrophomonas 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 infecting bacteria.
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Bacterial Infections
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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%. Atypical mycobacteria and yeast account for 5% of cases
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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 influenza, but also S. aureus, and gram-negative rods
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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 urinary workup should be perused, especially to rule out obstruction.
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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 elevated serum ferritin levels from transfusion overload.
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Many drug resistant bacteria hamper the Survival ..
• Methicillin Resistant Staphylococcus aureus (MRSA) Vancomycin Resistant Enterococci (VRE), Extended Spectrum β-lactamase (ESBL)-producing Klebsiella pneumonia, Carbapenem-resistant Acinetobacter baumannii (CRAB) and Clostridium difficile (antibiotic associated diarrhoea).
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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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During dialysis• Infections like Hepatitis B and C and bloodstream infections are spread from patient to patient most commonly by the hands of healthcare workers.
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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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Hand washing continues to be most basic care in dialysis
patient •Clean hands before and after every patient contact
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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 careTalk to patients about good vascular access care
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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 are two events that occur and may play a role in this presentation
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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 contact contamination.
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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 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.
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Dialysis Infection Prevention Strategies•Performed monthly hand
hygiene observations;• Performed regular
observations of vascular access care and catheter accessing;• Trained staff on infection
control topics, including access care and use of aseptic technique;
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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 patient’s endogenous flora are responsible for most infections in patients with end stage renal disease
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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.
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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 prophylaxis to S. aureus carriers only.
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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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Practising Universal Precautions
• Face protection (eyewear/goggles, masks) is required 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 termination of dialysis).
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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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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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HBV+ Isolation Room/AreaNew 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 patients
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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.
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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 manufacturer’s 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.
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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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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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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, monitoring, and
evaluation of preventive interventions
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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.
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Have a self auditMedical 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.
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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 intervals—once yearly and every five years, respectively
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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
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