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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2014  |  Volume : 25  |  Issue : 3  |  Page : 496-519
Infection control in hemodialysis units: A quick access to essential elements

Kanoo Kidney Center, Dammam Medical Complex, Dammam, Saudi Arabia

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Date of Web Publication9-May-2014


Infection is the most common cause of hospitalization and the second most common cause of mortality among hemodialysis (HD) patients, after cardiovascular disease. HD patients as well as the dialysis staff are vulnerable to contracting health-care-associated infections (HAIs) due to frequent and prolonged exposure to many possible contaminants in the dialysis environment. The extracorporeal nature of the therapy, the associated common environmental conditions and the immune compromised status of HD patients are major predisposing factors. The evident increased potential for transmission of infections in the HD settings led to the creation and implementation of specific and stricter infection prevention and control measures in addition to the usual standard precautions. Different international organizations have generated guidelines and recommendations on infection prevention and control for implementation in the HD settings. These include the Centers for Disease Control and Prevention (CDC), the Association of Professionals in Infection Control (APIC), the Kidney Disease Outcomes Quality Initiative (K/DOQI), the European Best Practice Guidelines/European Renal Best Practice (EBPG/ERBP) and the Kidney Disease: Improving Global Outcomes (KDIGO). However, these guidelines are extensive and sometimes vary among different guideline-producing bodies. Our aim in this review is to facilitate the access, increase the awareness and encourage implementation among dialysis providers by reviewing, extracting and comparing the essential elements of guidelines and recommendations on infection prevention and control in HD units.

How to cite this article:
Karkar A, Bouhaha BM, Dammang ML. Infection control in hemodialysis units: A quick access to essential elements. Saudi J Kidney Dis Transpl 2014;25:496-519

How to cite this URL:
Karkar A, Bouhaha BM, Dammang ML. Infection control in hemodialysis units: A quick access to essential elements. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2023 Jan 30];25:496-519. Available from: https://www.sjkdt.org/text.asp?2014/25/3/496/132150

   Introduction Top

Infection is the most common cause of hospitalization and the second most common cause of mortality among hemodialysis (HD) patients, after cardiovascular disease. HD patients are exposed to different types of infection, which include bloodstream infections and localized infections of the vascular access, blood-borne infections with hepatitis B virus (HBV), hepatitis C virus (HCV) and/or human immunodeficiency virus (HIV) and airborne infections like tuberculosis. Sources of infections could be contaminated water, equipment and environmental surfaces in the treatment area and patients with infections who pose a risk to other nearby patients being treated in the dialysis unit. The increased risk for contracting health-care-associated infections (HAIs) among HD patients are mainly due to (a) immune compromised status, (b) frequent and prolonged blood exposure during HD treatments through the vascular access and extra-corporeal circuit (with many ports and connections), (c) close proximity to other patients during treatment in the HD facility, (d) frequent contact with health-care workers, who frequently move between patients and between machines, (e) frequent hospitalization and surgery, and most importantly, (f) non-adherence or a break in implementation of recommended practices.

The break in implementation of recommended practices occurs inevitably as a result of one or more of the following factors: (a) understaffing with poor nurse to patient ratio, [1],[2],[3] (b) frequent turn-over of nursing staff, [1],[2],[3],[4],[5],[6] (c) lack or inadequate training and lower level of competency among HD staff, [2],[6],[7],[8] (d) inadequate or lack of patient/family education, (e) inadequate provision of necessary supplies/equipment, [7],[8] (f) poor design of HD unit lay-out (congested and inadequate segregation/isolation) [8] and (g) the urgency associated with dialysis complications (sometimes life-threatening situation) may sacrifice adherence to standard precautions. [6],[9],[10]

In addition to standard precautions, the international guideline-generating bodies recommended several specific infection prophylactic strategies for implementation in the HD settings. However, these published guidelines are usually extensive and sometimes variable. To facilitate access to concise information, increase the awareness and encourage implementation of recommended practices in HD units, we reviewed, extracted and compared the essential elements of infection prevention and control in HD units as recommended by the Centers for Disease Control and Prevention (CDC), the Association of Professionals in Infection Control (APIC), the Kidney Disease Outcomes Quality Initiative (K/DOQI), the European Best Practice Guidelines/Renal Best Practice (EBPG/ERBP) and the Kidney Disease: Improving Global Outcomes (KDIGO).

   Prevention and Control of Infections in Hemodialysis Units Top

Unlike the conditions in general hospital wards, the typical lay-out and associated conditions in most HD units, wherein multiple patients receive extracorporeal treatment with prolonged blood exposures in the same area and usually with one health-care worker (HCW) caring for more than one patient at the same time, are potential factors that may increase the transmission of infections. Therefore, stricter measures are specifically recommended in this setting in addition to standard precautions, which include but are not restricted to, the following:

Hand hygiene

Studies showed that the main route of transmission of HAIs is via the transiently contaminated hands of the HCW. [11],[12],[13],[14],[15],[16],[17],[18],[19],[20] Therefore, hand hygiene is singled out as the most important infection prevention intervention. However, the compliance rates of HCWs in hand hygiene is very poor, with an overall average of only 40%. [21] Based on hand hygiene indications as per recommendations from the APIC, [22] CDC [23] and World Health Organization (WHO) [24] [Table 1], we estimated the number of times a single dialysis staff is required to perform hand hygiene per HD session per patient [Table 2]. The estimated number is a minimum of 60-100-times when multiplied by the number of patients assigned per staff (e.g., two to three patients). The large number of times an HD staff is required to perform hand hygiene could be a reason for lack of compliance. However, compliance can be improved by continuous education and supervision, and by providing, in convenient locations, a sufficient number of sinks with soap dispensers, paper towels, hand lotions (e.g., one for every two to four dialysis stations) and alcohol-based hand rubs (ABHRs) placed at each patient station. [22] Because of the proven superior efficacy in decontamination, better skin tolerability and ease of use, ABHR is recommended to be used in all clinical situations if hands are not visibly soiled. If exposure to bacterial spores (i.e., Bacillus anthracis and/or Clostridium difficile) is suspected or proven, hand washing with soap and water is recommended because spores are resistant to most antiseptic agents and require physical removal by washing and rinsing. [25] Other preventive measures include restriction of having long nails and wearing of artificial fingernails or extenders by health-care personnel who provide direct patient care, as artificial nails could harbor gram negative bacilli and yeasts. [21],[22],[25],[26],[27],[28],[29]
Table 1: Hand hygiene indications as recommended by the APIC, CDC and WHO.

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Table 2: Estimated minimum number of times where hand hygiene is required per dialysis session per patient (regardless of use of gloves).

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Monitoring hand hygiene compliance is crucial, and direct observation is the current gold standard method. However, direct observation has several limitations, including being labor intensive, small sample size (may cover only 1% of total hand hygiene activity) and not standardized. A new model device application developed by the Computational Epidemiology Research Group at the University of Iowa (the "iScrub Lite," which is available for free download on the Apple iTunes store for Apple ® iPhone or iPod), can facilitate the work of the Infection Preventionist (IP) by recording the observations, which can be loaded to an excel spreadsheet for ready analysis. Advanced technologies, with automated electronic devices and software (Real Time Location System), can monitor the number of hand hygiene activity (10-50 thousands per month) in each department, floor or unit, and identify the HCW performing the hand hygiene through badge or wristband detection, with indication of the time of day and day of the week hand hygiene is performed and even provide feedback/cueing to encourage proper hand hygiene. [30]

Personal protective equipment

Personal protective equipment (PPE) refers to a variety of barriers and respirators used alone or in combination to protect mucous membranes, airways, skin and clothing from contact with infectious agents. They include gloves, gowns, masks, eye goggles, face shields and respirators. [25] In the HD setting, gloves are recommended to be worn whenever caring for a dialysis patient, whether touching patient's intact skin (e.g., taking blood pressure) or patient's equipment at the dialysis station. Gloves should be removed and followed by hand hygiene between patients or stations. [22],[31] The recommended practice of glove use for every contact with the patient(s) and equipment(s) at the dialysis station requires an enormous amount of glove supply, which is not always realistic in many HD units. However, when visible soiling is present and/or contact precautions are indicated, wearing gloves is a must. Sterile gloves must be used during procedures requiring a sterile aseptic technique, such as during catheter insertion or at any time a dialysis catheter is handled/manipulated. [32],[33],[34] Wearing gowns (fluid-resistant with full coverage of the arms and body front and preferably disposable ones) over the uniform and use of a face mask and eye goggles or face shield is recommended when performing procedures wherein splashes of blood can be anticipated, especially during initiation and discontinuation of dialysis. [22],[25],[31] If a face shield is used during catheter handling, a surgical mask should be worn underneath to protect the patient from the HCW's respiratory droplets. [22] Equally important is the fact that the patient should also wear a mask and be asked to turn his/her face away from the catheter site to reduce contamination from infectious droplets. [22],[34],[35],[36] Furthermore, wearing a mask is important when a staff member, a patient or a visitor is experiencing cold or cough. [22],[25] A respirator should be used by HCWs only when taking care of a patient with an airborne infection. HCWs uniforms can be colonized with potentially pathogenic bacteria in up to 60% of the situations, [37],[38],[39],[40],[41],[42] and, therefore, should be washed and changed daily in order to decrease the bacterial load.

Cleaning and disinfection of environmental surfaces

In the health-care setting, contamination of environmental surfaces with various pathogens and the persistence of these pathogens on surfaces [43],[44],[45],[46],[47],[48],[49] can be an important and frequent source of transmission of infectious agents through the frequent hand touching of HCWs. [50],[51] The environment in HD units is particularly prone for contamination with blood-borne pathogens such as HBV, HCV and HIV, and other infectious agents such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE) and Clostridium difficile. Microorganisms can survive on environmental surfaces for varying periods of time, ranging from few hours to days and months. Low temperature, high humidity and high inoculums favor the long persistence of pathogens on inanimate surfaces. [43] In order to prevent and control the spread of environmentally transmitted pathogens, cleaning and disinfection of the external surfaces of equipment (i.e., HD machine, dialysis chair or bed, procedure trolley) and other environmental surfaces inside the HD units, especially those that are frequently touched by patients and staff, should be performed between all patient treatments (irrespective of the patient diagnosis). [22],[31],[34] The application of friction during cleaning is emphasized as some organisms like C. difficile are not easily inactivated by most surface disinfectants (except bleach) and require removal by friction. [22],[25]

Cleaning and disinfection of external surfaces of HD machines

It is recommended to clean and disinfect the external surfaces of the HD machine after each dialysis session. [22],[31],[34] A low-level disinfectant or any EPA-registered disinfectant solution labeled for use in a health-care setting is recommended to be used on non-critical items (including HD machines), and should also be in accordance with the machine manufacturer's recommendations. [52] The presence of bio-burden will reduce the killing/inactivating effect of disinfectants. Therefore, if visible blood spills or other infectious material is present on the external surface of an HD machine, it should be cleaned separately (not to spread) before applying the disinfectant solution. In such cases, it is recommended to use an intermediate-level disinfectant or tuberculocidal agent (with specific label claims for HBV and HIV) or a 1:100 dilution of a hypochlorite solution (500-600 ppm free chlorine). [52] If using disinfectant wipes, one wipe should be used to exclusively clean the blood stain followed by another wipe(s) for disinfection. All external surfaces of the machine, especially the frequently touched front panel, including the intravenous pole, the side, back and base, should be thoroughly cleaned and disinfected using friction and be allowed to air dry. [22] All used towels or wipes and gloves that are contaminated with blood should be discarded in a biohazard waste container, and hand hygiene performed after glove removal.

Disinfection of the internal fluid pathway of hemodialysis machines

The CDC and APIC guidelines do not suggest the disinfection of internal fluid pathways of "single-pass" HD machines between patient uses, except when a blood leak event occurs. Routine disinfection and rinsing is recommended at the beginning or end of the day (or as recommended by the machine's manufacturer). [22],[31] The EBPG recommends routine disinfection of the HD-proportioning machine after each dialysis session either by heat or a chemical agent. [53] Chemical disinfection prior to patient use is recommended for standby machines, which could be inactive for variable periods of time and potentially develop bacterial growth. [22] The chemical disinfection protocol should be according to the machine manufacturer's recommendation, including the concentration and dwell time. [22]

Cleaning and disinfection of auxiliary equipment

Auxiliary equipment used in HD may include reusable jugs for mixing bicarbonate solution, reusable priming buckets and external pressure transducers. As per recommendation, any re-usable item should be cleaned and disinfected prior to being used on another patient, and external pressure transducers should be changed between patients' uses. Nowadays, many units have shifted to using the more hygienic automated process of mixing bicarbonate powder in cartridge on the individual machines, eliminating the use of reusable bicarbonate jugs. If bicarbonate solution in a jug is used, any "leftover" solution must be discarded and opened jugs should not be used after 24 h because sodium bicarbonate solution constitutes a good media for bacterial growth. [22] Reusable priming buckets are now seldom used as most dialysis companies include a disposable prime collection bag in each pack of sterile bloodline set and also with pre-attached external pressure transducers. With improved and better technology in some of the newer models of HD machines, prime collection bags or transducer protectors are not even required, because drainage of priming solutions can be done by connecting the bloodline to a drainage port in the machine and blood pressure sensors are completely non-invasive without using transducer connections and protectors.

Handling of disposable supplies and reusable items in HD units

Both CDC and APIC have recommended specific measures that include the following: (a) items taken into an individual patient's HD station should be used only for that patient and be disposed off after use, (b) unused item(s) should be cleaned and disinfected before returning to a common clean area or used on another patient, or be disposed off if it cannot be disinfected and (c) non-disposable items that cannot be comprehensively cleaned and disinfected (e.g., adhesive tape, cloth-covered blood pressure cuffs) should be dedicated for use on a single patient. [22],[31] In reality, allocating a blood pressure cuff for each patient may not be practical as too frequent detachment and re-attachment of the cuff can cause imminent damage to the line connections. Reusable blood pressure cuffs that are covered with waterproof material with a smooth surface (instead of cloth-covered cuffs) can be an attractive alternative as they can be comprehensively cleaned and disinfected between patient uses. There should also be a clear separation for storage and handling of clean supplies and medications from contaminated items (i.e., used supplies/equipment, blood samples, biohazard containers).

Water treatment: Purity and testing

Water quality is an essential component in the provision of good HD and in ensuring patient safety. This is especially the case in the settings of high-flux HD, hemofiltration and/or hemodiafiltration due to possible entrance of contaminants from the dialysis fluid into the blood by either convective transfer (back-filtration) or movements down the concentration gradient (back-diffusion) or the direct infusion of substitution fluid into the circulation. Failure to meet water quality standards has major consequences and may lead to increased patient morbidity and mortality. Studies have demonstrated that ultrapure dialysis fluid is associated with a reduction in inflammatory markers, reduced chronic inflammation, decreased erythropoietin resistance, preservation of residual renal function, a reduction in cardiovascular morbidity, a reduction in β2-microglobulin amyloidosis and decreased levels of advanced glycation end-products. [54],[55] Both CDC and APIC recommend adherence to the standards set by the Association for the Advancement of Medical Instrumentation (AAMI) for the quality of water used in dialysis. Fluids used for dialysis can be divided into three levels according to microbiological quality: Standard, ultrapure and sterile. The maximum allowable levels of microbiological contaminants and endotoxin in each level are summarized in [Table 3]. [56] "Online" prepared solutions that are used as substitution fluids and priming solutions (intravenous infusion) during hemofiltration and hemodiafiltration are considered as drugs and, therefore, should be sterile and non-pyrogenic. [56],[57],[58],[59] The quality of the fluid before the final filter (from the first bacteria- and endotoxin-retentive filter) and the functioning of this filter both determine whether the final fluid can be referred to as sterile and non-pyrogenic. [57] In this case, the fluid sample for micro-biologic testing should be taken from the dialysate sampling port (fluid that has passed only from the first filter). If the dialysate sample meets the standard for ultrapure water, then the substitution fluid (fluid that passed the second filter) can be assumed as sterile. Others insist that one other condition must be fulfilled in order to achieve a sterile fluid: A sterile, single-use filter must be used for the final filtration step, which is according to the definition in pharmacopoeias. [58] Frequent heat disinfection of the distribution loop is the preferable method to prevent formation of bio-film. Testing of product water of in-center reverse osmosis (RO) for bacteria and endotoxin assay are required at least monthly, [22],[56] and on a quarterly basis for portable RO or in a home setting. [22] To avoid false-negative results, fluid sampling for microbiological testing should be performed no sooner than 24 h after disinfection and, when disinfection is performed on consecutive days (or more frequently), samples should be taken before and as close as practicable to a disinfection procedure. [56] Analysis results from poor cultivation technique used by the laboratory can be misleading and may expose patients to high risks of adverse reactions. Suitable cultivation techniques are shown in [Table 4].
Table 3: Maximum allowable levels for total viable microbial count (TVC) and endotoxins in dialysis water, in standard and ultrapure dialysis fluid (dialysate) and online-prepared substitution fluid.

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Table 4: Cultivation techniques for dialysis water and dialysis fluids.

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Safe injection practices

Aside from the basic principles of aseptic technique, there are specific complementary recommendations for HD published by the CDC and APIC, which include the following: (a) all single-use injectable medications and solutions should be dedicated for use on a single patient and be used one time only, (b) medications packaged as multi-dose should be assigned to a single patient whenever possible, (c) medication preparation should occur in a clean area away from the patient treatment area, and be delivered separately for each patient, (d) to not carry multi-dose vials from station to station or carry medication vials, syringes, alcohol swabs or supplies in pockets, (e) unused medications or supplies taken to the patient's station should be used only for that patient and should not be returned to a common clean area or used on other patients, (f) to not use common medication carts to deliver medications to patients and, if trays are used to deliver medications to individual patients, they must be cleaned between patients. [22],[31],[60] The CDC's full recommendations on safe injection practices are shown in [Table 5].
Table 5: Key recommendations on safe injection practices in ambulatory care settings.

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Vascular access: Care and prevention of infection

Infection rates with tunneled dialysis catheters has been estimated to be 10-times higher than that of arteriovenous fistula (AVF) or AV graft, [22] and is found to be the leading risk factor of bacteremia in chronic HD patients. [61] The international bodies are in concert with the guidelines that vascular access should be a native AV fistula whenever possible, AV graft as the next preferred option and the use of catheters to be avoided as much as possible. [22],[33],[34],[35],[36],[62] Vascular access infection prevention measures unanimously recommended by the international bodies are outlined in [Table 6], and varying messages on dialysis catheter recommendations are outlined in [Table 7]. The relevance of "rubbing and soaking the catheter hub with the cap on with a povidone iodine swab for 3-5 minutes before the cap is removed" (as recommended by KDOQI) is understandably to disinfect the outside surface, thereby preventing inadvertent contamination of the inner hub and the resultant bloodstream contamination. In the 2011 update of the CDC Guidelines for the Prevention of Catheter-Related Infections, scrubbing of the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor or 70% alcohol) was recommended for needleless intravascular catheter systems. [62] The routine scrubbing of dialysis catheter hubs (after cap removal before accessing and before replacing a new cap) with an appropriate antiseptic was included as part of a recent CDC's core interventions for dialysis bloodstream infection (BSI) prevention [Table 8]. [63] Dialysis providers are cautioned to avoid inadvertent introduction of the used antiseptic solution into the bloodstream. [64] In an in vitro study by Salzman et al, the potential for the antiseptic used in cleaning the open catheter hub as well as few strands of cotton fibers to enter the blood-stream (simulated) and the effectiveness of normal saline solution (used as control) to reduce the microbial load at a level greater than 99% of the total number of microorganisms (suggesting mechanical removal) was demonstrated. [65] The cumulative effect of minute residues of toxic antiseptics and foreign substance that may get into the patient's bloodstream when applied repeatedly on open catheter hubs among chronic HD patients have not, and may not, be studied. Therefore, it is prudent to choose a safe and non-toxic solution for cleaning open catheter hubs and to emphasize the application of friction while cleaning (scrubbing not just wiping).
Table 6: Common recommendations on vascular access infection prevention.

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Table 7: Varying insructions on catheter-related infection prevention strategies.

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Table 8: The Center for Diseases Control core interventions for dialysis bloodstream infection (BSI) prevention.

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Because HD patients are more immune compromised than other surgical patients, pre-surgical infection prevention measures are recommended, which include: (a) pre-surgical shower/bath with an antiseptic agent such as chlorhexidine, the night before and morning of surgery, (b) if hair removal is necessary, to use clippers instead of razors to prevent infection associated with micro-abrasions resulting from razor use and (c) avoiding intravenous placements and phlebotomy in the arm where access is to be placed (helps prevent infection and maintains vasculature integrity). [22] Screening and decolonization for MRSA before an elective surgery may be used as an additional measure.

Screening/routine serologic testing and patient placement

The international bodies unanimously recommended that all HD patients should be screened for HBV and HCV infection on admission, and routinely tested thereafter. However, they differ with regard to testing for HIV infection. Recommendations for screening/routine testing and patient placement are shown in [Table 9]. Testing for HBV is required for the purpose of isolating the HBV-infected patient and for vaccination and monitoring of susceptible patients. To avoid an erroneous diagnosis of acute HBV infection, which may put the patient at risk when inappropriately taken for treatment in an HBV isolation room, care should be taken to ensure that blood sample for HBsAg testing is not drawn within two to three weeks after the administration of an HBV vaccine because, during this time, HBsAg may be detected (known as "transient antigenemia"). [22],[66],[67],[68] The testing for HCV is to identify infected patients, who may be considered as treatment candidates, and to monitor any occurrence of seroconversion to HCV. Screening of all HD patients for tuberculosis (TB) is also recommended by the APIC, CDC, KDOQI and ERBP, which should be done at baseline and whenever exposure is suspected, using the tuberculin skin test (TST) or blood test. [22],[69],[70]
Table 9: Recommendations on hepatitis B virus, hepatitis C virus and human immunodeficiency virus screening/testing and patient placement.

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Except for HBV isolation, the APIC, CDC and KDIGO did not recommend the segregation/isolation of HCV- and HIV-infected patients during HD treatments, [22],[31],[71] due to the following reasons: (a) HCV and HIV are not transmitted as efficiently as HBV (viral titer in the infected patients' blood and the virus' viability on environmental surfaces are much less as compared with HBV) and (b) standard precautions and the specific measures of infection control recommended for HD units are considered to be sufficient to prevent their transmission. However, treatment of HCV-positive patients in separate areas with dedicated staff is recommended by the EBPG in 2002 in units with a high prevalence of HCV infection, which has been reiterated in the 2009 ERBP position statement. [34],[72]

These viral diseases, however, remain a potential risk to both HD patients and staff for the following reasons: (a) there is no vaccine as yet to confer immunity for HCV and HIV, (b) the incidence of chronic persistent infection after an acute episode is high in both HCV (80-90%) and HIV (100%), (c) the prevalence of patients with chronic HCV is currently higher than that of HBV, and is much higher among the HD population, (d) the consequence of having a chronic infection with either HCV or HIV can be severe and/or fatal and (e) of utmost significance is the fact that implementation of standard precautions and stricter measures of infection control recommended for HD units cannot always be guaranteed to be consistently and reliably adhered to. Even in HD units with an "ideal set-up," unintentional breach of recommended infection control practices (i.e., as hand hygiene) do occur, especially at times when urgent interventions are required.

Many studies have proven that segregating HD patients according to their virology status have resulted in a decrease in the incidence and prevalence of infections. [73],[74],[75],[76],[77],[78],[79],[80],[81] By simple logic, this can be attributed to the physical barrier that prevents exposure of susceptible patients to patients who have identified infection/colonization with pathogenic microorganisms. The staff movements between susceptible and infected patients will definitely be prevented, as well as the sharing of possibly contaminated equipment and other items. Another strategy that can be used is the "temporal segregation," wherein patients who are suspected of being infectious are dialyzed in the last shift. [82] This simple and low-cost strategy is effective in preventing the immediate exposure of other susceptible patient(s) to possibly contaminated environmental surfaces and equipment used by a source patient. Also, the time factor (allowing more time before reusing the equipment and treatment area for another susceptible patient) may add to the effect of disinfection in attenuating the level of contamination.

Routine application of contact precautions in HD units has not been recommended by the CDC and APIC for patients infected or colonized with pathogenic bacteria for the following stated reasons: (a) transmission of pathogenic bacteria has not been well-documented in HD centers, (b) contamination of the patient's skin, bedclothes and environmental surfaces with pathogenic bacteria is likely to be less in outpatient HD units where patients spend less time (12 h/week) as compared with patients admitted in hospitals (24 h a day) and (c) the infection control practices recommended for HD units are more stringent than the standard precautions routinely used in hospitals, and should prevent transmission by the contact route. [22],[31] However, additional precautions are recommended for patients who are considered risky for transmitting pathogenic bacteria, such as those with an infected skin wound with drainage (the drainage does not have to be culture positive for VRE, MRSA or other specific pathogen), incontinence or diarrhea. These include (a) dialyzing the patient at a station with as few adjacent stations as possible (e.g., at the end corner of the unit), (b) staff members treating the patient should wear a gown over their usual clothing, remove and dispose the gown properly when they finish caring for the patient and (c) staff should not care for other susceptible patients at the same time. [22],[31]

As one component of standard precautions, respiratory hygiene/cough etiquette should be implemented all year round at the first point of contact with individual(s) who are coughing or potentially having any kind of respiratory infection. Outpatient facilities are recommended to post at the facility entrance visual alerts (clear and simple instructions, in appropriate languages) instructing patients and visitors to inform health-care personnel of symptoms of respiratory infection, and to follow recommended measures, which include (a) covering the mouth and nose with a tissue when coughing or sneezing, (b) to dispose used tissues in the nearest waste receptacle and (c) to perform hand hygiene (use of alcohol-based hand rub or hand washing) after contact with respiratory secretions and/or contaminated objects/materials. To promote compliance, the dialysis facilities should provide required materials in waiting areas as well as in treatment areas, which include supplies of tissues, pedal-operated waste receptacles, conveniently located alcohol-based hand rubs and supplies for hand washing where sinks are available. Symptomatic patients are offered face masks and segregated preferably in a single room, or as far as possible from others (at least 3 feet away) in common waiting areas. [25] Based on the current recommendations, the patient is preferably dialyzed in a single room and instructed to observe respiratory hygiene/cough etiquette. If not possible, then dialyze in an area with few adjacent stations with a spatial separation of 3-6 feet from other patients, and the curtain drawn around to separate and minimize contact with other patients. [25] The health-care worker caring for the patient should wear a surgical mask and perform hand hygiene as indicated (droplet precautions). Only immune staff should care for patients with vaccine-preventable diseases such as mumps, rubella and diphtheria. [22],[25]

The current belief is that influenza virus is spread by large particles that travel up to 3-6 feet from the infected person. However, several recent studies have indicated that a major part of emitted influenza virus from infected individuals are carried in smaller particles (<5 μm in diameter) during normal breathing and talking, which supports the idea of an airborne transmission. [83] Studies have shown that a surgical mask worn by an individual having influenza can significantly reduce the release of even the smallest droplets containing infectious virus, and is therefore an effective means of limiting the spread of influenza. [83] Health-care facilities should adhere to the current recommendations until further research can confirm all pathways of influenza virus transmission and recommendations are updated. [84]

Patients identified with a suspected airborne disease should be made to wear a mask immediately on arrival and geographically separated from other patients, preferably in a single room with the door closed and the health-care worker assigned to care for the patient should wear a properly fitted respirator (airborne precautions). Arrangements should be made for HD treatments at a facility that have an airborne infection isolation room (AIIR), which is equipped with monitored negative air pressure (12 air exchanges per hour for new construction and renovation and six air exchanges per hour for existing facilities; air exhausted directly to the outside or re-circulated through HEPA filtration before return); the patient may remove the mask once in an AIIR. If not on an AIIR, the mask should remain on; after the patient leaves, the room should remain vacant for at least one hour to allow for a full exchange of air. [25] It is recommended to assign staff with documented immunity to care for patients with vaccine-preventable airborne diseases such as measles, chickenpox and smallpox. [22],[25]

Immunization of patients and health-care personnel

Recommended immunization of patients with chronic kidney disease (CKD), especially those that are dialysis-dependent, include at a minimum (a) hepatitis B vaccine, (b) pneumococcal vaccine and (c) influenza-inactivated vaccine (IIV). [85] Other vaccines recommended for healthy individuals may be used if otherwise indicated, except for any live attenuated vaccines that are generally contraindicated in patients who are immune compromised. [85],[86],[87] Doses and schedules of licensed hepatitis B vaccines for HD patients is shown in [Table 10], and guidelines for administering recommended pneumococcal vaccines for adults with CKD is shown in [Table 11]. Recommended immunizations for dialysis personnel include: (a) Hepatitis B vaccine (b) Influenza vaccine, (c) Measles, mumps and rubella (MMR) vaccine, (d) Varicella vaccine and (e) tetanus, diphtheria with acellular pertussis (Tdap) vaccine [Table 12]. [86],[87],[88],[89] Hepatitis B vaccination is specifically recommended for susceptible health-care workers at risk for exposure to blood and body fluids (e.g., hemodialysis personnel). [88]
Table 10: Doses and schedules of licensed hepatitis B vaccines for hemodialysis patients.

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Table 11: Guidelines for administering pneumococcal vaccines (PCV13 and PPSV23) for adults with chronic kidney disease.

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Table 12: Immunization of health-care personnel (based on the CDC/ACIP recommendations).

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Tracking infections

Surveillance for infections (outcome measures) and monitoring adherence to recommended infection prevention practices (process measures) are important components of an infection prevention program. To enable accurate comparison and analyses of monthly rates within the same facility or meaningful benchmarking with other units/centers, it is important that a standardized and validated surveillance protocol be used uniformly by all dialysis facilities. A centralized surveillance system for health-care-associated infections like the CDC's national health-care safety network (NHSN), which requires all participating facilities to strictly follow every specific surveillance criteria, can provide accurate and reliable data that can be used to identify problem areas as well as measure progress of prevention efforts. Implementation of the CDC's NHSN Dialysis Event Protocol (accessible online: www.cdc.gov/nhsn/dialysis) by other dialysis facilities outside the United States have been demonstrated to be feasible. Dialysis events that should be reported include (a) intravenous antimicrobial starts, (b) positive blood cultures and (c) evidence of local access site infection (pus, redness or increased swelling at the vascular access site), and data collected from these three events can generate four other types of dialysis events: Blood-stream infection (BSI), local access site infection (LASI), access-related bloodstream infection (ARB) and vascular access infection (VAI). The number of maintenance HD out-patients who received HD in the unit/center during the first two working days of the month (including transient HD patients but excluding inpatients and PD patients) should be reported on a monthly basis and according to their vascular access type. This will serve as the denominators for rate calculation. Each patient is counted only once; if the patient has multiple vascular accesses, that patient is counted with the vascular access type of highest infection risk. Rates are calculated by dividing the number of events by the number of patient-months and multiplying the result by 100. [90]

As a means to reduce infection transmission, each dialysis facility should also monitor other parameters like dialysis water and dialysis fluid cultures and endotoxin results, incidence of drug-resistant infections, hospitalizations, as well adherence to standard precautions (hand hygiene, glove use and other PPE, equipment and environmental cleaning, safe injection practices, etc.) and other recommended practices (screening for HBV, HCV, HIV and tuberculosis infections and immunizations). Regular feedback of surveillance results to everyone involved in the health-care delivery (especially the frontline staff) would help to stimulate and encourage active engagement and improve compliance with infection prevention efforts. At least one designated person with training in infection control and epidemiology (infection preventionist) should be responsible for over-sight of the program as well as education of staff and patients related to infection prevention and control. [22],[23]

Steps that should be taken to control spread of infection, especially if there is an incidence of a positive seroconversion or outbreak in the HD unit, include the following: (a) review of the laboratory test results of all patients dialyzing in the same unit to identify any additional case(s), (b) performance of additional tests as indicated in [Table 13], (c) determination/tracking of potential sources for infection, which includes (i) revision of newly infected patients' recent history of blood transfusion, invasive procedure(s) and/or hospitalization and (ii) high-risk behavior such as history of injection drug use and sexual activity, and (d) revision of HD unit's practices and procedures of infection control. [31]
Table 13: Additional testing to be performed in case of positive seroconversions.

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Employee and patient/family education

Education and training in infection prevention and control should be provided to all health-care workers upon hire, and should be repeated regularly (at least on a yearly basis). Basic principles and practices for preventing the spread of infections should be covered and staff competencies should be assessed and documented upon orientation to the facility, and this should be repeated as appropriate for the specific staff and position. [23] The patient(s) and/or caregiver(s) should also be educated on the care of new access and whenever there is a change in access type, and this should be repeated at least every year. [91] Key areas for patient education as outlined by the CDC are shown in [Table 14].
Table 14: Key areas for patient education.

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   Conclusion Top

Evidence-based international guidelines are of great value and are instrumental in helping reduce health-care-associated infections. The cornerstone toward risk reduction is to be aware and abreast with the latest guidelines and be keen in implementing them reliably and consistently, as well as being conscientious and alert/active in engaging in quality improvement projects. The decision to follow any guideline statement must be made individually, by each HD unit at different locations with varying conditions, according to the incidence and prevalence of any type of infection. However, patient's safety and well-being deserves top priority in whatever decision is to be made.

Conflict of Interest: None

   References Top

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Correspondence Address:
Dr. Ayman Karkar
Department of Nephrology, Kanoo Kidney Center, Dammam Medical Complex, P. O. Box 11825, Dammam 31463
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.132150

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14]

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