Infection Control in Dialysis Overview - Webber Training Control in Dialysis Dr. Charmaine Lok, ......

Infection Control in DialysisDr. Charmaine Lok, University of Toronto

A Webber Training Teleclass

Hosted by Paul Webber [email protected]

Infection Control in DialysisCatheter related infections

Charmaine Lok, MD, FRCPC, MScUniversity of Toronto

Hosted by Paul [email protected]

www.webbertraining.com

Overview

Focus on hemodialysis catheter-related infections

BackgroundPathogenesis & Risk FactorsEpidemiology - Clinical studiesManagement

HICSConclusions

Infection

Most common cause of morbidity2nd most common cause of death75% of infectious deaths due to bacteremiaVascular access = main source of bacteremia Central venous catheters (CVC) = highest risk≈ 50% with have CRB by 6 mosSepsis related hospitalizations ↑50% (decade)Cost = $22 000 USD /bacteremia Multiple organisms involved

Pathogenesis

Distribution of Culprit OrganismsMajority are Gram Positive organisms

Lok, CE., Advances in Chronic Kidney Disease:13(3):225; 2006

Staphylococcus Aureus

Binds to nasal mucoproteinsProduces glycocalyxToxins lead to abscess formationMuch more toxic than S. epidermidis




Staphylococcus Epidermidis

Common organism that colonizes skinLess toxic than S. aureusEnveloped by amorphous slimy materialHost serum proteins aid in productionBiofilm provides environment for increased bacterial growth

Pathogenesis

Bacteria

Patient Catheter

Skin Contamination (Extraluminal)

Touch contamination (Intraluminal)

Bacterial attachment to catheter

Biofilm Formation

More Biofilm Formation

BACTEREMIA

Nasal Carriage - S. aureus Skin surface – S. Epidermidis Pathogenesis

Sources of infection:

Skin contamination (early)Hub contamination (later)Hematogenous seeding (uncommon)Infected infusate (rare)

Extraluminal: Skin contamination Early Infection

Bacteria from exit site track down the catheter into the catheter tip

Quantitative skin cultures show increased risk of infection with increased cfu/cm2

Bertone S, Inf Cont Hosp Epi 1994




Intraluminal: Hub contamination Later Infection

Caused by touch/hub contamination

Develops later in course

Frequent problem with hemodialysis catheters

Biofilm on a Catheter

S. Aureus

emu.arsusda.gov/typesof/images/staph.jpg

Anton van Leeuwenhoek

“SCURF” and “Animalculi” Biofilms




The Biofilm Micro-cosm




Biofilm Formation


BACTEREMIA

Nasal Carriage - S. aureus Skin surface – S. Epidermidis


Lessons from Peritoneal Dialysis

Instructions for PD exchange & catheter access:

Remove petsShut doorPut on maskCut off circulating air – cover or close ventsWash hands for 3 minutes

What precautions do your nurses, technicians, patients and colleagues follow in the Hemodialysis unit?

Epidemiology

Staphylococcal Infection

Annual incidence of SA bacteremia ≈ 6- 27%S. aureus bacteremia in HD ≈ 0.6- 3.9/1000 days23% hospitalized in ICU21% require re- admission within 3 months

70% of due to recurrent bacteremiaDeath at 12 weeks: 13%- 20% 88%: Vascular access is the source of bacteremia Avg Cost = $22 000 /uncomplicated bacteremia Avg Cost = $32 000 /complicated bacteremia

Costs and complications increase when MRSA +veEngemann,et. al. Infect Control Hosp Epidemiol, 2005; n=210, 1994-2001; Kaech Clin Microb Infect, 2006

Staphylococcal Infection

3%Stroke

31%Any

35%19%Mortality (12 weeks)

5%Septic Emboli

5%Septic Arthritis

6%Osteomyelitis

17%Infective endocarditis

MRSASAComplication

Engemann,et. al. Infect Control Hosp Epidemiol, 2005; n=210, 1994-2001

Reed,et. al. Infect Control Hosp Epidemiol, 2005; n=54 (143 total) 1996-2001

?

Nissensen, AJKD, 2005, n=11572, USRDS




US HD Patient Mortality 2002-2003

Annual mortality 23.5 /100 pt-years

Cardiac arrest 5.5Septicemia 2.6MI 1.9Stroke 1.2

Table H.29 Unadjusted Mortality.

USRDS 2005 Annual Report

Mortality & Bacteremia

In the USA in 2004308000 HD patientsCatheter rate ≈25% (now 1/3)81,000 pts with CVCCRB rate average 2/1000 days (0.5-5.5/1000 days)

(0.73 infection/pt- year)Mortality from bacteremia 10% (up to 20%)5913 deaths/year from bacteremia

Mortality and Sepsis

Foley et. al, JASN 15:1038, 2004

N=393 451MI

Sepsis

No Sepsis

Morbidity, Cost, Mortality

USRDS retrospective study (1996-2001)S. aureus vs. other bacteria11,572 S. aureus admissions

<.0013.8%13.5%Mortality

<.001$15,965$17,307Cost(Index admission)

<.0019 ± 1013 ± 13LOS

P valueOtherS. Aureus

Nissenson AR, AJKD 2005

Increase in Staphylococcal Infections

Foley et. Al, JASN, 2004

N=393,451

11%/1st yr

Of HD ↑51%

↑39%

Dialysis Surveillance Network (CDC)

1999Volunteer outpatient dialysis centersInternet-based systemData from 321,519 patient-months

Finelli, Semin Dial 2005

76%40%MRSA

30%12%VRE

20021995Centres with at least 1 case

Klevens, RM. NN&I 2005




Dialysis Surveillance Network (CDC)

Purposes

To provide a method for HD centers to record & track rates of vascular access infections, other bacterial infections, & IV antimicrobial startsTo provide rates for comparisons among various dialysis centers (benchmarking); Rate: 1.5/1000To use these data to motivate practice changes & to prevent infections, especially those caused by antimicrobial resistant organisms

ww.cdc.gov/ncidod/dhqp/index.html for protocols

Canada

Canadian Nosocomial Infection Surveillance ProgramNetwork of Canadian hospital that carries our surveillance examining the frequency & risk factors for hosp acquired infectionsMultiple publicationsHD units

Catheter related bacteremia (CRB)

8%Enteroccoci

10%Gram Negative

8%Mixed

40%Coag Neg Staph

32%S. Aureus

82%Gram Positive

PercentageOrganism

Taylor, G. Infect Control Hosp Epidemiol 23:716-720, 2002

CRB Risk factors

Catheter site: Femoral>IJ > subclavianCatheter characteristic: Non- cuffed vs. cuffed, Non- tunneled vs. tunneledProlonged duration of catheter usePrevious bacteremiaThrombosis of the catheterPatient “stressed state”

Recent surgeryDiabetesImmunocompromised

Poor hygiene

Epidemiology:

Clinical Prevention Trials

Extraluminational CRB prophylaxisElimination of Nasal Colonization:

Single courses of intranasal mupriocin +/- other

Problem: Effective but recurrence after 3 mos

Multiple, intermittent coursesProblem: Mupirocinresistance







Biofilm Formation


BACTEREMIA

Nasal Carriage - S. aureus Skin surface – S. EpidermidisMupirocin

Extraluminal CRB prophylaxis

Elimination of Exit Site Colonization:Prevention of hemodialysis subclavian vein catheter infections by topical proviodine–iodine (Levin, A. et. al. KI1991, RCT)

Prophylaxis of HD CVC with mupirocin (Sesso R. et. al., JASN 1998; Johnson DW et. al, Nephrol Dial Transplant 2002, nonblindedRCTS)

Prophylaxis of HD CVC with Honey (Medihoney)(Johnson D.W., JASN 2005; nonblinded RCT-no difference vs mupirocin)

Only selected honeys have activity: manuka honey (New Zealand) & Leptospermum honey (Australia)γ Sterilization (Clostridium botulism found in honey)

Death

Bacteremia

16%

2.48

Placebo

4%

0.63

PT

78%

60%

RRR

P=0.0048

P<0.00047

P valueNNT

* Number of events/1000 catheter days

A Reduction in catheter exchanges & hospitalizations

seen in PT group (P< 0.05)

Extraluminal CRB prophylaxis

DB RCT Prophylaxis of HD CVC with Polyantibiotic (Lok C.E., JASN 2003)




Biofilm Formation


BACTEREMIA


Topical Antimicrobial


Intraluminal CRB Prophylaxis

Antibiotic Lock Prophylactic Therapy (ABL)Developed in late 1980’s for TPN ptsVancomycin and amikacin

[luminal] 40- 80 & 60- 120 x systemic peak [blood] with conventional dosing[ ]Maintained 8- 12 hrs, stable & active 12 hrs

HD patients: ↓ CRB (interdialytic lock)

Prophylaxis with ABL solutions: RCT

0.44/1000 (Gent-Cit) vs.3.12/1000 (hep)

Cefazolin 10 mg/ml, Gentamicin 5 mg/ml +hep 1000 U/ml vs. hep only

N=120 TCCRB- 2 cultures pos same org (tip, CVC or periph)

Kim (KI 2006)

0% CRB (minoc-EDTA)8.3% (hep) NS;9.1% vs. 64.3% colonizn

Minocycline 3 mg/ml & EDTA 30 mg/ml vs.Heparin (concentration?)

N=57 TCCRI; thrombosis; both

Bleyer(ICHE 2005)

0.31/1000 (gent-hep) vs.

4.0/1000 (hep)

Gentamicin 5 mg/ml & heparin 5000 u/ml vsheparin 5000 u/ml

N=50 PCCRI by CDC definitions

McIntyre(KI 2004)

0/1000 CRB (Gent-cit) vs.2.6/1000 (hep)

Gentamicin 40mg/ml & Citrate 3.13% vs. heparin 5000 u/ml (+ intranasal mupriocin)

N=112 PC (83 pts)

CRI by CDC definitions

Dogra(JASN 2002)

ResultsStudy RxN/ EndpointAuthor




Concerns with ABL

Microbial resistanceSystemic leakage of Abx

Ototoxicity with AMGsIf lumen colonized with intrinsically R strains, overgrowth of resitant strains may occur when Abx susceptible organisms are suppressed

Physical & chemical compatibilityAnticoagulantCatheter material

Are ABL Indicated?

Artificial Heart ValvesPacemakerInternal defibrillatorsFemoral cuffed cathetersRecurrent infections with limited access

Anti-microbial Locks

Double blind trial: Citrate vs. HeparinNewly inserted catheters291 HD patients with CVC randomized

WeijmerJASN 2005

.00528%46%Catheter Removal

.02805Patient Deaths

<.0011.14.1CRB

P ValueCitrateHeparin

Taurolidine & citrate ↓ CRB (Betjes NDT 2004; Allon CID, 2003)




Biofilm Formation


BACTEREMIA




Catheter Locking Solution



What can I do?

Get rid of those catheters!Educate patientsMeasure and monitor bacteremia rate in your unitFollow universal infection control precautionsPharmacy)

Topical antimicrobial usagePrescribe antimicrobial or ABL solutions (from Pharmacy)

Appropriate antibiotic use & avoid resistance

Overriding Management Principles

Avoid CVC as much as possiblePreserve anatomy for permanent access placement

Always culture first before administering antibiotics → be clear and specific in ordersAlways follow up with sensitivitiesCatheter specific strategies dependent on clinical situation




Management Strategies for CVC Related Bacteremias

Catheter “salvage” Salvage + adjunctive antibiotic lockCatheter exchangeCatheter removal + delayed replacement

Concurrent IV antibiotics for all strategies

HICS

Hemodialysis Infection Control Subcommittee

HICSVA Coordinator

NephrologistInfection Control

Practitioner

Pharmacist

Student HICData Manager

Microbiologist

HICS: What we do

HD infection surveillanceSpecifically Vascular AccessExpanding

Identify & confirm suspected infectionsFU cultures, clinically exam patients prnHealth Canada guidelines

Guidance for managementBenchmarkingDevelop procedures & protocolsEducate nurses, physicians, patients

Identifying causative organisms

0

20

40

60

80

100

Percentage

Gram-positive Gram-negative Polymicrobial

Organism Type

Bacteremia

Exit Site Infection

Tracking Management Outcomes

36.0%Hospitalization for infection56.1%Catheter salvage43.9%Catheter removal

4.4%Recurrence at 3 months

1.8%Death

3.5%Infectious complications (septic arthritis)3.5%Recurrence at 6 months

77.2%Successful treatment

Treatment Outcomes




Duration of Treatment

0 5 10 15 20 25 30 35

S. aureus

CoNSt

Gram-negative

Fungal

Days of therapy

Organism

Duration of treatment required for maximum cure

Tracking Antibiotic Resistance

0%0%Resistance to Resistance to tobramycintobramycin

(1/11) 9.1%(1/11) 9.1%

(30/44) 68.2%(30/44) 68.2%

Resistance to Resistance to cefazolincefazolin

Resistance to vancomycin

GramGram--negative negative organismsorganisms

0%Staphylococcus aureusStaphylococcus aureus

0%CoagCoag--negneg. . StaphylococciStaphylococci

Selected Pathogen Resistance

Tracking Infection Rates

Catheter Related Infection Rates

00.20.40.60.8

11.21.41.6

2000 2001 2002 2003 2004 2005 2006*

Year

Even

t/100

0 CV

C da

ys

BacteremiaESITotal

* Jan-July only

CQI: Track Outcomes & RectifyBlood Stream Infection Rates

00.2

0.40.6

0.81

1.21.4

2003 2004 2005Year

Infe

ctio

n R

ates

/ 100

0 lin

e da

ys

BSI definite+Probable+PossibleBSI Definite+ Probable

PST

Problem

Follow guideline recommendation to have database to track VA use & outcomes

Non-access related infections

Lower/upper respiratory tract infectionsHIV infectionCentral Nervous system infectionGI tract infectionGenitourinary infectionCellulitis and osteomyelitisInfections due to highly drug- resistant organismsTuberculosis (new and reactivated)

Summary

Staphyloccocal infections are associated with great morbidity, mortality & costMonitoring & benchmarking infections in your own unit is important (DSN)The pathogenesis involves an intraluminaland/or extraluminal sourceOrganism attachment & biofilm formation =common pathwayPreventative strategies should targeted to pathophysiologyGet rid of those catheters!




AVOID THIS!

The Next Few TeleclassesMay 17 Ethics of Care During a Pandemic

… with Dr. Eric Wasylenko, Calgary Health Board

May 24 Importance of Vaccination Among Dialysis Patients… with Dr. Matthew Arduino, CDC

May 31 Evaluation and Management of Infectious Disease Outbreaks in Nursing Homes… with Dr. Chesley Richards, CDC

June 7 Infection Control in the Living and the Dead: The Angola Marburg Outbreak… with Dr. Adriano Duse, University of the Witwatersrand

June 20 Central Venous Lines and Prevention of Infection… with Dr. Steven Chambers, Australia

For the full teleclass schedule – www.webbertraining.comFor registration information www.webbertraining.com/howtoc8.php

Infection Control in Dialysis Overview - Webber Training Control in Dialysis Dr. Charmaine Lok, ......

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