There and Back Again: Relearning Infection Control

Matthew J. Arduino, M.S., Dr.P.H.

Division of Healthcare Quality PromotionNational Center for Preparedness, Detection and

Control of Infectious DiseasesCoordinating Center for Infectious Diseases

The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for DiseaseControl and Prevention

Outline

Introduction Bloodborne Pathogens

Hepatitis B Hepatitis C Hepatitis D Human Immunodeficiency Virus (HIV)

Tuberculosis Drug Resistant Microorganisms (MRSA, VRE, VISA,

VRSA) Dialysis Unit Precautions

Background October 20, 1972 Richard Nixon signed the

Social Security Amendments of 1972; Extended Medicare coverage to patients with chronic renal failure.

July 1973 patients became eligible for Medicare. Conditions of Coverage, first established in

1976 AAMI End Stage Renal Disease and

Detoxification Committee formed in 1981

Hemodialysis Numbers, 1982-2002

4,035

2,116

1,051

263,820

159,267

65,765

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

1982 1992 2002

0

50,000

100,000

150,000

200,000

250,000

300,000

Number of Dialysis facilities Number of Patients

Nu

mb

er o

f D

ialy

sis

Fac

ilit

ies

Nu

mb

er of patien

ts

So where are we today as related to infection control?

Infection Control added to conditions for coverage Incident transmission of hepatitis C and B (anti-HCV

screening is not recognized by CMS as an infection control issue)

Dialysis patients are sentinel population for antimicrobial resistance

Prevalence of MRSA and VRE is unknown Dialysis patients have an extremely high incidence of

invasive MRSA, more than 100-fold greater than the general U.S. population.

Breaks in Infection Control Not cleaning blood spills or splatters;

including prime buckets on side of machine

Not cleaning or disinfecting commonly touched environmental surfaces between patients (e.g. machine, chair or station)

Sharing equipment and supplies that were not disinfected; shared multidose vials placed on the top of the machines

Sharing a common medication cart

Bacterial/Fungal Infections Vascular access related Contaminated machines Reuse related Contaminated IV

medications

Contaminated Machines:Waste Handling Option

Several outbreaks since 1995 (U.S., Canada, and Israel) Enterobacter cloacae, Pseudomonas aeruginosa,

Escherichia coli, Candida parapsilosis Recent cluster in Chicago Phialemonium curvatum

(two patients sequentially on the same machine became fungemic, WHO port was removed prior to the investigation); Phialemonium was isolated in the water feeding the machine

Reuse Related Bacteremia/Fungemia

Organisms: Burkholderia cepacia complex, Ralstonia pickettii, Ralstonia mannitolytica, Stenotrophomonas maltophilia, Candida parapsilosis

Today most reuse related infections are associated with header removal “Header-sepsis”

In the past, most were associated with either poor water quality, or manual reuse

Drug Resistance an Emerging Infectious Disease Emergency

Resistance to antibiotics is becoming an increasing problem in healthcare delivery systems

Organisms with major public health importance include:

– Methicillin resistant Staphylococcus aureus (MRSA)– Multiply Drug Resistant Mycobacterium tuberculosis– Penicillin resistant Streptococcus pneumoniae– Vancomycin Resistant Enterococci (VRE)– Vancomycin Resistant Staphylococcus aureus (VISA)

Vancomycin Intermediate-Resistant S. aureus (VISA)

State, Year Site PD/HD*Michigan, 1997 Peritonitis Chronic PDNew Jersey, 1997 Blood Recent PDNew York, 1998 Blood Chronic HDIllinois, 1999 Endocarditis Chronic HDMinnesota, 2000 Bone Chronic HDNevada, 2000 Liver -----Maryland Blood -----

PD=peritoneal dialysis HD=hemodialysis

Fridkin Clin Infect Diseases 2001

First Case of Vancomycin - Resistant S. aureus (VRSA)

First fully vancomycin resistant clinical isolate of S. aureus

Michigan, June 2002 40-year old black female with diabetes mellitus,

peripheral vascular disease,on chronic hemodialysis

VRSA from foot ulcer and catheter exit site During the 6 months preceding VRSA:

patient experienced 6 hospitalizations, totaling 18 days patient received multiple antimicrobial therapy, including 5.5 weeks of vancomycin

Chang S et al, New England J of Med 2003; 348:14,1342-3447

Vancomycin Resistant S. aureus

9 cases of VRSA since 2002 (7 in Michigan, 1 PA, 1 NY)

Two were dialysis dependent (Including index case)

Most patients diabetics Infected wounds MIC vancomycin > 16µg/mL Acquisition of VanA gene: many cases shown to

have a VRE donor and MRSA recipientZhuW, et al. Vancomycin-Resistant Staphylococcus aureus Isolates Associated with Inc18-Like vanA Plasmids in Michigan. Antimicrob Agents Chemother 2008;52(2):452-7.

Resurgence of HBV outbreaks in the mid 1990s

Failure to review lab results; HBsAg+ patients treated with susceptible patients

Failure to isolate HBsAg+ patients

Sharing of staff, equipment, medications, and supplies among patients

Failure to vaccinate susceptible patients against hepatitis B

CDC. Hepatitis-Control measures For hepatitis B in dialysis centers. Viral hepatitis and Control Series, November 1977. HEW Publ No (CDC) 78-8358

What we have learned from our annual surveillance

In 2002, the incidence of HBV infection was higher among patients in centers where injectable medications were prepared on a medication cart or medication area located in the treatment area compared to a dedicated medication room.

Centers that used a disposable container versus a nondisposable container for priming the dialyzer had a significantly lower incidence of HCV.

Blood Contaminating a Pressure Transducer Filter

Have we forgotten the basics?

Bloodborne Pathogens Hepatitis B, C, and D Viruses Human Immunodeficiency Virus

(HIV/AIDS)

HBV HCV HIV

Estimates of Acute and Chronic Disease

Burden for Viral Hepatitis, United States

Acute infections(x 1000)/year* 125-200 140-320 35-180 6-13

Fulminant deaths/year 100 150 ? 35

Chronicinfections

0 1-1.25 million

3.5million 70,000

Chronic liver disease deaths/year 0 5,000 8-10,000 1,000

* Range based on estimated annual incidence, 1984-1994.

HAV HBV HCV HDV

Relative Infectivity of HBV, HCV, and HIV

HBV HCV HIV

Titer/ml 108-11 105 103

Environmental Stability

++++* +** -

*Can persist on environmental surfaces for at least 7 days** Can persist for 24 hrs (CDC unpublished data)

Hepatitis B

HBV is a vaccine preventable Disease

Outbreaks of HBV in the Hemodialysis

Blood leaks Transducer protectors cross-contamination of

environmental surfaces, supplies, medications, or equipment

simultaneous provision of care to both HBV-infected and susceptible patients by the same staff members

multiple dose medication vials

Extra Precautions for HBV

Can remain infectious on surfaces for at > 7 days high titer of HBV Blood can be diluted to below visible levels and still

contain enough infectious particles that indirect transmission can still occur

3.3% of centers reported >1 patients with newly acquired (incident) HBV infection

24.1% of centers reported >1 patients with chronic (prevalent) HBV infection

25.5% of centers reported >1 patients with either acute or chronic HBV infection.

0

2

4

6

8

10

12

14

1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000

Year

Cas

es p

er 1

00,0

00 P

opul

atio

n

Source: NNDSS

Vaccine licensed

HBsAg screening of

pregnant women

recommended

OSHA Rule enacted

Adolescent Immunization recommended

Decline among MSM & HCWs

Decline among injecting

drug users

Infant Immunizationrecommended

Hepatitis B by Year, United States, 1966 - 2000

1977 CDC Recs for Dialysis

Incidence and Prevalence of Hepatitis B in the United

States, 1976-2002

0

50,000

100,000

150,000

200,000

250,000

300,000

1976 1980 1985 1990 1996 2000 2002

Year

To

tal P

ati

en

t P

op

ula

tio

n

0

2

4

6

8

10

Icid

en

ce

/ P

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ale

nc

e

Patients Incidence Prevalence

1977 CDC Recommendations

Vaccine

2001 CDC Recommendations

Incidence of HBsAg in Hemodialysis Patients, by use of Hepatitis B Vaccine, 1996

% Patients Vaccinated # of Patients

HBsAg incidence (%) Relative Risk

None 48,526 52 (0.11) 1.9*

1-50 91,495 78 (0.08) 1.5*

>50 79,596 44 (0.06) ref

P<0.05 compared with reference group

Hepatitis C Virus

Most efficiently transmitted by direct percutaneous exposure to infectious blood

Risk factors: history of blood transfusions, volume of blood transfused, and years on dialysis (≥5 years)

No significant differences in HCV incidence or prevalence in centers that reused dialyzers compared to those who did not reuse dialyzers

Decline in prevalence may be attributable in part to a decline in new infections among patients as a result of increased awareness of the potential for HCV transmission in this setting.

HCV Prevalence by Selected Groups United States

Average Percent Anti-HCV Positive

0 10 20 30 40 50 60 70 80 90

Surgeons, other HCWs

Injecting drug users

Hemophilia

Hemodialysis

Gen population adults

Military personnel

STD clients

Pregnant women

Hepatitis C Virus Flavivirus (single stranded RNA, enveloped virus) Multiple HCV genotypes; in addition within

genotypes there are closely related genotypes or quasi species

Antibody elicited by infection with one genotype fails to cross-neutralize virus of another genotype.

Prior infection does not produce immunity

Estimated Incidence of Acute Hepatitis C United States, 1982-2000

02468

101214161820

82 83 84 85 86 87 88 89 90 91 92

93 94 95 96 97 98 9920

0

0

Ca s

e s p

er 1

0 0, 0

0 0

Decline amongtransfusion recipients

Decline amonginjection drug users

Surrogate testing ofblood donors

Anti-HCV test(1st generation)

licensed

Anti-HCV test(2ndgeneration)

licensed

Source: Sentinel Counties

Nosocomial Hepatitis C Transmission

Hemodialysis Units

Prevalence increases with increasing years on dialysis

Annual incidence is only 1-2% Transmission probably results from poor infection

control practices Prevalence in patients is approximately 10% Prevalence in Staff members is 2%

Tuberculosis

ESRD Patients With Active Tuberculosis

Site of Infection ESRD Patients Total US Cases

Extrapulmonary 31 (57%) 18%

Pulmonary 23 (43%) 82%

Tuberculin Skin Testing of ESRD Patients

ESRD Patients are at increased risk for developing TB- A survey in New Jersey (1994)

7.9% of all U.S. dialysis patients treated at least one patient with known active TB (CDC-1995 Survey)

Individual dialysis centers treating a high proportion of minority and foreign born patients, have reported higher incidences of TB

Guidelines for Skin Testing

Test groups with either: high rate of TB (substance abusers; residents

of correctional facilities, nursing homes, and other congregate settings; medically under served populations; high risk racial or ethnic/minority populations; children exposed to high risk categories)

medical risk factors that increase risk of disease progression

Tuberculin Skin Testing in Hemodialysis Patients

All patients with ESRD should receive at least one tuberculin test to identify latent infection.

If exposure to persons with active TB is likely, periodic rescreening is indicated

ESRD patients who are contacts of a person with infectious TB should be retested

A recent study of anergy in patients uninfected patients found only 18% of ESRD patients to be anergic

General Recommendations for Tuberculosis in the

Hemodialysis Setting

CDC. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Facilities, 2005. MMWR 2005;54 (No. RR-17). http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf

Patients with ESRD who need chronic dialysis should have at least one test for M. tuberculosis infection to determine the need for treatment of LTBI

Annual re-screening is indicated if ongoing exposure of ESRD patients to M. tuberculosis is probable.

Easier to treat patients with active pulmonary tuberculosis in an acute setting where TB isolation rooms, appropriate engineering controls, and respiratory protection programs are available

Patients can be admitted back to the unit when on appropriate therapy and are considered non-infectious.

Tuberculosis All patients with compromised immunity should be tested at least

once for latent TB infection.– Consider skin testing as part of patient intake process– Staff should be tested at time of hire

For patients who test positive a refer for medical follow up and treatment plan development

Patients and staff with latent TB should be offered prophylaxis and monitored regularly for signs of active infection

Patients with active pulmonary disease should be treated in the acute setting in an airborne isolation room until considered noninfectious

Haddad MB, Arduino MJ. Is tuberculosis a serious health riskfor hemodialysis patients? Nephrology Incite 2004;17:21-23

Infection Control Practices

CDC. Recommendations for preventing transmission of infections among chronic hemodialysis patients.

MMWR 2001; 50 (RR5):1- 43

http://www.cdc.gov/mmwr/PDF/rr/rr5005.pdf

Interpretation of serologic test results for hepatitis B virus infection

Serological Marker

HBs AgTotal Anti-

HBcIgM Anti-

HBcAnti-HBs Interpretation

- - - - Susceptible, Never infected

+ - - - Acute Infection, earlyincubation*

+ + + - Acute infection

- + + - Acute resolving Infection

- + - + Past infection, recovered andimmune

+ + - - Chronic Infection

- + - - False-positive (susceptible),past infection, or “low” level

chronic infection- - - + Immune if > 10mIU/ml

*Transient HBsAg positivity (lasting <18 days) might be detected in somepatients during the process of vaccination.

Patients Who Might Be At Increased Risk For Transmitting

Pathogenic Bacteria Uncontained wound drainage, fecal incontinence or

diarrhea uncontrolled with personal hygiene measures.– a) staff members treating the patient should wear a

separate gown over their usual clothing and remove the gown when finished caring for the patient and

– b) dialyze the patient at a station with as few adjacent stations as possible (e.g., at the end or corner of the unit).

Safe Injection Practices Use aseptic technique to avoid contamination of sterile injection equipment. Category

IA Do not administer medications from a syringe to multiple patients, even if the needle

or cannula on the syringe is changed. Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to access a medication or solution that might be used for a subsequent patient. Category IA

Use fluid infusion and administration sets (i.e., intravenous bags, tubing and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient’s intravenous infusion bag or administration set. Category IB

Use single-dose vials for parenteral medications whenever possible. Category IA Do not administer medications from single-dose vials or ampoules to multiple patients

or combine leftover contents for later use. Category IA If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile. Category IA Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer’s recommendations; discard if sterility is compromised or questionable. Category IA Do not use bags or bottles of intravenous solution as a common source of supply for

multiple patients. Category 1B

CDC Guidelines and Recommendations and the

New Conditions of Coverage CDC. Recommendations for preventing transmission of infections

among chronic hemodialysis patients. MMWR 2001; 50 (RR5):1- 43 http://www.cdc.gov/mmwr/PDF/rr/rr5005.pdf

Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 http://www.cdc.gov/ncidod/dhqp/gl_isolation.html

Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2002 http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html

Guideline for Hand Hygiene in Healthcare Settings – 2002 http://www.cdc.gov/ncidod/dhqp/gl_handhygiene.html

There and Back Again