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
rev
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
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