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|Year : 2020 | Volume
| Issue : 7 | Page : 46-50
Prevention of infection
|Date of Web Publication||15-Jul-2020|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Prevention of infection. Indian J Nephrol 2020;30, Suppl S1:46-50
Patients on HD are susceptible to infections. Bacterial infections carry a higher short-term mortality and increase the risk of long-term cardiovascular complications in dialysis patients. Viral infections such as HBV and HCV progress to liver cirrhosis and increase the morbidity and mortality.
The staff members of a dialysis unit are uniquely at risk of contracting these viral infections from contaminated blood and dialysate.
Preventing the transmission of infections involves several links in the chain involving patients, the dialysis procedure and ancillary care, the staff of the unit, and various administrative and waste disposal protocols. A comprehensive infection preventive protocol includes hygiene measures, vaccination, dialyzer reprocessing, and disposal of biohazardous materials.
The suggested guidelines have been prepared by combining essential features from several documents, which are meant to guide infection control implementation and surveillance in HD units.
We recommend that HD units should establish written protocols for all procedures including cleaning and disinfecting surfaces and equipment in the dialysis unit based on the following guidelines:
| Hand Hygiene|| |
- Unwashed hands of health-care workers are the major route of transmission of microorganisms in health-care settings. Staff should cover any cuts and abrasions with waterproof dressings. Staffs who have extensive untreated cuts or chronic skin disease, such as eczema, should not work in dialysis units when their skin lesions are active.
- Hand hygiene includes hand washing with soap and water and/or applying an alcohol-based hand rub.
- Hands should be washed with soap and water when visibly dirty or contaminated with proteinaceous material (e.g., blood or other body fluids).
- If hands are not visibly soiled, an alcohol-based hand rub can be used.
- Hand hygiene should be performed:
- Before and after patient contact.
- After contact with a source of microorganisms (body fluids and substances, mucous membranes, nonintact skin, or inanimate objects that are likely to be contaminated).
- After removing gloves.
- Hand hygiene facilities should be located as close as possible to the point of contact with patients and dialysis equipment.
- One hand wash basin should be provided for every 2–3 dialysis stations in the main dialysis area and a minimum of one in an isolation room.
- Soap solution must be provided in dispensers with disposable cartridges or single-use bottles, to prevent bacterial contamination of the product.
- Alcohol-based hand rubs should be placed at the point of contact, for example:
- Next to or attached to the frame of each dialysis bed or chair.
- At points of entry and exit of dialysis room.
- At staff stations or chart and medication trolleys.
Use of gloves
- Clean, nonsterile gloves should be worn when contact with blood or body fluids is anticipated; this includes contact with patients and dialysis equipment.
- Sterile gloves should be used during connection and disconnection of vascular access with dialysis tubing.
- Gloves must also be changed and hands must be cleaned between different activities on the same patient (e.g., moving from a contaminated to a clean body site).
- Gloves must be changed and hands must be cleaned between patients and/or stations.
- Gloves should be worn for any cleaning activities.
- Hands should be decontaminated or washed after removing gloves.
- Gloves should not be washed or reused.
- Face protection (e.g. eyewear and 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).
- Personal eyeglasses and contact lenses are not considered adequate eye protection.
- Plastic aprons are indicated to prevent contamination of clothing with blood, body fluids, and other potentially infectious material.
- A long-sleeved, fluid-barrier (impervious) gown should be worn if exposed areas of the body, for example, arms and body front, are likely to be contaminated by blood or body fluids.
- All personal protection equipment (with the exception of eyewear/goggles unless soiled) must be changed and hands be cleaned:
- Between attending different patients.
- If it becomes splashed with blood or body fluids.
- On leaving the work area.
Vascular access use
- We recommend reducing catheter use by identifying and addressing barriers to permanent vascular access placement (e.g., through patient education, vascular access coordinator).
- We recommend cleaning of skin with antiseptic before insertion of fistula needles or accessing the dialysis catheter.
- We recommend using Scrub-the-Hub protocol after the cap is removed and before accessing the hub (i.e., scrubbing the catheter hub with an appropriate antiseptic for at least 10–15 s).
- Access the stopcock or injection port only with sterile devices.
- We suggest an alcohol-based chlorhexidine (> 0.5%) solution as the first-line skin antiseptic agent for central line insertion and during dressing changes.
- We suggest applying an antibiotic ointment or povidone-iodine ointment to catheter exit sites during dressing changes.
Cleaning of external surfaces of dialysis machines and chairs/beds
- Dialysis machines should be externally cleaned (and disinfected if indicated) and dried after each session.
- The exterior of the machine should be effectively cleaned using manufacturer's protocols.
- 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.
- Cleaning of noncritical surfaces (e.g., dialysis bed or chair, countertops, external surfaces of dialysis machines, and equipment) should be done with neutral detergent and warm water.
- The following procedure should be adopted for any surface/item that is visibly contaminated with blood or following dialysis of a patient infected with blood-borne virus:
- Clean with neutral detergent and water, and then
- Disinfect with sodium hypochlorite 1% (1000 ppm available chlorine; 1:10 dilution).
- Remove chlorine residues from metallic surfaces with water
- The machine should be decommissioned if spillage occurs at inaccessible locations, such as behind the blood pump until proper cleaning and disinfection are done.
- The following practices should not be used:
- Blood tubing draped or clipped to waste containers.
- Use of attached waste containers during priming of dialyzers.
- Placing items on tops of machines for convenience (e.g., dialyzer caps and medication vials).
- We recommend that due to the instability of chlorine compounds, all diluted solutions should be discarded at the end of the day.
Disinfection of hemodialysis machines
- We recommend that dialysis units follow the manufacturer's recommendations.
- Disinfection should include the following:
- Heat disinfection (80°C–90°C) after each dialysis.
- Citric acid and heat disinfection at the end of the day.
- Bleaching (5% chlorine) once a week.
- We do not recommend frequent bleaching because of possible damage to the machine.
- Manufacturers producing dialysis machines each recommend a different procedure for decontamination, but they concentrate only on bacterial kill. It is recommended that the efficacy of decontamination procedure should additionally take into account the level of biofilm and endotoxin removal.
- We recommend not using liquid bicarbonate dialysate concentrate >24 h after opening as it supports rapid bacterial proliferation.
- Bottles containing unused dialysate should be immediately capped and the exterior of the bottle should be wiped over with detergent and water as part of the overall procedure of cleaning the HD machine.
- The date and time of opening should be recorded on the bottle using an indelible pen.
- Opened bottles containing unused fluid should be discarded after 24 h.
- Unfinished bottles used for infected patients must be discarded immediately after the dialysis session.
Equipment and consumables
- Storage of equipment close to dialysis machines and patients should be minimized.
- We recommend that regularly used equipment such as adhesive tapes, tourniquets, BP cuffs, and clamps should be designated to each patient.
- Consumables 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.
- We recommend that medications (including multiple dose vials) or supplies (syringes, swabs, etc.) 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.
- We suggest that multiple dose vials should be used for the same patient.
- We recommend that bags or bottles of IV solution should not be used as a common source of supply for multiple patients.
- We recommend that when multiple dose medication vials (e.g., heparin and vials containing diluents) or solution bags are used for multiple patients, individual patient doses should be prepared in a clean, centralized area away from dialysis stations and delivered separately to each patient.
- We recommend that medication vials should not be carried from station to station.
- We recommend not carrying vials, syringes, swabs, or other supplies in pockets.
- If trays are used to deliver medications to individual patients, they must be cleaned between patients.
- Do not handle and store medications or clean supplies in the same or an adjacent area to the place where used equipment or blood samples are handled.
Needles and sharps
- We recommend that all needles and sharps must be disposed of into an approved closed, unbreakable container according to the Bio-Medical Waste Management Rules.
- Needles should not be manually recapped.
- No-touch technique should be used to drop the needle into the container, as it is likely to have a contaminated surface.
- These containers should be located as close as possible to the point of generation either attached to a trolley or on a mobile stand.
- Containers should be large enough to accommodate the types of devices being used in the area.
- They should be closed and sealed when 2/3rd full and disposed of in approved manner.
- For minor spills on surfaces (e.g., benches and countertops), we recommend wiping up with a paper towel soaked in undiluted 1%, sodium hypochlorite and then wash with neutral detergent and hot water and allow it to dry.
- For major blood spills, we recommend the following: (a) Cover with chlorine powder (10,000 ppm available chlorine) and leave for 2 min or limit spread using paper towels and slowly flood the contaminated area with undiluted sodium hypochlorite 1% (10,000 ppm); leave for 2 min before cleaning up and (b) This should be followed by washing with neutral detergent.
- Common equipment including weighing scales should be cleaned after use with detergent and water at least daily and when they become visibly soiled or come in contact with body fluids.
Blood-borne virus screening and management
- We recommend that all patients should be tested for HBV, HCV, and HIV on admission to the dialysis unit including after transfer from another unit.
- We recommend testing for HBV and HCV infections using a nucleic acid-based method.
- All MHD patients should be retested every 6 months for HBV, HCV, and HIV infections.
- All HBsAg-negative patients must be vaccinated against HBV using approved protocol.
- Anti-HB titers should be checked 4 weeks after the last dose and at 6–12 monthly intervals thereafter.
- Nonresponders (anti-HB titers <10 IU/ml) should receive three more doses of the vaccine.
- All staff members should be vaccinated against HBV, have their anti-HB titer tested, and be aware of their serostatus, that is, whether or not they have titers >10 U/ml.
- Testing of staff and carers for HCV or HIV is only recommended following a needle stick injury or body fluid exposure.
- Patients with different blood-borne virus infections should be managed separately.
- HBsAg-, HBeAg-, and HBV DNA-positive patients should be dialyzed in a separate room.
- Units with high (>10%) prevalence of HCV infection should strongly consider dialyzing anti-HCV-positive patients in a separate room.
- Where there are no isolation facilities, positive patients should be separated from susceptible patients (negative for HBsAg, anti-HBs, anti-HBc, anti-HCV, or anti-HIV) and undergo dialysis on dedicated machines.
- Patients with anti-HBs ≥10 mIU/mL may undergo dialysis in the same area as HBsAg-positive patients. In case HBV patients are not dialyzed in a separate area, these patients should be placed as buffer between HBsAg-positive and HBsAg-negative patients.
- When a room/area/machine has been used for dialyzing infected patients, it should be used for uninfected patients only after cleaning and disinfection.
- Dialysis staff members caring for positive patients should not care for susceptible patients at the same time (e.g., during the same shift or during patient changeover), but may change in different shifts.
- If staff members must care for both positive and negative patients during the same shift, they must change their gown and gloves and clean their hands in between patients.
- Close contacts of positive patients should be tested for HBsAg and anti-HB testing and if necessary, vaccination.
- If a staff member or carer experiences a needlestick injury or exposure to blood or potentially blood-contaminated secretions from an infected patient, specialist opinion should be sought for management.
- In units with a high prevalence of such patients, we recommend having a written protocol for the management of needlestick injuries based on the existing CDC guidelines and the source and exposure codes.
- We recommend that patients should receive all recommended vaccinations including HBV and varicella.
- We recommend that all patients over the age of 5 years should receive pneumococcal vaccine (23vPPV).
- We suggest that influenza vaccine should be given annually before the beginning of the influenza season.
Multidrug resistant organism screening and management
- We recommend that dialysis units should institute the following measures to prevent transmission of MROs:
- Access to good clinical microbiology laboratory to ensure prompt detection of (MROs) Multi resistant organisms including antimicrobial susceptibility
- Appropriate antimicrobial stewardship (optimal selection, dose, and duration of treatment)
- Active surveillance cultures (screening) to identify patients colonized or infected with MROs
- Decolonization therapy where appropriate.
- Contact precautions are suggested for the management of patients with the following:
- An infected/colonized wound that cannot be covered by a dressing
- Urinary incontinence
- Uncontrolled fecal incontinence or diarrhea or enterostomies
- Exfoliative skin conditions (e.g., dermatitis and psoriasis) and burns.
- Contact precautions are suggested for all patients with an MRO when:
- The incidence of an MRO is increasing despite correct adherence to infection control precautions
- First case or outbreak of an MRO in the unit.
- For isolation, the following precautions are suggested in the given order of preference:
- Dialyze MRO-positive patients in a separate room designated only for them.
- In a separate area in the main unit.
- The main unit with ≥1 m separation between beds/chairs.
- Staff caring for these patients must wear a gown and clean nonsterile gloves for all interactions that with the patient or potentially contaminated areas in the patient's environment.
- Patients with different MROs should be managed separately.
- The room where MRO-positive patients have previously been dialyzed may be used for negative patients only after cleaning and the area is dry.
- Transport equipment (e.g., wheelchairs and trolleys) should be cleaned with detergent and water or detergent or alcohol-impregnated wipes after use.
Prophylaxis for Staphylococcus aureus infection
- The prevalence of S. aureus nasal carriage in many dialysis patients is higher than that of the normal population (≥50%) and increases with the duration of dialysis.
- It is suggested that units should make efforts to ascertain the rates of S. aureus nasal carriage among patients in their units by performing surveillance cultures of anterior nares.
- If the prevalence is found to be high, we suggest regular surveillance for S. aureus carriage and treatment of positive patients with twice-a-day intranasal mupirocin for 7 days, repeated every 3 months.
- Routine use of mupirocin in dialysis patients to prevent S. aureus carriage is not recommended because of the risk of developing resistance.
- There should a prominent display at entry to the unit or reception requesting that patients and individuals accompanying the patient promptly inform the staff if there are any symptoms of a respiratory infection (e.g., cough and flu-like illness); gastroenteritis (e.g., diarrhea, nausea, and vomiting); skin rash; or known exposure to an infectious disease (e.g., chickenpox, measles, and pertussis).
- Implementation of source containment measures is recommended to prevent the transmission of respiratory infections. Coughing patients should be asked to wear a surgical mask or cover their cough.
- All patients should perform hand hygiene as part of basic personal hygiene, including the use of alcohol-based hand rubs.
Staff education and competency
We recommend training of all staff in dialysis units in infection prevention and control practices including: proper hand hygiene technique; appropriate use of personal protection equipment; modes of transmission for blood-borne viruses, pathogenic bacteria, and other microorganisms; infection control precautions for dialysis units; rationale for segregating patients; and correct techniques for initiation, care, and maintenance of dialysis access sites. We recommend that new and inexperienced staff should be supervised until they are considered competent to practice safely on their own.
Patient education and engagement
Provide standardized education to all patients on infection prevention topics including vascular access care, hand hygiene, risks related to catheter use, recognizing signs of infection, and instructions for access management when away from the dialysis unit.
Surveillance and audit
- We recommend that all units should develop methods to monitor, review, and evaluate all infection data including rates of blood-borne viruses and bacterial infections overall and individually.
- They should calculate incidence and conversion rates for blood-borne viruses.
- The unit in charge should regularly review adherence to infection control practices annually and more frequently if there is significant staff turnover.
- Wastes generated by the HD facility should be considered infectious and handled accordingly.
- We recommend that solid medical wastes should be disposed of properly in an incinerator or sanitary landfill, according to and regulations governing medical waste disposal (Guidelines for the Management of Healthcare Waste as per Biomedical Waste Management Rules, 2016).