Review of Hemodialysis for Nurses and Dialysis Personnel, 8th Edition

Chapter 10. Infection control

Infection control is used in the dialysis setting to prevent patients and staff from acquiring infections specific to the dialysis unit. Infection control incorporates policies and procedures that include surveillance and monitoring activities for water treatment, dialyzer reuse, bacterial contamination, and transmission of blood-borne and other infectious diseases.

The Centers for Disease Control and Prevention (CDC) has issued and updated blood-borne infection control strategies and precautions (including standard precautions) over the years for dialysis centers as well as for other healthcare agencies. The Centers for Medicare & Medicaid Services (CMS) new rules, which went into effect October 2008, require dialysis providers to follow the CDC documents “Recommendations for Prevention and Transmission of Infections among Chronic Hemodialysis Patients” (MMWR, 50[RR-5], 2001) and “Prevention of Intravascular Catheter-Related Infections” (MMWR, 51[RR-10], 2002).

The Occupational Safety and Health Administration (OSHA) has issued regulations that enforce the use of standard precautions and other infection control strategies for all healthcare agencies. The OSHA blood-borne pathogen regulations provide specific measures that healthcare workers and their employers can take together to substantially reduce the risk of healthcare workers contracting a blood-borne disease while on the job. The CDC has also issued recommendations for preventing the spread of drug-resistant organisms and other potentially infectious diseases such as tuberculosis.

This chapter reviews information that personnel are required to know to help prevent the spread of infectious diseases in dialysis facilities. It also includes a review of blood-borne diseases and standard precautions, as published by the CDC, as well as strategies to prevent the spread of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), and tuberculosis (TB). Questions commonly asked by dialysis personnel regarding water treatment, bacterial contamination, dialyzer reuse, and infection control issues are addressed in the specific chapters dealing with those subjects. Updated guidelines consistent with the October 14, 2008, CMS Conditions for Coverage will be addressed to reflect regulations applicable to both chronic in-center dialysis and home dialysis programs.

The CDC has issued specific recommendations for the prevention of blood-borne pathogens in dialysis facilities. Box 10-1 outlines these guidelines.

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Box 10-1 Components of a Comprehensive Infection Control Program to Prevent Transmission of Infections among Chronic Hemodialysis Patients

Infection control practices for hemodialysis units:

1. Infection control precautions specifically designed to prevent the transmission of blood-borne viruses and pathogenic bacteria among patients

2. Routine serologic testing for hepatitis B virus and hepatitis C virus infections

3. Vaccination of susceptible patients against hepatitis B

4. Isolation of patients who test positive for hepatitis B surface antigen

5. All single-use injectable medications and solutions be dedicated for use on a single patient and not be punctured more than once

6. Surveillance for infections and other adverse events

7. Infection control training and education

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What are standard precautions?

A recommendation that blood and body fluid precautions be used consistently for all patients, regardless of their blood-borne infection status, is the basic tenet of standard precautions. Blood-borne pathogens, such as the human immunodeficiency virus (HIV) and hepatitis B virus (HBV), infect people of all ages, of all socioeconomic classes, and from all geographic areas. Healthcare workers may not be able to identify patients who harbor a virus or who may transmit infection. The application of “standard precautions” assumes all patients are infectious.

Reducing exposure to and transmission of blood-borne pathogens through the use of standard precautions involves appropriate work practices, such as the use of barrier precautions. Appropriate barrier precautions are to be used to prevent skin and mucous membrane exposure in contact with blood or any other body fluid of any patient. Healthcare workers should wear the personal protective equipment that is most appropriate to the anticipated potential exposure. Barrier precautions, also known as personal protective equipment (PPE), include the use of the following:

• Gloves

• Face shields or masks and goggles

• Gowns or aprons

Gloves are to be worn for touching blood and body fluids, mucous membranes, or nonintact skin of all patients; for handling items or surfaces soiled with blood or body fluids; and for performing vascular access procedures where blood spill is likely. Gloves should also be worn when touching the patient’s equipment or other environmental surfaces. Disposable gloves are for single use only and come in a variety of materials such as vinyl, latex, and nitrile. Gloves are to be changed and hands washed after contact with each patient, whenever the gloves are bloodstained, and after handling infectious waste containers. Hand hygiene should be performed using soap and water or alcohol-based antiseptic hand rubs.

Masks and goggles or full face shields shall be worn during any procedure likely to generate droplets, blood splashes, or body fluids near the face. Masks should fully cover the nose and mouth. Goggles should fit snugly over and around the eyes. Personal eyewear, such as prescription glasses, are not a substitute for protective eyewear. Face shields should cover the forehead, extend below the chin, and wrap around the side of the face when worn properly. Initiating and terminating dialysis and troubleshooting the vascular access are examples of procedures that may increase a healthcare worker’s risk of exposure to blood-borne pathogens if barrier precautions, such as gloves, face shield, and impervious gowns or aprons, are not used.

Cover garments, such as impervious gowns or aprons, are to be worn during procedures likely to generate droplets, blood splashes, body fluids, potentially contaminated substances, or chemicals near the body. The protective garment should provide full protection to the arms and torso from the area of the neck to the thigh or knee. The use of protective aprons is appropriate only if they have incorporated sleeves. Before leaving the work area, all PPE should be removed and placed in a designated area or container for washing, decontamination, or disposal. Hands should be thoroughly washed after the removal of PPE and before leaving the work area. In addition to barrier precautions, employee work practices, such as diligent handwashing, are essential in order to reduce risk of exposure to and transmission of blood-borne pathogens.

Employee work practices include precautions that healthcare workers should take to prevent injuries caused by needles, scalpels, and other sharp instruments that may be responsible for the transmission of blood-borne diseases.

Precautions should be taken in the following situations: when cleaning used instruments, during disposal of used needles, and when handling sharp instruments after procedures. Needles should not be recapped, purposely bent, or broken by hand; removed from disposable syringes; or otherwise manipulated by hand. After use, disposable syringes and needles, scalpel blades, and other sharp items must be placed in puncture-resistant containers located as close as practical to the use area.

Sharps containers should not be mounted too high, but should be easily accessible. They also should not be allowed to overfill.

To minimize the need for emergency mouth-to-mouth resuscitation, mouthpieces, pocket masks, resuscitation bags, or other ventilation devices should be available for use in areas where the need for resuscitation is predictable.

Healthcare workers with exudative lesions or weeping dermatitis should refrain from direct patient care and from handling patient equipment until the condition resolves. All skin defects (cuts, abrasions, ulcers, etc.) must be covered with an occlusive bandage.

Pregnant healthcare workers are not known to be at greater risk of contracting HBV or HIV infection than healthcare workers who are not pregnant; however, if a healthcare worker develops HBV or HIV infection during pregnancy, the infant is at risk of infection resulting from perinatal transmission. Therefore, pregnant healthcare workers should be especially familiar with and strictly adhere to precautions to minimize the risk of HBV or HIV transmission.

Why is handwashing so important?

The most common method of transferring pathogen from patient to patient or staff to patient is by the hands. Handwashing reduces the risk of transferring contamination from hands to other individuals, to other areas of the body, or to the other surfaces the healthcare worker may later contact. Hands should be washed when entering or leaving patient care areas, before gloving and immediately after removal of gloves or other personal protective equipment, in between patient contacts, and after touching an environmental surface such as the dialysis machine without having gloved first. Dialysis facilities must identify and dedicate “clean” sinks used for handwashing purposes only. Care must be taken not to use the “clean” sink for draining fluids or for placing items that have been used in the course of the patient treatment. Sinks must also be made available to patients to wash their access sites and hands before treatment.

It is important to remember that gloves should never be used as a replacement for handwashing.

Adherence to handwashing guidelines is essential to provide safe patient care. Handwashing should always be performed after gloves are removed. The CDC has issued guidelines on the use of alcohol-based hand rubs as an alternative to using traditional soap and water when providing patient care: before patient contact; after contact with a patient’s intact skin, body fluids or excretions, nonintact skin, or wound dressings; and after removing gloves. The traditional method of handwashing with soap and water is indicated when hands are visibly dirty, contaminated, or soiled.

When handwashing with soap and water, the hands should be rubbed together for at least 15 seconds followed by a rinse. When decontaminating with an alcohol-based hand rub, the product should be applied to the palm of the hand and the hands rubbed together until dry. Some dispensers can be set to deliver the exact amount of soap or hand rub recommended by the manufacturer.

The length of fingernails should be considered because studies have documented that long fingernails (>¼ inch) may harbor high concentrations of bacteria. Even after careful washing, long fingernails may harbor significant numbers of pathogens—such as gram-negative rods, corynebacteria, and yeasts—in the subungual space. Artificial fingernails also contribute to the spread of certain gram-negative pathogens and should not be worn when providing care to patients who have compromised immune systems. This is extremely important to keep in mind when caring for those with a high risk of developing infections.

What are specific examples of standard precautions in a dialysis unit?

Standard precautions in a dialysis unit can be summarized into four main categories:

• Barrier precautions and PPE, such as gloves, face shields, masks, protective eyewear, gowns, and aprons

• Protection against penetration caused by sharps

• Good personal hygiene

• Good environmental control and avoidance of environmental contamination

During initiation and termination of dialysis, or any time there is a risk of exposure to blood-borne pathogens, a mask, protective eyewear (goggles or face shield), and gloves must be worn. An impervious gown or plastic apron should be worn if there is likely to be blood splashed. A sharps container should be positioned within reach of the patient caregiver so that the needle can be disposed of immediately without it having to be placed down and picked up a second time. Hands must be washed after removing gloves and before touching any environmental surfaces, such as machine knobs, charts, phones, or other equipment. Eating, smoking, applying cosmetics, or handling contact lenses in the treatment room must be prohibited. Good environmental controls include maintaining separate areas for clean and soiled areas, as well as adequately cleaning and disinfecting the treatment area and equipment in contact with the patient, such as chair and blood pressure cuff.

What is the needlestick safety and prevention act?

The Needlestick Safety and Prevention Act went into effect on April 18, 2001, with a goal of protecting healthcare workers from accidental exposure to blood-borne diseases. The CDC estimates that each year 385,000 needlesticks and other sharps-related injuries are sustained by hospital personnel. This does not include needlesticks sustained in other settings such as long-term or home healthcare locations or private offices.

This law applies to any facility that is bound by federal OSHA regulations where an employee may be exposed to blood or other potentially infectious material. This Act requires healthcare employers to provide their employees with safety-engineered sharp devices. Employers must also maintain a log of injuries from contaminated needlesticks. Information to be collected must solicit exposure information on type and brand of device causing the injury, department where the injury occurred, and how the injury was sustained. Employers are required to obtain employee input when choosing safer needle devices, and staff must be properly trained in the appropriate use of safe needle devices used in their facility.

What are the most significant blood-borne pathogens?

A blood-borne pathogen simply means a microorganism (usually a virus) transmitted in the blood or body fluids that can cause disease in humans. The most significant blood-borne pathogens are HBV, hepatitis C virus (HCV), and HIV. Efficiency of transmission varies among the viruses because of the number of viruses present in the blood. The risk of infection will vary and is dependent on the pathogen involved, the type of exposure, the amount of blood involved, and the amount of virus in the patient’s blood at the time of the exposure.

What is hepatitis?

Hepatitis is an inflammation of the liver caused by infectious agents, medications, or toxins. There are several types of infectious hepatitis but the most common types are hepatitis A (HAV), HBV, and HCV. The CDC estimated that 12,000 HBV infections occurred in healthcare personnel in 1985. The number declined to an estimated 500 in 1997, largely because of the widespread immunization of healthcare workers and the use of standard precautions. The three hepatitis viruses are transmitted through different routes. Vaccines are available for both HBV and HAV. No vaccine exists at this time for HCV.

How infectious is hepatitis B?

HBV is a highly transmissible virus because of the high concentration of the virus in the blood of infected people (1 mL of HBsAg-positive blood may contain 100 million infectious doses of virus) and the ability of the virus to survive for several days on environmental surfaces at room temperature. The CDC estimated 46,000 new infections in 2006 and an estimated 800,000 to 1.4 million people with chronic HBV infection (CDC, 2009).

How is hepatitis B transmitted?

In the dialysis unit, exposure to blood with the possibility of HBV transmission can be either direct or indirect. Direct exposure consists primarily of penetration of the skin (percutaneous) by sharp objects, such as needles, scalpels, and broken capillary tubes, or blood on broken skin and on mucous membranes of the eyes, mouth, or nose.

Indirect exposure involves transmission from environmental surfaces, such as clamps, control knobs on dialysis machines, and doorknobs.

The most common ways that HBV is spread in dialysis units are by penetration of the skin by sharps and by contact of blood with broken skin or mucous membranes.

Are additional precautions necessary to safely dialyze an hbsag-positive patient in the dialysis unit?

The CMS suggests routine testing of all patients for HBV before admission to the dialysis unit following the CDC guidelines. All susceptible patients and staff should be offered the hepatitis B vaccination. As of February 9, 2009, every new facility must have an isolation room for the treatment of HBV-positive patients, unless the facility is granted a waiver of this requirement. If this is impossible, the HBV-positive patient should be separated from hepatitis B seronegative patients in an area removed from the mainstream of activity and should be dialyzed on a dedicated machine. The same hemodialysis equipment should not be used for both HBsAg-positive and seronegative patients. HBV-positive patients should also have dedicated supplies and medications. HBsAg-positive patients should not participate in a dialyzer reuse program. Ideally, dialysis staff members should not care for both HBsAg-positive and seronegative (susceptible) patients during the same shift, but can care for HBsAg-positive and anti–HBs-positive (immune) patients during the same shift. Staff members who are HBsAg positive may be assigned preferentially to care for HBsAg-positive patients. If, for some reason, staff members must care for both HBsAg-positive and seronegative patients during the same shift, they must change gowns between patients, wash hands, and change gloves to prevent cross-contamination.

What are the cdc recommendations for hepatitis B serologic screening?

Patients should be screened for HBsAg, anti-HBc (total), anti-HBs, and alanine aminotransferase (ALT) to determine their serologic status before they first enter the dialysis unit (Table 10-1). Patients are identified as HBsAg positive, meaning the patient has tested positive for the presence of the hepatitis B surface antigen; HBsAg negative, meaning the patient does not have the hepatitis B surface antigen; or hepatitis B surface antigen susceptible, meaning the patient does not have sufficient hepatitis B surface antibody levels to achieve immunity to the hepatitis B virus. Results of the anti-HBs assay should be quantified numerically; a simple “positive” or “negative” result is not acceptable. The CDC recommends periodic screening for each of the above categories of serologic status (Tables 10-2 and 10-3). Refer to Box 10-2 for the Hepatitis B Screening Panel information.

Table 10-1 Interpretation of Hepatitis B Serologic Test Results

HBsAg
anti-HBc
anti-HBs

negative
negative
negative

Susceptible

HBsAg
anti-HBc
anti-HBs

negative
positive
positive

Immune due to natural infection

HBsAg
anti-HBc
anti-HBs

negative
negative
positive

Immune due to hepatitis B vaccination

HBsAg
anti-HBc
IgM anti-HBc
anti-HBs

positive
positive
positive
negative

Acutely infected

HBsAg
anti-HBc
IgM anti-HBc
anti-HBs

positive
positive
negative
negative

Chronically infected

HBsAG
anti-HBc
anti-HBs

negative
positive
negative

Interpretation unclear; four possibilities:

Anti-HBc, Antibody to hepatitis B core antigen; anti-HBs, antibody to hepatitis B surface antigen; HBsAg, hepatitis B surface antigen; IgM anti-HBc, immunoglobulin M antibody to hepatitis B core antigen.

Adapted from Mast, EE et al.: A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices, part I: immunization of infants, children, and adolescents, MMWR 54(RR-16):1–23, 2005.

Table 10-2 Schedule for Routine Testing for Hepatitis B Virus and Hepatitis C Virus Infections

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Table 10-3 Recommendations for Staff Hepatitis B Serologic Surveillance in Chronic Hemodialysis Centers

Vaccination and serologic status

Staff frequency of HBsAg screening

Staff frequency of anti-HBs screening

Unvaccinated

Susceptible

Semiannually

Semiannually

HBsAg carrier

Annually

None

Anti-HBs positive*

None

None

Vaccinated

Anti-HBs positive*

None

None

Low level or no anti-HBs

Semiannually

Semiannually

Anti-HBs, Antibody to hepatitis B surface antigen; HBsAg, hepatitis B surface antigen.

* At least 10 miU (milli-international units)/mL or at least 10 SRUs (sample ratio units) by RIA (radioimmunoassay) or positive EIA (enzyme immunoassay).

From CDC: Recommendations for preventing transmission of infections among chronic hemodialysis patients, MMWR 50(RR-5), 2001.

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Box 10-2 Hepatitis B Screening Panel

Hepatitis B surface antigen (HBsAG) is a protein on the surface of the hepatitis B virus that indicates that the person is infectious. It persists indefinitely in chronic carriers.

Hepatitis B surface antibody (anti-HBs) is a marker of immunity. It indicates recovery and immunity from hepatitis B virus infection, either from past infection or through vaccination.

Total hepatitis B core antibody (anti-HBc) appears at the onset of symptoms in acute hepatitis B and indicates previous or ongoing infection with hepatitis B virus.

IgM antibody to hepatitis B core antigen (IgM anti-HBc), if positive, indicates recent infection with hepatitis B virus (<6 months) and acute infection.

IgM, immunoglobulin M.

Adapted from Mast, EE et al.: A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices, part I: immunization of infants, children, and adolescents, MMWR 54(RR-16):1–23, 2005.

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What are the cdc recommendations for the hepatitis B vaccine?

The CDC strongly recommends the administration of hepatitis B vaccine to susceptible patients and staff as an additional means of preventing HBV in the hemodialysis unit (Table 10-4). In addition, if a healthcare worker has the potential to be exposed to HBV on the job, the employer is required by law to make the hepatitis B vaccination available at no cost.

Table 10-4 Doses and Schedules of Licensed Hepatitis B Vaccines for Hemodialysis Patients and Staff Members

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Today’s vaccines are safe and effective. Hepatitis B vaccines now used in the U.S. are made from yeast and cannot be infected with HIV or blood-borne pathogens. More than 2 million U.S. healthcare workers have already been vaccinated. The complete series of hepatitis B vaccinations is 85% to 97% effective at protecting someone from getting the disease or becoming a carrier.

What if i lose antibody protection after a couple of years?

The Public Health Service’s Advisory Committee on Immunization Practices states: “Individuals who have initially responded to the hepatitis B vaccine with protective levels of anti-HBs, and then lose detectable antibodies, do not need to receive booster shots. They are protected and will not develop clinical hepatitis.” However, dialysis patients may have less complete vaccine-induced protection that may persist only as long as the antibodies remain at a certain level. Dialysis patients may need a booster dose and should have antibody testing done annually.

What steps should be taken after occupational exposures to blood?

Institutions have in place a plan for occupational exposures that include reporting, evaluating the risk of infection, available treatments, and postexposure monitoring. When exposed to blood, the administration of first aid to the exposed individual is the first step. Needlesticks and cuts should be washed with soap and water, and splashes to the mouth, nose, or skin should be flushed with water. Eyes that have been exposed to blood should be irrigated with clean water, saline, or sterile saline solution. The exposure should then be reported to the immediate supervisor so the appropriate evaluation and counseling can take place. Postexposure blood testing of the exposed and source patient should be completed as soon as possible. Postexposure prophylaxis (PEP) will be offered if indicated to reduce the chance of becoming infected with HIV or hepatitis. It is important to be prompt when seeking PEP because the prophylaxis for HIV should be instituted within hours after the exposure. The medications used for PEP have numerous side effects, which is why it is recommended only when the exposure is a risk of transmission. PEP for hepatitis B should begin within 24 hours after exposure, which can significantly reduce the risk of acquiring the virus (Table 10-5). No PEP exists for a HCV exposure. Baseline testing for anti-HCV and ALT is recommended as well as follow-up testing and monitoring for symptoms. Healthcare workers should always protect themselves and their co-workers by using safe needle devices (SNDs) when indicated; using SNDs as the manufacturer suggests; disposing of needles and sharps immediately and into an appropriate container; and reporting all sharps and needlestick exposures.

Table 10-5 Recommended Postexposure Prophylaxis for Exposure to Hepatitis B Virus

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What is HIV?

HIV attacks the body’s immune system, causing the disease known as acquired immune deficiency syndrome (AIDS). Currently, there is no vaccine to prevent HIV infection. Through December 2006 the CDC had received voluntary reports of 57 documented and 140 possible episodes of HIV transmission to healthcare personnel in the U.S. Of the 57 documented episodes, 48 transmissions were from a percutaneous exposure.

How infectious is HIV?

The efficiency of HIV transmission in the dialysis setting is much less than with HBV because of the lower concentration of HIV in blood when compared with HBV. The concentration of HIV in blood is approximately 10 to 10,000 infectious viruses per milliliter. The average risk for HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3%; after a mucous membrane exposure, average risk is approximately 0.09% (MMWR 54[RR-9], 2005).

How is HIV transmitted?

Like other blood-borne pathogens, the human immunodeficiency virus is present in the blood of infected individuals. HIV is transmitted primarily through sexual contact, but may also be transmitted through contact with blood and body fluids. The virus can also be passed to a newborn infant from an infected mother. Transmission through contact with contaminated environmental surfaces has not been documented. The virus is very sensitive to chemical disinfection and is completely inactivated by a 10% solution of 0.5% sodium hypochlorite (bleach) within 1 minute of exposure.

No airborne transmission of HBV or HIV has been documented. However, splashing, splattering, centrifuge accidents, or removal of stoppers from tubes can produce droplet transfer into the mouth or eyes or onto defects in the skin surface.

What HIV precautions are necessary in a dialysis unit?

Standard precautions are the only thing necessary to protect patients and staff from HIV infection in the dialysis setting. Patient isolation is not necessary due to the lack of an environmental route for transmission of the virus and the low number of viruses in the blood. It is not necessary to cohort or group together HIV-positive patients. HIV testing is not recommended as a part of infection control in a dialysis unit. Also, it should not be used as a prerequisite for admission to a dialysis unit, but it may be helpful for optimal medical management and counseling. HIV testing should be part of a transplant workup because a transplant could be contraindicated in someone who is already immunosuppressed because of HIV. If HIV antibody testing is performed, informed consent, appropriate confirmation testing, appropriate professional counseling, and confidentiality of test results must be provided.

Can dialyzers for known hiv-positive patients be reused?

Although the CDC believes that dialyzer reuse poses no specific threat if done correctly, there are dialysis units that do not reuse dialyzers of known HIV-positive patients.

What if i am exposed to blood of someone known to be positive for or who tests positive for HIV?

As with any blood exposure, you should immediately notify your supervisor. The source patient should be tested for evidence of HIV infection after consent is obtained. The CDC recommends that workers with occupational exposures to HIV should receive follow-up counseling and medical evaluation, including HIV antibody tests at baseline and periodically for at least 6 months postexposure (e.g., 6 weeks, 12 weeks, and 6 months), and should observe precautions to prevent possible secondary transmission.

In 1996 the Public Health Service published source material and provisional recommendations for chemoprophylaxis (preventive drug therapy) after occupational exposure to HIV, by type of exposure. Although these recommendations are provisional, because they are based on limited data, chemoprophylaxis should be recommended to exposed workers after occupational exposures associated with the highest risk for HIV transmission. For exposure with a lower, but nonnegligible risk, PEP should be offered, balancing the lower risk against the use of drugs having uncertain efficacy and toxicity. For exposure with negligible risk, PEP is not justified. If exposed, you should consult your physician regarding chemoprophylaxis.

What is hepatitis C?

HCV is the most common form of hepatitis in the U.S., with an estimated 3.3 million chronically infected persons nationwide (CDC, 2009). A vaccination for the prevention of HCV does not exist.

How infectious is hepatitis C?

HCV is less concentrated in blood than HBV and does not survive long on environmental surfaces. Concentration of infectious virus is thought to be less than 1000 virus organisms per milliliter. However, outbreaks have occurred in dialysis units and are thought to be due to poor infection control practices. Persons at increased risk of acquiring HCV include intravenous drug users, healthcare workers with occupational exposure to blood, hemodialysis patients, and transfusion recipients. Long-term dialysis patients are at an increased risk for contracting HCV. The number of years on dialysis, history of blood transfusions, and the volume of blood transfused are all risk factors associated with HCV infection. HCV transmission may also occur due to inadequate infection control practices. Cross-contamination between patients can be a problem when machine and other environmental surfaces are not disinfected between patient use, when supplies are shared between patients, and when blood spills are not cleaned up promptly. The estimated number of new HCV infections in the U.S. in 2007 was 17,000 and the number of persons living with chronic HCV infection is estimated to be approximately 2.7 to 3.9 million (Armstrong, 2006).

How is hepatitis C transmitted?

Like HBV and other blood-borne pathogens, HCV is transmitted through percutaneous exposure to infected blood. HCV transmission within the dialysis environment can be prevented by strict adherence to infection control precautions recommended for all hemodialysis patients.

Are additional precautions necessary to safely dialyze a hepatitis C–positive patient in the dialysis unit?

Patients who are positive for HCV antibody do not have to be isolated or dialyzed separately on dedicated machines. They may participate in dialyzer reuse programs if liver enzyme values are acceptable.

What are the cdc recommendations for hepatitis C serologic screening?

Routine screening of patients or staff for HCV antibody is not necessary for purposes of infection control. However, dialysis centers may wish to conduct serologic surveys of their patient populations to determine the prevalence of the virus in the centers and to determine medical management for patients or staff with a diagnosis of HCV.

Although the HCV antibody test has a sensitivity of about 90%, it does not distinguish between acute and chronic infection. In addition, the test does not distinguish between people who are infectious and those who have completely recovered and cannot pass the disease to someone else. Although the CDC does not recommend routine screening for HCV, regular monitoring of liver enzymes is recommended for the detection of all types of hepatitis, including HCV.

All patients should be monitored monthly for liver enzymes, ALT, and aspartate aminotransferase (AST) to detect HCV. Elevations in liver enzymes are currently more sensitive indicators of acute HCV infection than is detection of HCV antibody.

In the absence of unexplained ALT elevations, testing for anti-HCV every six months should be sufficient to monitor the occurrence of new HCV infections. If unexplained ALT elevations are observed in patients who are anti-HCV negative, repeat anti-HCV testing is warranted. If unexplained ALT elevations persist in patients who repeatedly test anti-HCV negative, testing for HCV ribonucleic acid (RNA) should be considered (CDC, 2001).

What should be done if i am exposed to hepatitis C virus?

Testing for the HCV antibody and liver enzymes should be done immediately after an exposure and repeated four to six months after the exposure. Anti-HCV tests detect the presence of antibodies to the virus, indicating exposure to HCV. These tests cannot tell if you still have an active viral infection, only that you were exposed to the virus in the past. Testing for HCV RNA four to six weeks postexposure will detect infection earlier. Unlike antibody tests, HCV RNA tests directly measure for the presence of the hepatitis C virus.

What is tuberculosis?

TB is an infectious disease caused by the bacterium Mycobacterium tuberculosis.

How is tuberculosis transmitted?

The bacterium is carried in airborne particles (droplet nuclei) that are generated when people with pulmonary or laryngeal TB, who are not on effective antituberculosis medication, cough or sneeze. The small droplets can remain suspended in the air for prolonged periods. While airborne on normal room current, these droplet nuclei can infect individuals as soon as the inhaled droplets containing the bacilli become established in the alveoli of the lung.

Two to ten weeks after initial infection, the healthy immune system usually limits further multiplication, and the person does not become ill. A positive TB skin test is usually the only evidence of infection.

Approximately 10% of these healthy individuals with latent TB will develop active TB months or years later. However, for people infected with HIV, the risk of progression to active infectious disease is markedly increased. The CDC estimates that approximately 10 to 15 million people in the U.S. are infected with M. tuberculosis.

What is the difference between tuberculosis infection and active tuberculosis?

Patients who progress to active contagious TB are capable of transmitting the disease. Those who are infected but who have not progressed to active TB will have no symptoms, will not be contagious, and will not know they are infected unless they have a positive Mantoux skin test. It may take months or years before the person progresses into active TB, or the person may never develop active TB. Symptoms of active TB include prolonged coughing for three weeks or more, fatigue, fever, weight loss, and night sweats. Medication and therapy are available.

Is tuberculosis a problem in dialysis units?

In 2009 a total of 11,540 cases of TB were reported in the U.S., showing the greatest single-year decrease reported. TB rates decreased in both foreign-born and U.S.-born citizens. Outbreaks have been reported in correctional facilities, hospitals, and some dialysis units. The level of risk for transmission varies by the type of healthcare facility. For example, the risk of acquiring TB may be greater in emergency departments, where patients are provided care before screening and diagnosis take place.

Can a patient with active contagious tuberculosis be safely dialyzed in the outpatient facility?

Patients with active TB disease should not be dialyzed in ambulatory settings while infectious. These patients must be referred to hospitals with appropriate isolation accommodations (separate room, negative pressure, etc.) as prescribed by CDC guidelines. End-stage renal disease (ESRD) program regulations require freestanding dialysis units to have backup agreements with a hospital. This may provide the mechanism for referring active TB patients for dialysis treatment until no longer infectious.

What are the cdc recommendations for tuberculosis screening?

Staff should be screened at the onset of employment. TB screening is often done at least annually. Frequency of TB screening is based on an institution’s risk assessment, including the community TB profile. If you live and work in an area with a high incidence of TB, screening may be more frequent.

Patients should be screened on or before their first dialysis encounter. The CDC recommends that all dialysis patients be tested at least once for baseline tuberculin skin test (TST) results and be rescreened if TB exposure is detected.

New dialysis patients may arrive after a hospitalization or extensive workup. If a recent (within the past year) chest x-ray or TST was included, initial screening may not be necessary unless risk factors are present.

The CDC recommends that the two-step Mantoux skin test be used for baseline screening. The Mantoux technique involves intradermal injection of 0.1 mL of purified protein derivative (PPD) tuberculin containing 5 tuberculin units. The two-step procedure (if initial PPD is negative, PPD is repeated one to three weeks later) is used for baseline testing in people who periodically receive TB skin tests to reduce the likelihood of mistaking a booster reaction for a new infection.

Nonroutine screening of patients and staff should be conducted as needed in response to clinical symptoms or documented exposure, for example, an active case identified among patients or staff.

What are drug-resistant organisms?

Drug-resistant organisms are bacteria that have mutated to defend themselves against commonly used antibiotics. Resistant strains develop quickly and crossbreed, transferring their resistance to other bacteria. VRE and MRSA are two bacteria known to be resistant to antibiotic therapy. Both have become significant nosocomial pathogens in U.S. hospitals and healthcare facilities. MRSA and VRE may cause infections in patients who are immunosuppressed, including ESRD patients, cancer and HIV patients, the elderly, newborns, and those being treated with multiple antibiotics. Those at increased risk of acquiring infections due to drug-resistant organisms include nursing home patients; patients with frequent hospital admissions or prolonged hospital stays; patients with chronic illnesses requiring steroid therapy; patients with catheters, such as subclavians; and patients with incisions and other openings into the body.

How are mrsa and vre transmitted?

Mrsa.

The main route of transmission of MRSA is by healthcare workers’ hands that have become contaminated by contact with a patient who either is infected with or carries the organism. People may carry the organism in their nose or on the skin. Some people are carriers; others can become infected through boils, wound infections, pressure ulcers, and so on. MRSA commonly infects wounds, exit sites, and access sites. Environmental surfaces may also be contaminated with MRSA and act as a reservoir for the bacteria.

Vre.

Enterococci are normal flora of the gastrointestinal and female genital tracts. Because of this, most infections with these microorganisms have been attributed to sources within the patient. However, recent reports indicate that enterococci, including VRE, can spread by direct person-to-person contact or indirectly via transient carriage on the hands of personnel or contaminated environmental surfaces and patient care equipment.

Can a patient with mrsa and vre safely dialyze in the outpatient facility?

Standard infection control or standard precautions recommended by the CDC should provide sufficient protection against the transmission of MRSA in the dialysis unit.

The CDC standard precautions include the following:

• Wash hands after touching blood, body fluids, excretions, and contaminated items, even when wearing gloves. Also, wash hands after gloves are removed, between tasks, and between procedures on the same patient to prevent cross-contamination of different body sites.

• Wear gloves when touching blood, body fluids, excretions, and contaminated items. Gloves should be put on before touching mucous membranes and nonintact skin, and they should be removed promptly after use.

• Wear a mask and eye protection or face shield. These will protect the mucous membranes of the eyes, nose, and mouth during procedures that are likely to cause splashing or spraying of body fluids.

• Wear a gown for protection from skin contamination and soiling of clothing during procedures and patient care activities.

• Handle patient care equipment that is soiled with body fluids and excretions in a manner that prevents skin exposures and contamination of clothing. Make sure reusable equipment is not used for the care of other patients until it has been sanitized.

In addition to these standard precautions, patients with VRE who have draining wounds not contained by dressings, who have diarrhea or are incontinent, who have poor hygiene, or who are confused and are handling their dressings, and so on should be dialyzed in a separate room or area. It is important to dedicate the use of noncritical items, such as stethoscope or sphygmomanometer, to a single patient or group of patients who are infected with or are carriers of VRE. If such devices are to be used on other patients, adequate cleaning and disinfecting must first take place.

What are the sterilization and disinfection procedures in a dialysis unit?

All dialysis units must have written policies and procedures that deal with disinfection of the dialysis fluid pathway of the hemodialysis machine. These procedures are targeted to control bacterial contamination and have nothing to do with preventing blood-borne infections. The procedures generally consist of using sodium hypochlorite (bleach) on a regular basis (according to the manufacturer’s instructions) and a sterilant overnight at certain intervals (e.g., every 100 hours of use). Studies have shown that HIV is inactivated rapidly after being exposed to commonly used chemical germicides at concentrations that are much lower than used in practice. The much hardier HBV is also known to be inactivated by common household bleach. Suggested concentrations of sodium hypochlorite prepared daily range from 500 parts per million (ppm) (1:100 dilution of household bleach) to 5000 ppm (1:10 dilution).

How should other surfaces be cleaned?

Machine surfaces, patient chairs, and other surrounding furniture and equipment, such as an infusion pump, should be routinely wiped down with a 1:100 to 1:10 bleach solution following every patient treatment. Environmental surfaces, such as walls, floors, and other surfaces, should be routinely cleaned consistent with good housekeeping practices. Disinfection must adhere to the minimum duration of wet contact as specified by the product label. Patients should not be at the station during that time. Extraordinary attempts to disinfect or sterilize these surfaces are not necessary. Blood spills should be cleaned immediately. Linen soiled with blood or body fluids should be transported in leakproof bags.

What about waste disposal?

There are two kinds of waste seen in the dialysis unit: regular trash and infectious waste. Regular trash, which is mostly paper and plastic, can be disposed of by the usual practice. Infectious waste, which is usually defined in a dialysis unit as “bloody,” must be disposed of in specially labeled red bags. Various states have laws regarding the definition of infectious waste and its disposal.

Has peritoneal dialysis waste tested positive for HIV?

HIV antibody has been detected in the dialysate waste of AIDS patients. To date there are no national guidelines for the disposal of waste dialysate from AIDS patients.

Should additional precautions be taken when caring for the patient on home peritoneal dialysis?

Standard precautions must be observed with all patients when there is a possibility of contact with blood or body fluids. In addition, each renal unit devises its own criteria for safe disposal of waste fluids for the patient both at home and in the unit setting. Patients at home should be instructed to drain their bags into the toilet and then seal the empty bag in a plastic bag before disposal with household garbage. In the continuous ambulatory peritoneal dialysis (CAPD) unit, a toilet or sluice should be used whenever possible. Many units use a 1:10 bleach solution following the dialysate. Some units suggest adding 10 mL of bleach to the bag before disposal. If a sink is used for waste disposal, a bleach solution should follow the waste and preferably sit for 30 minutes.



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