HD RELATED INFECTIONS- HD workshops.pptx

hemodialysis related infections

1. Haemodialysis Related Infections Dr. Omima Mohamed Taha Abdel Aziz MBBS, UofK MRCP, UK Nephrology Fellowship, SMSB ISN-CNC Diploma GN ( glomCon )

2. INTRODUCTION Patients on dialysis are at high risk of infections because of underlying illness and numerous environmental and procedural risks. Establishing a comprehensive infection prevention and control programme for dialysis settings will reduce the infection risks for both patients and healthcare workers

3. RISKS OF ACQUIRING INFECTIONS IN DIALYSIS PATIENTS: Diabetes mellitus Hypertension Cardiovascular disease Frequent exposure to antibiotics Immunosuppressive therapy Other critical diseases Direct access into normally sterile areas Contamination: either extrinsive or intrinsive

4. HAEMODIALYSIS ASSOCIATED INFECTIONS: Catheter related infections (CRI) Hepatitis B Hepatitis C Acquired Immunodeficiency Syndrome (AIDS) Mycobacterium (TB) Other bacterial infections Fungi COVID-19

5. CATHETER RELATED INFECTIONS: Tunnelled cuffed catheters (TCC) have been found to be associated with as much as a threefold increased mortality compared with AVFs Sepsis related death is 100 times greater in dialysis patients than in general population Infection related death and all cause mortality are highest in those with TCC The cost of placing the TCC is high and that of treating a TCC related episode of bacteraemia is much higher Several fold increase in cardiovascular risk is also noted with TCC

6. COMPLICATIONS ASSOCIATED WITH TCC: Poor quality of life Reduced dialysis adequacy Central venous stenosis

7. SERIOUS COMPLICATIONS RELATED TO CATHETER BACTERAEMIA: Infective endocarditis Septic arthritis Septic emboli Osteomyelitis Epidural abscess Severe sepsis

8. PREDISPOSING FACTORS:

9. THE MOST COMMON TYPES OF DIALYSIS-ASSOCIATED INFECTIONS: Access site infections Catheter’s Tunnel Infection. Bacteraemia Peritonitis Pyrogenic reactions Infections with blood-borne pathogens

10. PATHOGENS:

11. CLINICAL PICTURE Often suspected clinically in a haemodialysis patient who presents with fever or chills, unexplained hypotension and no other localizing signs Mild symptoms include malaise and nausea, in the setting of a normal catheter exit site or tunnel, on physical exam More-severe symptoms include high fever with rigors, hypotension, vomiting and changes in mental status Older and more-immunocompromised patients might present with low-grade fever, hypothermia, lethargy, hypoglycaemia, or diabetic keto - acidosis

12. EXIT SITE INFECTION: Infection is indicated by the presence of erythema, swelling, tenderness and purulent drainage around the catheter exit and the part of the tunnel external to the cuff

13. TUNNEL INFECTION: Symptoms of tunnel infection are swelling, erythema, fluctuation and tenderness over the catheter tunnel central to the cuff.

14. DIAGNOSIS: Requires positive blood cultures obtained from the catheter and from a peripheral vein with quantitative colony count at least four fold higher in the catheter sample A more practical definition is the presence of positive blood cultures in a febrile catheter-dependent patient, in the absence of alternative sources of infection upon clinical evaluation

15. CATHETER RELATED BACTERAEMIA PROPHYLAXIS: Antibiotic lock Exit site antibiotic application Heparin coating

16. TREATMENT: Empiric therapy should include vancomycin and antibiotic with broad-spectrum gram-negative bacterial coverage (3 rd generation cephalosporin) Antibiotic regimen should be modified as soon as the sensitivity reports are available Linezolid should be reserved for treatment of vancomycin-resistant organisms With these measures, outpatient management is feasible in greater than 80% of patients with catheter-related bacteremia

17. TREATMENT (Continued) : Because of the bacterial biofilm formation, treatment of catheter-related bacteremia without catheter removal is relatively ineffective. Different options include : TCC salvage. TCC exchange over a guidewire with antibiotics. Immediate TCC removal with delayed reinsertion and antibiotics .

18. TREATMENT (Continued) : Criteria to attempt catheter salvage Difficult to replace catheters Blood sterile in 48–72 h No sign of tunnel infection No signs of metastatic infection Microorganisms medically treatable A hemodynamically stable patient There is a 5-fold higher risk of treatment failure when TCC salvage is attempted, and an 8-fold higher risk in cases associated with S. aureus bacteremia Salvage should be used only as a treatment of last resort

19. TREATMENT (Continued) : Catheter removal with replacement in new site One option is immediate catheter removal, followed by placement of a temporary catheter, then conversion back to tunneled catheter. Indications for immediate removal are the following: Severe sepsis Hemodynamic instability If fever or bacteremia persists 48 to 72 hours after initiation of antibiotics to which the organism is susceptible Metastatic infection Signs of tunnel infection Fungal organisms.

20. TREATMENT (Continued) : Studies that have evaluated antibiotic lock therapy for treatment have varied in the types of antibiotics and concentrations used, the addition of heparin to the solutions, and dwell times in the catheter lumen Reported success in small series ranged between 40% to 87% depending on the pathogen Stronger evidence however is available for exchanging catheter over a guidewire

21. TREATMENT (Continued) :

22. RECOMMONDATIONS 1- To create infection control team to set standard measures and to supervise the HD centers and assure implementation of these measures. 2-To decrease the use of tunneled catheters as a permanent access for dialysis . 3-If possible to put the creation of AVF as a pre-requisite for HD centers distribution. 4- To pprovide OR make available antibiotics under umbrela of common health insurance

23. HEPATITIS B VIRUS Hepatitis B virus (HBV) is transmitted through per cutaneous or per mucosal exposure to the blood of infected patients (HBsAg-positive or HBeAg-positive). HBV remains viable at room temperature for at least 7days HBV has been detected on: clamps, scissors, and external surfaces and parts of dialysis machines. HBV can be transmitted to patients or staff on gloves or unwashed hands.

24. ROUTINE SEROLOGIC TESTING FOR HBV Patient Status On-Admission Monthly Semi-Annually Annually All patients HBsAg*, Anti-HBc (total) Anti-HBs, Anti-HCV, ALT HBV Susceptible including vaccine Nonresponders HBsAg Anti-HBs positive (≥10mIU/mL), Anti-HBc negative Anti-HBs Anti-HBs and Anti-HBc positive No Additional HBV testing needed * Results of HBsAg testing should be known before the patient begins dialysis

25. MANAGEMENT OF HBSAG-POSITIVE PATIENTS : Infection control practices for hemodialysis units for all patients Dialyze HBsAg-positive patients in a separate room using separate machines, equipment, instruments, and supplies. Staff members caring for HBsAg-positive patients should not care for HBV susceptible patients at the same time (e.g., during the same shift or during patient change-over).

26. HEPATITIS B VACCINATION Tow types of vaccine: a- Heplisav B vaccine ….2 doses 0—1---6 b- Engerix B vaccine 3 doses. 0---1---2------6 Dose is 40 microgram given intramuscular in deltoid Individuals who carry antibodies against the HBV (anti-HBs) above 10mlu/ml are protected. For CKD pts who donot respond to the primary vaccination, a new schedule with 4 doses of 40 mcg is recommended. For responders, testing should be done annually. For pts with antibody titre less than 10 mlu /ml booster dose is recommended.

27. HEPATITIS C : HCV is transmitted by per cutaneous exposure to infected blood. Factors that increase HCV infection in HD patients history of blood transfusions. volume of blood transfused. years on HD (≥5 years). inadequate IPC practices. Transmission of HCV through: shared equipment and supplies not disinfected between patients. use of common medication carts. shared multi-dose medication vials. contaminated HD machines, related equipment & blood spills.

28. HEPATITIS C VIRUS INFECTIONS IN DIALYSIS : Prevalence: 8-10% (1.6% in general popn ) Majority of infections are asymptomatic; majority develop chronic infection Isolation is not recommended, no vaccine Prevention requires strict attention to infection control practices

29. PLACE WHERE INJECTABLE MEDICATIONS WERE PREPARED AND ASSOCIATION WITH HEPATITIS C VIRUS INFECTION, 1999, UNITED STATES Place Where Medication is Drawn up in a Syringe Anti-HCV Prevalence, No (%) Patients Had Patients Who Became anti-HCV + in 1999, No (%) Centers Separate medication room or area 6,898 (8.6) 145 (10.3) Dialysis Station 1,178 (9.1) 23 (11.2) Medication Cart 2,623 (9.7) 56 (15.8)

30. HEPATITIS C VIRUS

31. HEPATITIS C VIRUS

32. ACQUIRED IMMUNE DEFICIENCY SYNDROME (AIDS ): Human immunodeficiency virus (HIV) is transmitted by blood or blood-containing body fluids. There have been very few reports of HIV transmission in dialysis and these resulted from inadequate disinfection of equipment, including access.

33. Haemodialysis-Associated Transmission of HIV In the U.S. there have been no patient infections, however there has been patient to healthcare worker transmission (1 definite, 3 possible) due to needlestick injuries (CDC. U.S. HIV and AIDS cases reported through June 2000. HIV/AIDS Surveillance Report2001;12 (1)) Outside U.S., transmission has occurred associated with reuse of vascular access needles, syringes, and injection practices (Argentina, Columbia, Ecuador, Egypt)

34. RCOMMONDATIONS FOR PREVENTION OF BBVs 1- Prevention of severe aneamia and blood transfusion requirement by : Ensuring availability of ESAs and injectable iron Using AVF as an access of HD 2- Infection control team including virologist, infection control nurse and doctor to strictly implement infecion control measure. 3- proper isolaion of HBV pts. 4- Availability of nursing staff and to decrease the ratio of urse : pt as close as possible to 1:1.

35. MYCOBACTERIA Reports of mycobacterial infections in dialysis patients from contaminated water. High-risk for progression from latent tuberculosis to active TB disease. Frequent hospitalization of dialysis patients increases the risk of transmission of TB to other patients or to HCWs.

36. FUNGI Dialysis patients are susceptible to fungal infections such as Aspergillus spp. In addition, there is a risk of Candida fungemia and peritonitis with the patient’s skin as a source.

37. COVID-19

38.  Thank You 