Infection Prevention in Dialysis

Settings
 Why are Dialysis Patients at Risk for Infection?

• Patients who undergo hemodialysis have a higher risk of

infection, due to the following factors:
– Frequent use of catheters or insertion of needles to
access the bloodstream
– Weakened immune systems
– Frequent hospital stays and surgery
 Infections in Dialysis Patients
• Dialysis patients are at risk of getting hepatitis B and C infections
and bloodstream infections
– Hepatitis B and C are bloodborne viral infections that can cause
chronic (life-long) disease involving inflammation (swelling) of the
liver
• Hepatitis B and C viruses can live on surfaces and be spread
without visible blood
– A bloodstream infection is a serious infection that can occur
when bacteria or other germs get into the blood
• One way bacteria can enter the bloodstream is through a
vascular access (catheter, fistula, or graft)
 Infections in Dialysis Patients
• Bloodstream infections are a dangerous complication of dialysis
• 1 in 4 patients who get bloodstream infection caused by
S. aureus (staph) bacteria can face complications such as:
– Endocarditis (infected heart valve)
– Osteomyelitis (infected bone)
• Total costs for each infection can be more than $20,000
• Bloodstream infections can cause sepsis (a potentially deadly
condition)
• Up to 1 in 5 patients with an infection die within 12 weeks
 National Burden of Dialysis Infections
A Cause for Concern
• In the US, there are about
370,000 people relying on
hemodialysis
• About 75,000 people receive
hemodialysis through a central
line
• Central lines have a higher risk of
infection than a fistula or graft
• CDC estimates 37,000 central line-
associated bloodstream infections may
have occurred in U.S. hemodialysis
patients in 2008
 How Do Infections Happen?
Three elements must be present for an
infection to occur:
Contact
1. A source of germs (like bacteria or
viruses)
2. A susceptible host, meaning a
person who is at risk of getting an
infection from the germs
Droplet
3. A way for the germs to move from
the source to the host
– There are three ways in which
germs move from the source to the
host: Contact, Droplet, and
Airborne Transmission Airborne
SOURCE
HOST
 Your Role in Contact Transmission

Contact

SOURCE HOST
DIALYSIS DIALYSIS
PATIENT PATIENT
Healthcare Worker Hands
A B

• During dialysis, infections can be spread by Contact

Transmission
• Most commonly by healthcare worker hands!
Photo provided by Stephanie Booth, used with permission
 Spread of Respiratory Infections

Droplet

Airborne

SOURCE HOST

• Certain infections are spread by certain routes:

– Flu may be spread by Droplet Transmission
– Tuberculosis is spread by Airborne Transmission
 What Can You do to Prevent the Spread of
Infections?
Understand and Follow the Basics of Infection
Control
• All healthcare workers are expected to follow Standard Precautions
for infection control.
• In addition, CDC has developed specific recommendations tailored
for hemodialysis healthcare workers, recognizing the increased risks
for infection.
Standard Precautions for all Healthcare
Workers in All Healthcare Settings
Standard Precautions for all Healthcare
Workers
• Perform hand hygiene
• Use personal protective equipment (PPE)
• Follow safe injection practices
 Perform Hand Hygiene

• When hands are visibly soiled with blood or

other body fluids, wash hands with soap
and water

• If hands are not visibly soiled, use an

At least 15
alcohol-based hand rub seconds

Remember: hand hygiene is one of the most important

ways for you to prevent the spread of infections
 When you should perform hand hygiene

• Before you touch a patient

• Before you inject or infuse a medication
• Before you cannulate a fistula/graft or access a catheter
• After you touch a patient
• After you touch blood, body fluids, mucous membranes, wound
dressings, or dialysis fluids (e.g., spent dialysate)
• After you touch medical equipment or other items at the dialysis
station
• After you remove gloves

Remember: perform hand hygiene between each patient or station

 Use Personal Protective Equipment (PPE)
Correctly
• For your own protection and to protect
patients
• Wear gloves, a gown, and/or face
protection when you think you may come
into contact with blood or other potentially
infectious materials
• Change gloves during patient care if the
hands will move from a contaminated body-
site to a clean body-site
• Remove gloves after contact with a patient
and/or the surrounding environment
(including medical equipment)
• Do not wear the same pair of gloves for the
care of more than one patient
 Follow Safe Injection Practices

• Medications are injected directly or indirectly

into the patient’s bloodstream
• Any germs that have entered the medication
vial or syringe can cause serious infections
in the patient
• Germs also can be introduced at the time of
injection (e.g. contaminated injection port)
 Follow Safe Injection Practices
Three things you need to know:
1. Needles and syringes are single use devices. They
should not be used for more than one patient.
2. Do not administer medications from a single-dose vial or
IV bag to multiple patients.
3. Perform hand hygiene and cleanse the access port before
injecting into it.
 Specific Infection Control Precautions
for Hemodialysis Healthcare Workers
• Wear gloves and other personal protective equipment
(PPE) for all patient care
• Promote vascular access safety
• Separate clean areas from contaminated areas
• Use medication vials safely
• Clean and disinfect the dialysis station between patients
• Perform safe handling of dialyzers
 Wear Gloves During Patient Care
• Wear disposable gloves when caring for the patient or touching
equipment at the dialysis station
• Wear gloves when cleaning surfaces in the environment or medical
equipment
• Remember to remove gloves and perform hand hygiene between
each patient or station, and if moving from a contaminated to clean
area of the same patient or within the same dialysis station
 Use Personal Protective Equipment (PPE)
• In addition to gloves, you should wear
gowns and face protection to protect
yourself as needed:
– During initiation and termination of
dialysis
– When cleaning dialyzers
– When handling lab samples
• PPE should be changed if it becomes dirty

Aseptic technique means taking great care to not

contaminate the fistula or graft site before or during the
cannulation or decannulation procedure
 Basic Steps in Fistula/Graft Care
Cannulation Procedure:
1. Wash the site
2. Perform hand hygiene
3. Put on a new, clean pair of gloves
4. Wear proper face protection
5. Apply skin antiseptic and allow it to dry
6. Insert needle using aseptic technique
7. Remove gloves and perform hand
hygiene
 Basic Steps in Fistula/Graft Care
Decannulation Procedure:
1. Perform hand hygiene
2. Put on a new, clean pair of gloves
3. Wear proper face protection
4. Remove needles using aseptic technique
5. Apply clean gauze/bandage to site
6. Compress the site with clean gloves
7. Remove gloves and perform hand hygiene
 Basic Steps in Catheter Care

Catheter Connection Procedure:

1. Perform hand hygiene
2. Put on a new, clean pair of gloves
3. Wear proper face protection
4. Apply antiseptic to catheter hub and allow it to dry
5. Connect the catheter to blood lines using aseptic technique
6. Unclamp the catheter
7. Remove gloves and perform hand hygiene
 Basic Steps in Catheter Care
Catheter Disconnection Procedure:
1. Perform hand hygiene
2. Put on a new, clean pair of gloves
3. Wear proper face protection
4. Disconnect the catheter from blood lines using aseptic
technique
5. Apply antiseptic to catheter hub and allow it to dry
6. Replace caps using aseptic technique
7. Make sure the catheter remains clamped
8. Remove gloves and perform hand hygiene
 Catheter Exit Site Care
1. Perform hand hygiene
2. Put on a new, clean pair of gloves
3. Wear a face mask if required
4. Apply antiseptic to catheter exit site and allow it to dry
5. Apply antimicrobial ointment
6. Apply clean dressing to exit site
7. Remove gloves and perform hand hygiene
 Dedicate Supplies to a Single Patient
• Separate Clean Areas from Contaminated Areas
• Clean areas should be used for the preparation, handling and
storage of medications and unused supplies and equipment
– Your center should have clean medication and clean supply
areas
• Contaminated areas are where used supplies and equipment are
handled
• Do not handle or store medications or clean supplies in the same
area as where used equipment or blood samples are handled

Remember: Treatment stations are contaminated areas!

 Dedicate Supplies to a Single Patient
• Any item taken to a patient’s dialysis station could become
contaminated
• Items taken into the dialysis station should either be:
– Disposed of, or
– Cleaned and disinfected before being taken to a common clean
area or used on another patient
• Unused medications or supplies taken to the patient’s station should
not be returned to a common clean area (e.g., medication vials,
syringes, alcohol swabs)
 Safe Use of Medication Vials
• Prepare all individual patient doses in a clean area away from
dialysis stations
• Prepare doses as close as possible to the time of use
• Do not carry medications from station to station
• Do not prepare or store medications at patient stations
• CDC recommends that dialysis facilities:
– Use single-dose vials whenever possible and dispose of them
immediately after use
Guidelines for Carrying Medications
• Do not use the same medication cart to deliver
medications to multiple patients
• Do not carry medication vials, syringes, alcohol swabs, or
supplies in pockets
• Be sure to prepare the medication in a clean area away
from the patient station and bring it to the patient station for
that patient only at the time of use
 Cleaning and Disinfecting the Dialysis Station

• Cleaning and disinfection reduce the risk of spreading an infection

• Cleaning is done using cleaning detergent, water and friction, and is
intended to remove blood, body fluids, and other contaminants from
objects and surfaces
• Disinfection is a process that kills many or all remaining infection-
causing germs on clean objects and surfaces
– Use an EPA-registered hospital disinfectant
– Follow label instructions for proper dilution
• Wear gloves during the cleaning/disinfection process
 Disinfecting the Dialysis Station
• All equipment and surfaces are considered to be
contaminated after a dialysis session and therefore
must be disinfected
• After the patient leaves the station, disinfect the
dialysis station (including chairs, trays, countertops, and
machines) after each patient treatment
– Wipe all surfaces
– Surfaces should be wet with disinfectant and
allowed to air dry
– Give special attention to cleaning control panels on
the dialysis machines and other commonly touched
surfaces
– Empty and disinfect all surfaces of prime waste
containers
Safe Handling of Dialyzers and Blood Tubing

• Before removing or transporting used dialyzers and blood

tubing, cap dialyzer ports and clamp tubing
• Place all used dialyzers and tubing in leak-proof containers
for transport from station to reprocessing or disposal area
• If dialyzers are reused, follow published methods (e.g.,
AAMI standards) for reprocessing

AAMI is the Association for the Advancement of Medical Instrumentation

Infection Control Policies and Practices
for Outpatient Hemodialysis Facilities
 Infection Control Policies and Practices for
Dialysis Facilities

• Vaccination of dialysis staff and patients

• Preventing the spread of hepatitis B
• Preventing the spread of bacterial infections
 Vaccine-Preventable Infections

• Influenza
– Influenza or the “flu” is a respiratory infection that infects
the nose, throat, and lungs
– The flu is spread mainly by droplets that are made when
people with flu cough, sneeze or talk
– The single best way to prevent the flu is to get a flu
vaccine each year
• Hepatitis B
– Hepatitis B is a serious infection that affects the liver. It
can cause acute (short-term) or chronic (long-term)
infection and liver cancer
– Hepatitis B virus is easily spread through contact with
the blood or other body fluids of an infected person
– Hepatitis B vaccine can prevent hepatitis B infection
 Take Care of Yourself
Get Vaccinated
• Get the flu vaccine each year
• Complete the hepatitis B vaccine series
 Preventing the Spread of Hepatitis B

• Dialyze hepatitis B (HBsAg+) patients in a separate room using

separate machines, equipment, instruments, and supplies
– Be sure to use a separate gown when treating these patients
• Staff members caring for patients with hepatitis B (HBsAg+) should
not care for HBV-susceptible patients at the same time (e.g., during
the same shift or during patient changeover)

• HBsAg+ means hepatitis B surface antigen (a lab test for hepatitis B virus)
was positive
• HBV-susceptible means anyone who has never been infected and lacks
immunity to hepatitis B virus
Preventing the Spread of Bacterial Infections

• Hemodialysis patients who might be at increased risk for spreading

germs to other patients include those with:
– An infected skin wound with drainage that is not contained by
dressings
– Fecal incontinence or uncontrolled diarrhea
• For these patients use the following precautions:
– Wear a gown and gloves when you are caring for the patient and
remove the gown and gloves when you are finished caring for the
patient
 Cont.
– Do not wear the same gown when caring for other patients
– Dialyze the patient at a station with as few adjacent stations as
possible (e.g., at the end or corner of the room)
• Patients with respiratory illness and a fever are at risk of spreading
bacterial and viral respiratory infections
– These patients should be dialyzed at least 6 feet away from other
patient stations or any shared supplies
 How to Recognize an Infection
• Advise patients to inform you if they notice any of the
following possible signs of infection:
- Fever
- The access site is:
* Swollen (bulging), red, warm, or has pus
- Severe pain at the access site
Remember: infections of the vascular access site can be life
threatening
 Training and Education of
Patients and their Caregivers
• When a new patient starts dialysis and on an annual basis, review:
– Personal hygiene and hand hygiene technique
– Patient responsibility for proper care of the access site and
recognition of signs of infection
– Recommended vaccinations (including hepatitis B, influenza, and
pneumococcal)
– Reasons for selecting a fistula or graft over a catheter to lower
the risk of infection
 Key Infection Prevention Practices

• Perform hand hygiene frequently and change gloves

• Maintain separate clean areas for supplies and medications and
separate contaminated areas for used items
• Practice proper handling and delivery of patient supplies and
medications
• Perform effective cleaning and disinfection of dialysis equipment and
environmental surfaces
• Carefully handle medications and the patient’s vascular access to
avoid contamination

Remember: Use aseptic technique every time!

 Conclusion
• Infections that patients can get while receiving dialysis are
serious and preventable!
• Healthcare workers like you following infection control
precautions and other safe care practices are the key to
prevention
• Infection prevention is everyone’s responsibility