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There and Back Again: Relearning Infection Control Matthew J. Arduino, M.S., Dr.P.H. Division of Healthcare Quality Promotion National Center for Preparedness, Detection and Control of Infectious Diseases Coordinating 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 Disease Control 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 4,500 300,000 263,820 4,000 Number of Dialysis Facilities 3,500 4,035 3,000 200,000 159,267 2,500 150,000 2,000 2,116 1,500 100,000 65,765 1,000 50,000 1,051 500 0 0 1982 1992 Number of Dialysis facilities 2002 Number of Patients Number of patients 250,000 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 “Headersepsis” 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 New Jersey, 1997 New York, 1998 Illinois, 1999 Minnesota, 2000 Nevada, 2000 Maryland Peritonitis Blood Blood Endocarditis Bone Liver Blood Chronic PD Recent PD Chronic HD Chronic HD Chronic HD --------- 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 recipient ZhuW, 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 HBV Hepatitis B, C, and D Viruses Human Immunodeficiency Virus (HIV/AIDS) HCV HIV Estimates of Acute and Chronic Disease Burden for Viral Hepatitis, United States Acute infections (x 1000)/year* Fulminant deaths/year Chronic infections Chronic liver disease deaths/year HAV HBV HCV HDV 125-200 140-320 35-180 6-13 100 150 ? 35 0 1-1.25 million 3.5 million 70,000 5,000 8-10,000 1,000 0 * Range based on estimated annual incidence, 1984-1994. Relative Infectivity of HBV, HCV, and HIV Titer/ml Environmental Stability HBV 108-11 HCV 105 HIV 103 ++++* +** - *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. Hepatitis B by Year, United States, 1966 - 2000 HBsAg screening of Infant pregnant Immunization women recommended recommended Cases per 100,000 Population 14 Vaccine licensed 12 1977 CDC Recs for Dialysis 10 OSHA Rule enacted Adolescent Immunization recommended 8 6 4 Decline among MSM & HCWs 2 Decline among injecting drug users 0 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 Source: NNDSS Year Incidence and Prevalence of Hepatitis B in the United States, 1976-2002 250,000 2001 CDC Recommendations 10 8 Vaccine 200,000 6 150,000 4 100,000 50,000 2 0 0 1976 1980 1985 1990 1996 2000 2002 Year Patients Incidence Prevalence Icidence/ Prevalence Total Patient Population 1977 CDC Recommendations 300,000 Incidence of HBsAg in Hemodialysis Patients, by use of Hepatitis B Vaccine, 1996 % Patients Vaccinated HBsAg incidence (%) Relative Risk # of Patients 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 Hemophilia Injecting drug users Hemodialysis STD clients Gen population adults Surgeons, other HCWs Pregnant women Military personnel 0 10 20 30 40 50 60 70 Average Percent Anti-HCV Positive 80 90 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 Surrogate testing of blood donors 20 18 16 14 12 10 8 6 4 2 0 Anti-HCV test (1st generation) licensed Anti-HCV test (2ndgeneration) licensed Decline among transfusion recipients Source: Sentinel Counties Decline among injection drug users 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 (CDC1995 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. RR17). 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 risk for 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 Ag Total AntiHBc IgM AntiHBc AntiHBs Interpretation - - - - Susceptible, Never infected + - - - + + + - Acute Infection, early incubation* Acute infection - + + - Acute resolving Infection - + - + + + - - Past infection, recovered and immune 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 some patients 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