Preventing Infections in Patients Undergoing Hemodialysis Hepatitis B Preventing transmission of hepatitis B virus (HBV) in dialysis centers has been

an important part of infection control in hemodialysis for decades. In 1977, the CDC published infection control recommendations for the control of HBV in hemodialysis facilities, and by 1980 there had been a decline in the incidence of HBV infection both in patients [9,105] undergoing hemodialysis and among facility staff members. In 1982, hepatitis B vaccination was recommended for [10] chronic hemodialysis patients and hemodialysis staff, further reducing the risk for transmission. Following these efforts, the incidence of acute HBV infection in chronic hemodialysis patients has decreased from approximately 6.2% nationally in 1974 to 0.12% in 2002. Hepatitis C The prevalence of antibody to hepatitis C virus (HCV) is higher in hemodialysis patients (7.8%) than in the [11,13] [3] general population (1.6%) and may increase as a function of a patient's time on dialysis. As this virus is primarily transmitted through percutaneous contact with blood, patients undergoing hemodialysis may be at risk for transmission if proper infection control techniques are not followed. The CDC investigated a number of outbreaks of HCV infections in [14] dialysis centers between 1998 and 2006. These outbreaks involved breaches in infection control practices that afforded opportunities for cross-contamination, including the preparation of multidose medications in the dialysis treatment station, use of a mobile medication/supply cart to deliver supplies between patient stations, failure to clean and disinfect the dialysis station or dialysis machine, and/or shared use of single-dose medication vials for more than one patient. Preventing Influenza Individuals with chronic kidney disease, including those receiving hemodialysis, have been identified as a group at higher [16] risk for developing complications of seasonal influenza and therefore the prevention of influenza infection in this group of patients should be a priority in all hemodialysis facilities. Vaccination is an effective way to prevent infection with seasonal influenza. Influenza vaccination has been associated with a decreased risk of hospitalization and death in ESRD [17] patients. Yearly vaccination with inactivated influenza vaccine is recommended for all patients with chronic kidney [16] [2] disease. USRDS reported that 64% of ESRD patients on hemodialysis received influenza vaccination in 2007 while [12] Bond et al. found rates of 76% in their study in 776 dialysis facilities in three US regions (2005 2006). Both are below [2,106] the Healthy People 2010 goal of 90% for influenza vaccination coverage for those with ESRD. In addition to influenza vaccine, adult hemodialysis patients should be vaccinated with the pneumococcal polysaccharide vaccine once and then again after 5 years Preventing Bloodstream Infections Hospitalizations for infection among patients undergoing hemodialysis rose by 26% from 1993 to 2006, according to data [2] gathered by USRDS. The infectious syndrome with one of the highest rates of hospitalization was BSIs, with a rate of [2] 105 admissions per 1000 patient-years for 20052007. These infections are associated with high levels of morbidity and mortality; a 19% mortality rate at 12 weeks has been reported for Staphylococcus aureus BSIs among hemodialysis patients. Environmental Cleaning Blood contamination of equipment, of frequently touched surfaces and of the patient station in the dialysis unit is common. Studies have shown that the presence of bloodborne pathogens (e.g., HBV and HCV) can be detected on various [4952] surfaces within the dialysis unit. The hemodialysis machine and its components can also be vehicles for patient-to[5355] patient transmission of bloodborne viruses and pathogenic bacteria. The external surfaces of the machine are the most likely sources for contamination. These include not only frequently touched surfaces (e.g., the control panel), but also attached waste containers used during the priming of the dialyzers, blood tubing draped or clipped to waste containers, and items placed on tops of machines for convenience (e.g., dialyzer caps, clamps and medication vials) Injection Safety Between 1998 and 2006, the CDC and other public health authorities investigated six outbreaks of HCV transmission in [14,57] dialysis centers in the USA. These investigations identified 40 patients who likely acquired HCV infection in hemodialysis centers due to breaches in infection control, including unsafe injection practices. Syringe reuse, which has been implicated in many outbreaks of HBV or HCV in other healthcare settings, has not been recognized as a major contributor to transmission in dialysis settings. Instead, improper handling of shared medication vials in a manner that could facilitate contamination has been more prevalent. Some of the unsafe injection practices linked to bloodborne pathogen outbreaks include preparation of parenteral medications for multiple patients in patient treatment areas and [57] reuse of single-dose medications for multiple patients. In 2001, investigators documented an outbreak of Serratia liquefaciens BSI in hemodialysis patients, which resulted from multiple entry into and pooling of medication from single-

dose medication vials. Although pooling of medications was explicitly prohibited by the CMS following the outbreak, reuse of single-dose medications for multiple patients has remained a common practice in dialysis centers until fairly recently. Preventing Transmission of Multidrug-resistant Organisms Multidrug-resistant organisms (MDROs) are organisms that are not susceptible to one or more classes of antimicrobial agents. Most of these organisms are bacteria, and their nonsusceptibility to multiple commonly prescribed antimicrobials makes treatment of these organisms a challenge. Although a number of bacteria or groups of bacteria meet this broad definition, the organisms often listed in this category include vancomycin-resistant enterococci (VRE), vancomycinresistant and methicillin-resistantS. aureus (VRSA and MRSA) and multidrug-resistant Gram-negative bacilli; Clostridium difficile is intrinsically resistant to most antimicrobials and is also frequently included in this group. Decolonization Colonization with S. aureus is a recognized risk factor for subsequent S. aureus infections in patients on [70] hemodialysis. Along with coagulase-negative staphylococcus, S. aureus is one of the most common causes of BSIs in patients on hemodialysis, accounting for approximately 22% of these infections. In addition, S. aureus infections, particularly BSIs, have been associated with high rates of morbidity and mortality. S. aureus BSIs in hemodialysis patients have also been associated with the development of complications, including endocarditis and osteomyelitis. Reference: http://www.medscape.com/viewarticle/723600_4

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The prevention of healthcare-associated infections continues to garner increasing attention in the USA. Although much of this attention is focused on inpatient settings, outpatient settings are also facing greater scrutiny. The increase in the rate of infectionrelated hospitalizations of hemodialysis patients reported by USRDS despite a fall in the rate of hospitalizations for other disorders suggests there is an urgent need for effective strategies to prevent dialysis-related infections. Prevention efforts will likely require the cooperation of stakeholders from diverse fields, including experts in nephrology and hemodialysis, infection control, public health officials and other groups that may not have historically worked closely together. Establishing the capacity for basic infection control in outpatient dialysis settings is a fundamental undertaking with many important aspects. Characterizing facility-specific events through surveillance of outcomes and practices is a crucial but sometimes overlooked first step. Other critical aspects include vaccinating susceptible patients and staff, following best practices for the prevention of catheter-associated infections, ensuring that environmental surfaces are cleaned and disinfected correctly, and implementing safe injection practices. Staff training to promote and reinforce adherence to basic infection control practices should also be considered a key component of infection prevention activities within the facility. Beyond enhancing infection prevention activities at the facility level, several issues related to infection control in outpatient hemodialysis may be of increasing significance in the coming 5 years. First, there is a need for ongoing prevention research. Many issues in infection control remain to be definitively studied, and the development of new technologies and strategies will require continuing evaluation. Historically, many studies of infection control interventions have been observational and have involved the implementation of several interventions at once, making it difficult to determine the relative contribution of specific interventions. The use of rigorous, controlled trials will be necessary to definitively answer many of the remaining and emerging questions. Establishing and prioritizing the questions will also be an important step, as the resources available to address these problems are not unlimited. This process of forging an effective research agenda and generating demand for translatable evidence will require the input and collaboration of stakeholders from a wide variety of fields. A second issue that will likely take on increasing importance in the near future is surveillance and reporting of healthcare-associated infections from dialysis facilities. CMS requires outpatient dialysis facilities to 'analyze and document' the incidence of a number of [111] infections or syndromes and to review and act upon this information. However, reporting of this information, except in a few [111] circumstances (i.e., acute HBV/HCV infection and clusters of infections), is generally not required. A number of states have [81] mandated public reporting of healthcare-associated infections. One US state has passed a law requiring the reporting of BSIs from [112] healthcare settings, including outpatient dialysis centers, and has begun to implement this mandate. Their experience may demonstrate to others the value and limitations of statewide public reporting for dialysis infections. Third, the use of a collaborative model to implement prevention efforts might increasingly find its way into dialysis settings. In this model, facilities join with other facilities to work together as a group to address key issues. Participants jointly decide on interventions that are to be employed and use standard outcome measures to gauge the effect of the interventions. These efforts may also incorporate behavioral change techniques to maximize the uptake of infection control interventions. This approach has [82,83] been successful in reducing healthcare-associated infections in inpatient facilities and has the potential to work well in dialysis facilities for the prevention of infections, including BSIs. The prevention of infections is an essential part of providing high-quality care to patients. Hemodialysis providers have a responsibility and a unique opportunity to prevent infectious complications in their patients. However, there continues to be a role in this process for all stakeholders, including infection preventionists, regulators and public health officials. The challenge is to ensure that recommended practices are implemented, to evaluate whether these practices have the desired effect, and to work to better define and address the uncertainties that remain.