Transcript There and Back Again - Network of New England

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
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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?
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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
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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
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Vascular access related
Contaminated machines
Reuse related
Contaminated IV
medications
Contaminated Machines:
Waste Handling Option
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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