Guidelines for the Selection of Anti-infective Agents for Complicated Intra-abdominal Infections

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• Vascular access for prolonged periods
• Multiple patients on dialysis concurrently
• Person-to-person transmission
• Directly
• Indirectly
• Devices equipment
• Supplies
• Environmental surfaces
• Hands of HCW
• Loading with nosocomial pathogens
• Antimicrobial resistance

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• Safety
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Infection Control Components-Study on the
Efficacy of Nosocomial Infection Control (SENIC)

• Surveillance and control activities
• Infection preventionist
• Trained hospital epidemiologist
• A system

Am. J. Epidemiol. 121, 182205 (1985)
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Comprehensive Infection Control Program in
Hemodialysis Unit

• Infection control practices
• Infection control precautions
• Bloodborne viruses
• Pathogenic bacteria
• Routine serologic testing for HBV HCV
• Vaccination of susceptible patients against
  hepatitis B.
• Isolation of patients with HBsAg
• Surveillance for infections
• Infection control training and education

CDC MMWR 2001501-41
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Dialysis Center Guidelines

• Prevention of vascular access infections
• Environmental disinfection
• Hand hygiene
• Prevention of MDR organisms
• Vaccinations
• Pevention of bloodborne viruses

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Isolation strategies

• Airborne precaution
• Droplet precaution
• Contact precaution

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2013
lt200 (50) CFU/ml lt2 EU/ml
ISO 139592009 lt100 (50) CFU/ml lt0.25
EU/ml
2009
2004
AAMI RD52 200 (50) CFU/ml, 2 (1) EU/ml
2004
USP XXVII 100 CFU/ml, 2 EU/ml
2002
ISO 13959 100 CFU/ml, 1 - (5) EU/ml
2002
EDTA Best Practice Guideline lt100 CFU/ml,
lt0.25 IU/ml (high fluxlt 0.1 CFU/ml, lt0.03 IU/ml)
2002
Eur Pharm 4th ed 2002102 CFU/ml,lt0.25 IU/ml
2001
EDTNA Guideline lt102 CFU/ml, 0.25 IU/ml
1998
ISO 13959 100 CFU/ml, 5 EU/ml
1992
Eur Pharm 2nd ed 1992 102 CFU/ml, 0.25 IU/ml
1990
Sweden LS1990 lt102 CFU/ml, lt0.25 IU/ml
1982
AAMI 200 CFU/ml, - EU/ml
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Bloodborne VirusesHEPATITIS B
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• GOT/GPT 2-3X
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• Interferon
• Lamivudine 100 MG QD
• Adefovir 10 MG QD

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• Routine testing
• Vaccination
• Restricting exposure
• Hepatitis B immune globulin

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Routine Testing
Patient Status On Admission Monthly Semiannual Annual
All patients HBsAg Anti-HBs, Anti-HBc Anti-HCV ALT
Anti-HBs ( - ) Anti-HBc ( - ) HBsAg
Anti-HBs () Anti-HBc ( - ) Anti-HBs
Anti-HBs () Anti-HBc () No additional HBV testing No additional HBV testing No additional HBV testing
Anti-HCV( - ) ALT Anti-HCV
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Vaccination

• Subjects
• All patients on chronic hemodialysis
• The healthcare providers

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Vaccination

• anti-HBs Testing
• 1-2 months after last dose
• lt10 mIU/mL susceptible
• Revaccinate with an additional 3 doses
• Retest anti-HBs.
• gt10 mIU/mL immune
• Retest annually.
• Booster dose if anti-HBs lt10 mIU/mL
• Continue to retest annually

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HBsAg-Positive Patients

• Infection control practices as for all H/D
  patients
• Dialysis in a separate room with separate
  machines, equipment, instruments, and supplies
• Staff members should not care for HBV-susceptible
  patients at the same time
• Same shift
• Patient changeover

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Outbreaks of HBV Infection

• Cross-contamination to patients via
• Environmental surface, supplies ( eg. hemostats,
  clamps), or equipment was not routinely
  disinfected after each use
• Multiple dose medication vials and intravenous
  solution were not used exclusively for one pt
• Medications for injection were prepared in areas
  adjacent to areas where blood samples were
  handled
• Staffs simultaneously cared for both HBV-infected
  and susceptible pts.

MMWR 2001501-41
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Other Measures

• General infection control practices
• Cleaning disinfecting nondisposable items
• Using gloves when touch patients and equipments
• Between patients
• Changing gloves
• Cleaning disinfection of equipment
  environment
• Adherence
• Hand hygiene
• Safe injection and medication preparation
• Surveillance for HBV infection in susceptible
  patients
• HBsAg monthly

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Bloodborne VirusesHEPATITIS C
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• Blood transfusions
• Duration of dialysis
• Mode of dialysis
• Lower risk in peritoneal dialysis
• Previous organ transplantation
• Intravenous drug abuse

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Cross Contamination

• Preparation of multidose medications in the
  dialysis treatment station
• Mobile medication/supply cart to deliver supplies
  between patient stations
• Failure to clean and disinfect the dialysis
  station or dialysis machine
• Shared use of single-dose medication vials for
  more than one patient.

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Infection Control Technique

• Safe injection practices
• Hand hygiene
• Between patients
• Cleaning disinfection of equipment
  environment
• Isolation of patients not recommended

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Routine Testing
Patient Status On Admission Monthly Semiannual Annual
All patients HBsAg Anti-HBs, Anti-HBc Anti-HCV ALT
Anti-HBs ( - ) Anti-HBc ( - ) HBsAg
Anti-HBs () Anti-HBc ( - ) Anti-HBs
Anti-HBs () Anti-HBc () No additional HBV testing No additional HBV testing No additional HBV testing
Anti-HCV( - ) ALT Anti-HCV
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Bloodborne VirusesHIV
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Routine Testing

• Not recommanded
• Only for
• Patients with risk factors of infection

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• Source patient
• HBsAg () or unknown
• Hepatitis B immune globulin
• Test for HIV
• Inform patient consent required
• Prophylaxis
• RPR for syphilis
• PCN 3M u IM stat
• aHCV Ab

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• Staff
• HBsAg HBsAb HIV Ab RPR aHCV Ab
• Time of incident
• 6 weeks later
• 6 months later

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BSI (Blood Stream Infection)CLA-BSI(Central
Line Associated BSI)
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• Pathogenesis
• More common
• Pathogen migration along external surface
• Early (lt 7days)
• Hub contamination with intraluminal colonization
• Late ( gt10 days)
• Less common
• Hematogenous
• Seeding from another source
• Contaminated infusates

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• Source of Infection
• Contiguous skin flora
• Contamination
• Catheter hub or Lumen
• Infusate
• Hematogenous colonization
• From distant, unrelated sites of infection

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• Pathogens
• Coagulase-negative staphylococci
• S. aureus
• Candida spp.
• Gram-negative bacilli
• Enterococci

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Resistance CLA-BSI Agents
Pathogen ICU Non ICU Staph. coag neg
MRSE 75 65 Staph. aureus MRSA 50
40 Enterococci - Vanco R 12
12 Pseudomonas aeruginosa Fluoroquinolone 26
25 Imipenem 20 12 Ceftazidime
15 8 Piperacillin 17
12 Enterobacter 3rd Cef 36 5 E. coli
3rd Cef 36 5
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• Biofilm
• Attachment to intravascular catheters
• Sanctuary from antimicrobial agents
• Extracellular polysaccharide
• esp. Staphyloccoci
• Quorum-sensing" proteins
• Pseudomonas
• Drug resistance

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Extraluminal Route of Infection

• Cutaneous microflora
• Migration between
• Catheter
• Cannulated vessel
• Migration to
• First the catheter tip
• Then the bloodstream

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Intraluminal Route of Infection

• Contamination
• Catheter hubs
• Ports of needleless systems
• Over longer periods of time
• Surgically implanted catheter
• Cuffed catheters

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Intraluminal Route of Infection

• Extrinsic contamination
• Patient's skin
• Immediate environment
• Uncleaned hands of healthcare workers
• Intrinsic contamination
• Hematogenous colonization
• Epidemic infection
• Faulty manufacturing
• Onsite compounding

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Healthcare Personnel Hand Contamination
Hub Contamination
Contaminated Infusate
Contamination of insertion site
Hematogenous spread
Extraluminal Contamination
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Clin Infect Dis 2011 52108799
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• Universal precautions
• Staff must wear fluid-impermeable garments
• Gloves for potential exposure to blood or body
  fluids
• Gloves changed and hands washed between patients
• Protective eyewear and face shields for potential
  splashing of blood
• No recapping of contaminated needles w/ prompt
  disposal in appropriate container
• No eating or drinking in dialysis unit

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• General precautions for staff and patients
• Isolation
• ? HBsAg ()
• ? aHCV Ab ()
• ? HIV ()
• Dialyzer reuse
• ? HBsAg ()
• ? aHCV Ab ()
• ? HIV ()
• Cleansing w/ with 1 bleach
• Dialysis machines
• blood/body fluid contaminated areas

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Infection Control Precautionsfor All Patients

• Gloves Wear disposable gloves when caring for
  the patient or touching the patients equipment
  at the dialysis station
• Handwashing Remove gloves and wash hands between
  each patient or station
• Items taken into the dialysis station should
• Either be disposed of, dedicated for use only on
  a single patient
• Or cleaned and disinfected before being taken to
  a common clean area or used on another patient

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Infection Control Precautionsfor All Patients

• Unused medications (including multiple dose vials
  containing diluents) or supplies (e.g., syringes,
  alcohol swabs) taken to the patients station
  should be used only for that patient and should
  not be returned to a common clean area or used on
  other patients.
• When multiple dose medication vials are used
  (including vials containing diluents), prepare
  individual patient doses in a clean (centralized)
  area away from dialysis stations and deliver
  separately to each patient. Do not carry multiple
  dose medication vials from station to station.
• Do not use common medication carts to deliver
  medications to patients. Do not carry medication
  vials, syringes, alcohol swabs, or supplies in
  pockets. If trays are used to deliver medications
  to individual patients, they must be cleaned
  between patients.

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Infection Control Precautionsfor All Patients

• Clean areas should be clearly designated for the
  preparation, handling, and storage of medications
  and unused supplies and equipment. Clean areas
  should be clearly separated from contaminated
  areas where used supplies and equipment are
  handled. Do not handle and store medications or
  clean supplies in the same or an adjacent area to
  where used equipment or blood samples are
  handled.
• Use external venous and arterial pressure
  transducer filters/protectors for each patient
  treatment to prevent blood contamination of the
  dialysis machines pressure monitors. Change
  filters/protectors between each patient
  treatment, and do not reuse them. Internal
  transducer filters do not need to be changed
  routinely between patients.

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Infection Control Precautionsfor All Patients

• Clean and disinfect the dialysis station (e.g.,
  chairs, beds, tables, machines) between patients.
• Give special attention to cleaning control panels
  on the dialysis machines and other surfaces that
  are frequently touched and potentially
  contaminated with patients blood.
• Discard all fluid and clean and disinfect all
  surfaces and containers associated with the prime
  waste (including buckets attached to the
  machines).
• For dialyzers and blood tubing that will be
  reprocessed, cap dialyzer ports and clamp tubing.
  Place all used dialyzers and tubing in leakproof
  containers for transport from station to
  reprocessing or disposal area.

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Infection Control

• Respiratory virus prevention in general
• Hemodialysis center
• Patient identification
• Patient education
• Self reporting
• Before arrival
• Respiratory hygiene and cough etiquette
• Segregation from other patients and staff
• Staff not allowed to work

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Acknowledgement

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Thank You