Section 17

Infection Control
Purpose
The purpose of this section is to provide a cognitive understanding of
current concepts in infectious diseases and their implications for
practice in hemodialysis centers.
Objectives
Upon completion of this section, the learner will be able to:
1. Describe the difference between exposure to tuberculosis and
active disease.
2. Outline current recommendations for immunizations in patients
with chronic kidney disease.
3. List the methods that decrease the risk of infections in the
vascular access.
4. Identify how contamination of the delivery system fluid pathway
can contribute to patient infections.
5. Explain how hepatitis B, hepatitis C, hepatitis D, and HIV are
spread in the dialysis unit.
6. Describe infection control measures that should be taken with any
dialysis patient.
7. List the factors that contribute to development of drug resistance.
8. Discuss the specific infection control requirements for a patient
with hepatitis B.
9. Describe why persons with chronic kidney failure are predisposed
to development of active tuberculosis after exposure to the
bacterium.
10. List the ways that dialyzer reprocessing can contribute to
bacteremia.
11. Desribe how a recommendation promulgated by a
professional organization may be formally adopted as a
regulation.
 12. Define how the CQI process may be used to address
infection control issues in the dialysis unit.
13. List the reasons why patients with HIV do not require
special isolation or infection control procedures.
14. Discuss the unique characteristics of the tuberculosis
bacterium that make it more difficult to diagnose and treat.
15. Describe the infection control measures to be used with a
patient with hepatitis delta virus (HDV).

Infection Control
Overview
I . Patients with chronic kidney disease, stage 5, are at risk of infection
for a number of reasons.
A. Impaired immune function.
B. Presence of a vascular acces to perform kidney replacement
therapy.
C. Presence of one or more additional chronic illnesses.
D. Frequent hospitalizations, surgeries, and/or medical procedures
E. Provision of care in a setting where multiple patients are treated
at the same time by multiple caregivers.
F. Use of immunosuppressive medications.

II. In patients with chronic kidney disease, stage 5, infection are the
second most common cause of death. A large number of
hospitalizations of dialysis patients and transplant patients are due to
infections.
III. In healthy individuals, inflammation is a protective mechanism that
assists in removing the antigen and facilitates the healing process.
Patient with CKD are known to have ongoing, micro-inflammation.
Inflammation in patients with CKD is due to multiple factors.
A. Infection.
 B. Use of bioincompatible dialyzer membranes.
C. Backfiltration of nonsterile dialysate during the hemodialysis
treatment.
D. Periodontal disease.
E. Ongoing uremic environment.
F. Malnutrition.
G. Hemolysis.
H. Surgery.

IV. When inflammation becomes excessive or continous, inflammatory

processes no longer contribute to healing. Growth factors are inhibited
and wound healing cells do not function normally. Healing is impaired
and a vicious cycle of ongoing injury begins. Ongoing inflammation
leads to:
A. Loss of muscle mass and hypoalbuminemia.
B. Cardiovascular disease.
C. Erythropoietin resistance.

V. Recent studies imply that cardiovascular events

( such as myocardinal infarction and congestive heart failure) may be
influenced by infections because of increased inflammatory mediators
that accompany the infections.

Bacteremia
I. Risk Factors.
A. Kidney failure and bacteremia risk factors include:
1. Chronic hemodialysis requiring vascular acces for prolonged
periods.
2. The hemodialysis environment, which provides opportunities for
transmission of infectious agents.
3. Patients with kidney failure have higher incidence of blood
stream infections ( bacteremia ).
A. Altered immune response due to kidney failure.
B. Impaired neutrophil function.
C. Frequent hospitalizations.

4. Patient factors.
a. Extreme of age ; older adults at greatest risk.
b. Chronic health problems.
1. Diabetes mellitus.
2. Disorders of the kidney.
3. Malnutrition.
4. Debilitation.
5. Splenectomy.
6. Wounds.
c. Immunosuppression due to:
(1) Suppressed inflammatory response.
(2) High level of circulating uremic toxins.
(3) Abnormal intake of nutrients neccessary for white
blood cell ( WBC ) growth and function.

5. Treatment factors.
a. Hospitalization.
b. Invasive procedures.
c. Instrumentation: artificial devices that penetrate the body.
(1) Frequency of manipulation.
(2) Site of insertion.
(3) Conditions at insertion. Portals of entry by which the
infectious agent can center the human body include
discruption of the skin, the body’s first line of defense. A
susceptible host is one who lacks effective resistance to
the infectious agent. Risk factors include:
 (a) Age of host and general health, including
comorbidities.
(b) Nutritional status.
(c) Absent or abnormal immunoglobulins / ability of
hematopoietic system to function
(4) Skin colonization.
(a) Number of organisms present at exposure.
(b) Duration of exposure.
d. Catheters.
(1) Catheter colonization. A significant growth of a
microorganism(>15 colony forming units) from a
catheter tip, subcutaneous segment of the cathter, or
catheter hub.
(2) Duration of cathetererization.
(3) Dialysis catheter are associated with a 7.6-fold increase
in the relative risk of bacteremia compared to
arteriouvenous fistulas.
e. Immunosuppression.
(1) Suppressed inflammatory response.
(2) High level of circulating uremic toxins.
(3) Abnormal intake of nutrients necessary for WBC growth
and function.

II. Causes.
A. Pathogenic organisms. Any pathogenic organism can cause
bacteremia.
1. Gram-positive bacteria.
a. Staphylococcus.
(1) Staphylococcus aureus. Considered part of norma human
skin flora. Colonization common in anterior nares and
moist body areas. S. Aureus causes a wide variety of
infections, ranging from localized (e.g.,wound infection)
to disseminated disease (e.g.,septicemia). Foreign
 bodies, Such as intravascular catheters commonly lead to
infection with S. Aureus.
(2) Staphylococcus epidermidis. Commonly found on skin
and mucosal surfaces.This organism is a frequent cause
of infection of vascular acces devices. Coagulase
negative staphylococci (CNS). Eleven species of this
organism, thought most infections are caused by S.
Epidermidis. Infection can result from invasion from a
person’s endogenous strain. Foreign bodies such an
intravascular catheters or prosthetic heart valves are
predisposed to infection with CNS.
b. Streptococcus.
(1) Pneumococcus.
(2) Enterococcus.
2. Gram-negative bacteria.
a. Escherichia coli.
b. Klebsiella pneumonia.
c. Serratia.
d. Enterobacter.
e. Pseudomonas.
3. Fungsi.
4. Viruses.
5. Mycobacteria.

B. Systemic inflammatory response syndrome (SIRS).

1. Widespread, systemic inflammatory response to invading
organism(s).
2. SIRS criteria. Presence of two or more of the following:
a. Temperature alteration.
b. Heart rate > 90/ minute.
c. Respiratory rate > 20/ min.
d. White blood cell count alteration.
3. Causes of SIRS.
a. Trauma / tissue injury.
 b. Pancreatitis.
c. Radiation.
d. Thermal injury.
e. Infection.
(1) Initial insult with microbial toxins.
(2) Release of inflammatory substances.

C. Sepsis. Infection plus SIRS equals sepsis.

1. Sepsis criteria.
a. Hypotension ( functional hypovolemia ).
b. Hypoperfusion of tissues and organs.
c. Organ dysfunction.
(1) Oliguria.
(2) Mental change
(3) Hyperdynamic state.
(a) Increased cardiac output.
(b) Peripheral vasodilatation.
(c) Decreased systemic vascular response (SVR).
2. Sepsis is a systemic response to infection, resulting in :
a. Damage to the vascular endothelium.
b. Microcapillary leakage occurs toward the third space.
c. Cardiac dysfunction secondary to toxins and inflammatory
mediators; diminished ejection fraction.
3. Increasing incidence of sepsis is due to:
a. Immunocompromised patients ( including those with
kidney disease ).
b. Resistant microorganisms.
c. Increasing elderly population.
d. Increased awareness of infections and their complications.
e. Increased use of invasive procedures /lines.
4. Sepsis has been identified as one of the most common causes
of death in the intensive care unit (ICU).
5. Mortality due to severe sepsis is approximately 29%.
III. Management of sepsis includes:
1. Eradication of the causative organism.
a. Empirical intravenous antibiotics.
b. Adjustment of antibiotics based on culture sensitivity results.
c. Surgical management of septic source when appropriate.
2. Hemodynamic support consist of :
a. Administration of fluids.
b. Use of vasoactive drugs such as :
(1) Epinephrine hydrochloride.
(2) Levophed.
(3) Vasopressin.
3. Respiratory support.
4. Continous renal replacement therapy (CRRT).

B. Criteria for septic shock.

1. Sepsis-the hypodynamic phase, including:
a. Hypotension despite fluid resuscitation.
b. Decreased cardiac output.
c. Peripheral vasoconstriction.
d. Increased systemic vascular resistance.
e. Hypoperfusion ; tissue hypoxia.
f. Multiple organ dysfunction result in :
(1) Oliguria.
(2) Hepatic failure.
(3) Mental changes.
(4) Respiratory failure.
(5) Disseminated intravascular coagulation ( DIC ).
2. Septic shock occurs as result of bacteria and/or toxins released
by bacteria circulating in the blood.
a. Proinflammatory cytokines and other metabolites (
prostaglandins ) cause an increase in endothelial-derived
nitric oxide.
 b. Nitric oxide causes change in cell wall transport
mechanisms. Decreases in intracellular calcium leads to
vasodilatation and resistance to vasopressor agents.
c. A primary cause of the shock is systemic vasoactive
mediators released by gram – negative affecting almost
every physiologic system.
d. Some vessels ( arterioles ) remain vasoconstricted due to
various inflammatory mediators (e.g., tumor necrosis
factor)leading to maldistribution of blood flow.
e. These processes affect all physiologic systems of the body.
f. The incidence of septic shock approaches 500,000 cases
annually.

IV. Interpretation of lab results.

A. Interpretation /evaluation of culture and sensitivity,CBC with
differential.
1. Identify causative agent.
a. Using microscopy, bacterial growth is identified and
classified by shape and size.
b. Organisms are identified as gram-positive or gram-
negative.
c. Shape of organism is determined-rods vs. Cocci.
2. Organism identification by isolation from culture.
a. Common pathogens such as Staphylococci, Streptococci,
and Enterococci can be identified within 48 hours.
b. Fungal organisms may take 10-14 days for identification.
c. Viruses often take 2-3 weeks to grow in culture.
3. Sensitivity reports are obtained on the isolates, based on:
a. Minimum inhibitory concentration that will inhibit growth
of an organism.
b. Agar diffusion tests reported as resistant if growth is not
altered . Reported as sensitive if growth is inhibited.
4. White blood cell count.
 a. Provides important information concerning the
inflammatory response of the patient , as well as the
response to therapy.
b. Total number of circulating leukocytes and the differential
change during bacterial or viral infection.
c. Acute bacterial infection causes a rise in the white blood
cell neutrophils and increased bands ( immature
neuthrophils ).

B. When to report to physician or advanced practice nurse ( APN ).

1. Consider populations at risk.
a. Previous antibiotic therapy.
b. Underlying chronic disease such as diabetes and kidney
disease.
c. Decreased immunity.
d. Central venous catheter use.
e. Over 65 years of age.
f. Extended lenght of stay in health care facilities.
2. Blood cultures.
a. Avoid administration of antibiotics for organisms that may not
be the causative agent of the infection. For example, if a single
blood culture is positive for CNS and other blood cultures are
negative, consider the possibility that the culture was
contaminated with skin flora ( S. epidermidis ).
b. Notify patient care providers regarding presumptive
identification of vancomycin resistant enterococci ( VRE ) for
implementation of appropriate isolation precautions.
Vancomycin resistance is confirmed by repeating
antimicrobial susceptibility testing. Note: Stool or rectal swab
screening can detect presence of VRE due to VRE intestinal
colonization prior to clinical identification.

3. Causative agent.
 a. Organism is identified by isolation from culture.
b. Sensitivity reports are obtained on the isolates.
4. Complete blood count (CBC) provides:
a. White blood cell count (WBC).
(1) Total number of circulating leukocyctes.
(2) Differential.
b. Red bood cell count (RBC): hematocrit/hemoglobin levels.
c. Platelets: presence of thrombocytopenia.

Drug Resistance
I. Causes of drug resistance
A. Repeated antibiotic therapy.
B. Misuse of antibiotics.
1. Antibiotics should not be taken for viral infections such as a
cold or flu.
2. Antibiotics are not effective againts viruses.
3. Normal flora can be killed, allowin the multiplication of
resistant bacteria.
4. Proper collection and handling of specimens is imperative for
the causative organism to be correctly identified.
a. Avoid potential contamination of the specimen. Aseptic
techniques is mandatory to avoid contaminating the
specimen with organisms that colonize the skin or are
present on the central venous catheter hub or port.
b. For blood cultures, specimens obtained by venipuncture are
preferred over sampling from vascular catheters. Cultures
drawn from central venous catheters may reflect organisms
that have colonized the cathteter and may not accurately
reflect organisms freely circulating in the patient’s blood
stream.
c. Evaluate results drawn from central venous catheters
carefully. If bacterial growth is present only in the sample
obtained from the central venous catheter and not from
 peripheral cultures , the bacteria from the central venous
catheters may not be the cause of the infection and may not
require treatment with antibiotics.
d. CDC recommends treatment only for demonstrated
bacteremia , and not for result obtained from catheter tips.
e. Follow Current CDC guidelines for vancomycin use.
Consider use of first generation cephalosporins when
indicated

C. Nonadherence with the prescribed treatment regimen.

1. Failure to follow the instructions for when and how much
medicine should be taken.
2. As the person feels better may stop taking the medication
before the full medication course is completed.
3. Bacteria that have not been killed survive and develop
resistance to the antibiotic.
D. Multiple-drug resistant bacteria can spread from:
1. Person to person.
2. Contaminated environmental surfaces/objects.
3. Unwashed hands.

II. Methods to decrease development of antibiotic resistance.

A. Prudent use of antibiotics.
B. Patient education.
1. When and how much medication to be taken.
2. Take all medication prescribed. Do not stop medication early.
3. Do not take medication prescribed for someone else.
4. Do not share medications with others.
5. Do not take old or outdated medication.
6. Avoid close contact when sick with a fever :
a. Cover mouth and nose when sneezing and/or coughing.
b. Wash hands often.
7. Be involved with own care and take an active role in decisions.
 8. Remind health care team members to wash their hands.
9. If diabetic, perform regular foot checks.
10. Follow procedure for cleaning access before every
cannulation.
11. Ask health care team about when to wear masks or gloves.
12. Patient and family education on hand washing and
environmental cleaning at home. Additional education for
patients who require wound dressing changes and/or have
invasive devices such as catheters.

C. Hand hygiene.CDC continues to emphasize use of appropriate

hand hygiene.
1. Frequent hand washing.
2. Use of waterless hand antiseptics may be appropriate if hands
are not visibly soiled.
3. It is important to set an example for proper hand hygiene for
coworkers.
4. Partner with patients to educate them on access care and
infection control measures they can take. Regular and
consistent patient educationis critical.

D. Environmental cleaning and disinfection.

1. Environmental cleaning with approved disinfectant.
2. Disinfectant of patient equipment.
a. Use patient-specific equipment when possible.
b. Adequate cleaning and disinfection of reusable equipment
between patients following facility procedures

III. Infection control precautions.

A. Isolation. Maintain isolation precautions as appropriate for
infection.
 1. Patients with MRSA or VRE who do not have any
uncontrolled drainage may be treated in the facility using
standard and dialysis precautions defined by CDC.
2. Patients with infective material that cannot be contained (e.g.,
wound drainage that is not contained by a dressing, or an
incontinent patient with positive stool cultures and diarrhea
that cannot be contained by adult briefs) should be treated
using contact and dialysis precautions defined by CDC.
a. Infected patients with positive cultures for VRE or MRSA
whose drainage cannot be contained should be placed in a
designated isolation room or area of the facility that has
ready access to handwashing equipment.
b. Infected patients may be placed in the same area as other
patients with the same bacteria and antibiotic
resistance(cohorted).
3. When transferring a patient to another outpatient facility or
hospital, notification of the resistant bacteria is important so
appropriate precautions can be implemented.
B. Personal protective equipment (PPE).
1. Use according to facility’s infection control policies and
procedures.
2. Follow Centers for Disease Control and Prevention (CDC)
recommendations and Occupational Safety and Health
Administration (OSHA) standard precautions when coming
into contact with any body fluids.
3. When caring for a patient with antibiotic resistant bacteria, a
frequent change of gloves might be necessary after contact
with material that could contain high concentrations of
organisms(e.g.,stool, wound drainage ). Avoid cross-
contamination via contaminated gloves (i.e., transfer of
infectious material from dirty gloves to the patient or
environmental surfaces).

IV. Colonization vs. Infection.

 A. Colonization : bacteria requires surface on which to attach.
1. Prosthetic devices or materials can become colonized.
2. Bacterial biofilm can from within 24 hours.
3. Biofilm protects bacteria , allowing bacteria to grow, divide,
and multiply.
a. Resistance to antimicrobial agents is an important feature of
biofilm.
b. Biofilm is difficult to eliminate.
4. Patient does not exhibit signs / symptoms of active infection.
5. Strict attention to infection control practices must be followed
with every patient.
B. Infection : bacterial activity.
1. Signs and symptoms of infection present.
2. Culture of bacteria from source.

V. Common resistant organisms: Gram-positive organisms.

A. staphylococcus.
1. Staphylococcus aureus.
a. MRSA – Methicillin /oxacillin-resistant S.aureus
b. CA-MRSA-Community-associated MRSA emerging as
significant pathogen among patients without established
risk factors for MRSA infection.
2. Common findings.
a. Skin-to-skin-contact.
b. Compromised skin integrity.
c. Sharing of contaminated items.
d. Poor hygiene practices.

B . S. Epidermidis.
1. MRSE – Methicillin/oxacillin-resistant
S. epidermidis, coagulase-negative staphylococcus(CNS).
2. May occur after major surgical procedures involving
implantation of prosthetic materials or devices ( cardiac and
vascular procedures ).
a. Total hip replacement.
b. Valve replacement.

C. Streptococcus.
1. Enterococcus.
a. VRE – Vancomycin – resistant Enterococci.
b. Most VRE are also resistant to drugs previously used to treat
infectionby common disease-causing bacteria
(e.g.,aminologlycosides and ampicillin).
c. Patient –to-patient transmission of the microorganisms can
occur either through direct or indirect contact via:
(1) Hands of personnel.
(2) Contaminated patient – care equipment.
(3) Contaminated environmental surfaces.
2. Possibility exists that vancomycin-resistant genes present in
VRE can be transferred to other gram-positive
microorganisms, such as Staphylococcus aureus.
a. VISA-Vancomycin-intermediate S.aureus.
b. VRSA-Vancomycin-resistant S. Aureus.
c. Researchers are concerned that Staphylococcus aureus may
also develop resistance to Vancomycin.
d. Resistance to vancomycin virtually eliminates. All
treatment options for these common disease-causing
bacteria.
e. Decrease in new antibiotic production since 1983.

D. Clostridium difficile.
1. Incubation period may be 5 to 10 days or 2 to 10 weeks
following antibiotic treatment.
 a. Discruption in the normal enteric flora induced by
antimicrobials allow C. Difficile to overgrow and cause
disease.
b. Sudden onset diarrhea by C. Difficile overgrowth and
toxin production produces foul smelling stool containing
mucus.
c. Symptoms may include abdominal pain and distention ,
nausea, fever.
2. Period of communicability continues until diarrhea subsides.
3. Spread in the clinical environment is thought to be the result
of ingestion of bacterial spores.
a. Spores are stable in the environment for several months on
floors, toilet and furniture in areas where patients with
C.difficile infection have been treated.
b. Patient with existing C, difficile infections are thought to be
the main source of infections for other patients.
c. Enteric precautions include isolation of infected patients,
use of PPE, strict hand washing with soap and water, and
“deep” cleaning of areas used by patients; restriction on
patient movements in facility by treating in designated area
are all used to halt spread of the organism.
4. Alcohol-based hand gels/foams not recommended as spores
are resistant to alcohol.

VI. Management of patients with drug-resistant organisms

A. Assessment of vascular acces site.
1. Signs of a healthy vascular access.
a. Surronding skin with natural appearance.
b. No drainage,redness,swelling, or crusting.
2. Signs of access site infection.
a. Redness.
b. Warmth.
c. Swelling.
d. Pain / tenderness.
 e. Purulent exudate.

B. Locate the source of the infection and remove source(when

possible).
C. Treat the infection by initiating antibiotic therapy.
1. Appropriate for the organism.
2. Begin as early as possible.
D. Prevent the infection.
1. Consistent hand washing/hand cleansing.
2. Carefully monitor immunosuppressed patients for
signs/symptoms of infection.
3. Practice vigilant infection control.
4. Assessment of adherence.
5. Five most frequently cited reasons for nonadherence with
theraphy.
a. Dissatisfaction with regimen.
b. Improvement noticed prior to beginning the medication, so
initiation of therapy was delayed.
c. Improvement in symptoms after completing only part of the
drug regimen.
d. Forgetfulness in taking medications.
e. Unwanted side effects.
E. Outbreak management.
1. Notify identified infection control professional immediately if
outbreak of resistant bacteria is suspected.
2. Resources for developing a plan regarding the admission and
discharge of patients with resolving infections and/or
colonized with antimicrobial-resistant microorganisms may
include local and state health departments.

Hepatitis B virus (HBV)

II. incidence and prevalence.
 A. In the united states, approximately 1.2 million persons have
chronic hepatitis B infection.
B. During 1990-2002, the incidence of reported acute hepatitis B
infection in the united states decline 67%. Decline was greatest
among children and adolescents indicating effective
immunization practices(see figure 17.1 ).
C. Risk of hepatitits B infection is 100 times that of HIV infection
after a contaminated needlestick.
D. Chronically infected persons are central to the epidemiology of
HBV transmission.
II. Characteristics and markers (see figure 17.2).
A. DNA virus and member of the family hepadnoviridae.
B. Virus has an outer covering consisting of a lipoprotein known as
the surface antigen (HBsAg). Presence in the blood indicates a
current infection and transmissibility.
C. Hepatitis E antigen (HbeAg) is part of the interior core antigen or
HbcAG. It appears simultaneously with the HBsAg and denotes
viral replication. It is thought to indicate a highly contagious state.
The antibody to HBeAg indicates low viral replication, but does
not confer immunity.
D. Interior core antigen( HbcAG) detected in liver tissue but not in
serum. Antibodies to the core antigen (anti-HBc) appear together
in the lgM class (anti-HBc-IgM), during acute hepatitis B, and the
lgG class ( anti-HBc-lgG), during convalescence or chronic
infection. The anti-HBc does not confer immunity.
E. HBV surface antibodies (anti-HBs) appear 2 to 3 months after the
onset of symptoms. Confer immunity and convalescence.
F. Many subtypes of HBV exist. Imunization or infection with one
subtype provides immunity to all subtypes.
G. Vaccination is available and has been recommended for
hemodialysis staff and patients since it became availablein 1982.
III. Transmission HBV is the microbe that is most efficiently
transmitted in the dialysis setting.
A. Percutaneous (i.e., puncture throught the skin) or permucosal
(i.e., direct contact with mucous membranes) exposure to
infectious blood or to body fluids that contain blood.
B. Chronically infected patients are central to the epidemiology of
HBV transmission in dialysis centers. All HBsAg-positive
patients are infectious and able to transmit the virus.
C. Health care workers with acute or chronic hepatitis rarely infect
patients. They may continue to work when infection control
measures are followed.
D. Family members of persons with acute hepatitis or chronic carries
are considered at risk.
E. HBV can be present on environtmental surfaces in the absence of
any visible blood and still result in transmission.
F. Virus is stabe in the environment and remains viable for at least
7 days on environmental surfaces at room temperature.

Figure 17.1 incidence*of acute hepatitis B, by age group sex, and year-
united states, 1990-2002.(*=per100,000 population)
Source centers for disease control and prevention
(CDC).(2004a).incidence of acute heoatitis B- united states,1990-2002.
MMWR,52(51&52),1252-1254.

Figure 17.2 Structure of HBV. Source: parker,j.,Dickenson,

L,wiseman,K.C,Alexander,.D & Peacock,E (1998). Control of
infectious diseases in the real patient.in J.Parker (Ed.), nephrology
Nurses’Association.Used with permission.

G. Blood – contaminated surfaces that are not routinely claned and

disinfected represent a reservoir for HBV transmission.
 H. Detected in dialysis centers on champs, scissors, dialysis machine
control knobs, and doorknobs.
I. Outbreaks of HBV infection among hemodialysis patients have
been caused by cross-contamination to patients via:
1. Environmental surfaces,supplies (e.g.,hemostats, clamps).
2. Equipment not routinely disinfected after each use.
3. Multiple dose medication vials and intravenous solutions not
used exclusively for one patient.
4. Medications for injection prepared in areas adjacent to areas
where blood samples were handled.
5. Staff members who simultaneously cared for both HBV –
infected and susceptible patients.

IV. Clinical features and disease outcomes.

A. Causes both acute and chronic hepatitis.
B. Incubation period 45 to 160 days.
C. Immunosuppressed adults with newly acquired infection are
ussualy asymptomatic.
D. Clinical symptoms often insidious and include:
1. Anorexia.
2. Malaise.
3. Nausea.
4. Vomiting.
5. Abdominal pain.
6. Jaundice.
E. 94% to 98% of adults with normal immune status recover
completely eliminating virus from the

Table 17.1
Schedule for Routine Testing for Hepatitis B Virus ( HBV ) and
Hepatitis C Virus (HCV) infections
Blood. They then have live time immunity from future infection.
F. Most newly acquired HBV infections in hemodialysis patients
result in chronic infection and serve as ongoing source of HBV
transmission.
G. Liver disease develops in two thirds of chronic carriers.
Approximately 15% to 25% die prematurely from cirrhosis or
liver cancer.

Sreening and vaccination of staff.

A. Sreening for HBV infection among staff is no longer considered
necessary.
B. Testing for HBV markers not recommended except when
required to document response to vaccination.
C. Hepatitis B vaccination recommended for all susceptible staff.
Recombinant vaccines available in the United states are
Recombivax HB® and Engerix-B®.
D. Test all vaccinated staff for anti-HBs 1 to 2 months after last
primary vaccine series.
E. Nonresponders should receive a second series of the HBV
vaccine and be retested for response. No additional doses are
warranted for those who do not respond.
F. Staff not responding to the second full series of the HBV vaccine
should be evaluated for HBsAg positivity and follow-up with
medical evaluation and counseling.

IV.Screening and vaccination of patients.

A. Routine serologic testing (see Table 17.1).
1. Routine serelogic testing for markers of HBV infection and
prompt review of the result is vital to the prevention of HBV
transmission. Patients should be screened prior to or at entry to
the dialysis facility (see Tables 17.2 and 17.3).
a. HBsAg.
 b. HBsAB or anti-HBs.
c. Anti-HBc (total).
2. Hepatitis B vaccination recommended for all susceptible patients.
Table 17.2
Interpretation of serologic test results for Hepatitis B virus infection
B. HBV-susceptible patients (negative HBsAg and HBsAB or Anti-
HBs, Anti-HBc).
1. Vaccinate all susceptible patients with a full series of the HBV
vaccine.
a. Test for anti – HBs 1 to 2 months after last dose.
b. If anti-HBs is < 10 mlU/mL or at level considered
susceptible , revaccinate with an additional vaccine series
and retest for anti HBs. No additional doses are warranted
for those who do not respond. Consider the patient
susceptible and test for HBsAg monthly.
2. If anti –HBs is ≥ 10 mlU/mL or at a level considered as
protective, consider patient immune and retest annually for
antibodies.
a. Administer booster dose if anti-HBs declines to < 10
mIU/mL or is at a level considered susceptible and continue
to test annually for antibodies.
b. Test susceptible patients monthly for HBsAg, including
those who:
(1) Have not yet received hepatitis B vaccine.
(2) Are in the process of being vaccinated.
(3) Have not adequately responded to vaccination.
C. HBV-immune patients.
1. Annual anti-HBs testing of patients who are positive for
anti-HBs(>10mIU/mL,or reported as protective by the
lab perforning the test ) and negative for anti – HBc,
determines the need for booster doses of vaccine. These
patients have vaccine induced immunity and may be
susceptible when antibodies drop below
10mIU/mL.Note : A number of new assays for hepatitis
 B testing have recently been licensed by the food and
drug administration. Many of these new assays quantify
and report hepatitis results in a different manner than
previous assays.CDC is aware and is in the process of
developing revised guidelines. In the interim, the lab
perfoming the testing will provide instruction for the
evaluation and interpretation of hepatitis test results,
based on the specific assay used by the lab.
2. No routine follow-up testing for patients who are positive
for both anti-HBs and anti –HBc. These patients have
life-long immunity from a past infection and do not need
to be vaccinated.

Table 17.3
Doses and Schedules of Licensed Hepatitis B Vaccines for
Hemodialysis Patients and Staff Members

D. HBV-infected patients are able to transmit the virus and require

additional precautions to prevent transmission.
1. Chronically infected patients (i.e.,those who are HBsAg positive,
total anti-HBc positive, and IgM anti – HBc negative) do not
required additional HBV testing.
2. A positive HBsAg test result may be the only serologic marker
initially detected in patients newly infected.
a. Repeat HBsAg testing and test for anti-HBc ( including IgM
anti-HBc ) 1 to 2 months later.
b. Repeat HBsAg testing and test for anti – HBs 6 months later
to determine clinical outcome and need for counseling,
medical evaluation, and vaccination of contacts.
3. Patients who become HBsAg negative are no longer infectious.

E. Isolated Anti-HBc positive patients.

 1. Patients who test positive for isolated anti-HBc (i.e., those who
are anti – HBc positive, HBsAg negative , and anti – HBs
negative) should be retested for total anti- HBc,and if positive
, for IgM anti – HBc.
2. If total anti-HBc is negative , the patient is considered
susceptible and should be provided vaccination.
3. If total anti – HBc is positive and IgM anti-HBc is negative,
follow recommendations for vaccination.
a. If anti – HBs is < 10 mIU/mL even after revaccination, test
for HBV DNA. If HBV DNA is negative, consider patient
susceptible and test monthly for HBsAg.
b. If HBV DNA is positive, consider patient as having past
infection or “low-level” chronic infection. No further
testing is necessary and isolation is not necessary because
HBsAg is not detectable.
c. If both total and IgM anti –HBc are positive, consider
patient recently infected and test for anti-HBs in 4 to 6
months. No further routine testing is necessary and isolation
is not necessary because HBsAg is not detectable.
f. Transient HBsAg positivity lasting 18 days or less has been
reported during the time the patient is receiving the
vaccination series.

VII. Precautions for dialysis.

A. Preventing transmission of HBV from an infected hemodialysis
patient requires infection control precautions recommended for
all hemodialysis patients , routine serologic testing for markers of
HBV infection, and isolation of HBsAg-positive patients during
treatment.
B. Incidence of HBV infection is substantially lower in hemodialysis
units where HBV infected patients are isolated.
C. Isolation practices have resulted in a 70-80% reduction in the
incidence HBV infection.
 D. Isolation requires a designated separate room for treatment, a
dedicated machine,and dedicated equipment and supplies that
will not be used by HBV-suceptible patients.
E. Staff members who are caring for HBsAg-positive patients
should not care for susceptible patients at the same time.
F. If a separate room is not possible,HBsAg-positive patients should
be separated from HBV – susceptible patients in an area removed
from the mainstream of activity and should undergo dialysis on
dedicated machines.
G. If a machine that has been used on an HBsAg-positive patient is
needed for an HBV-susceptible patient, internal pathways of the
machine should be disinfected using conventional protocols.
External sufaces should be cleaned using a detergent germicide
or a low level disinfectant.
H. HBV-infected patients should not participate in dialyzer
reprocessing programs.

Hepatitis C Virus (HCV)

I. Incidence and prevalance.
A. Approximately 170 million people worlwide are infected with
HCV.
B. An estimated 4.1 milion of U.S. population have been infected
;3.2 million are chonically infected.
C. Number of new infections per year decreased from approximately
240,000 to 26,000 over the past 25 years. Transfusion related
infections account for less than one per million units of blood.
D. Most infections are due illegal intravenous drug use.
E. Approximately 40% to 60% of chronic liver disease is
attributable to HCV.
F. Ther are limited incidence and prevalence data in the chronic
hemodialysis population as not all dialysis units perform routine
testing.
1. Prevalence approximately 7.8%.
2. Incidence approximately 0.34%.
 II. characteristics and markers.
A. Single-stranded RNA virus classified as a separate genus in the
flaviridae family. There are six known genotypes and more
than 90 subtypes.
B. Multiple quasispecies may co-exist in a single infected
individual. Infection with one genotype or subtype does not
protect against reinfection or superinfection with other strains.
C. Different genotypes and subtypes have different geographic
distributions. Predominant genotypes in the united states are Ia
and Ib.
D. Different genotypes and subtypes are associated with different
rates of disease progression, severity, and response to
treatment.
E. Hepatitis C antibody (Anti-HCV) tests (enzyme
immunoassays[EIAs] and a supplemental recombinant
immunobolot assay (RIBA™] detect anti-HCV in > 97% of
infected persons. They do not distinguish between acute ,
chronic , or resolved infection.
F. Positive anti-HCV can be detected in 80% of patients within
15 weeks after exposure , in > 90% within 5 months, and in >
97% within 6 months.
G. HCV virus (RNA) can be detected in serum within 7 to 14 days
after exposure and weeks before onset of ALT elevations.
H. Almost all patients develop a vigorous antibody and cell-
medicated immune response that fails to clear the infaction but
may contribute to liver damage.
I. Anti-HCV usually persists indefinitely and does not confer
immunity.
J. A vaccine is not available.

III.Transmission.
A. Most efficently transmitted by direct percutaneous exposure to
infectious blood.
 B. Chronically infected person is central to the epidemiology of
transmission in dialysis.
C. Number of years on dialysis is major risk factor independently
associated with higher rates of HCV infection.
D. Inadequate infection control practices are associated with
outbreaks of HCV in dialysis units.
1. Use of common medication carts to prepare and distribute
medications at patients’ stations.
2. Supply carts moved from one station to another.
3. Sharing of multiple dose medication vials, which were placed
at patient’s stations on top of hemodialysis machines.
4. Contaminated priming buckets that were not routinely changed
or cleaned and disinfected between patients.
5. Machine surfaces not routinely cleaned and disinfected
between patients.

IV. clinical features and disease outcomes.

A. Causes both acute and chronic hepatitis.
B. Incubation period ranges from 14 to 180 days.
C. Those with newly acquired infection are asymptomatic or have a
mild clinical illnes ; often goes unnoticed.
D. Elevated alanine aminotransferase (ALT) often precedes anti-
HCV seroconversion. Characteristic feature is fluctuating ALT
levels.
E. Most hemodialysis patients with newly acquired HCV infection
have elevated serum ALT levels. Aspartate aminotransferase
(AST) is a less specific indicator of HCV-related liver disease.
F. Up to 85% of newly infected persons develop chronic infection .
cirrhosis develops in 10% to 20% of persons who have chronic
enfection and hepatocellular carcinoma in 1% to 5%

v.Screening.
 A. Routine testing of stall members is not recommended.
B. Routine ALT and anti-HCV testing of patients for monitoring
transmission within centers and ensuring appropriate dialysis
precautions are being followed.
C. Routine anti-HCV testing should include use of both an EIA test
and confirmatory testing with a more specific assay(i.e.,RIBA).
D. Use of the RT-PCR for HCV RNA as the primary screening test
is not recommended.
E. Test all patients at admission for anti-HCV and ALT levels.
1. In the absence of unexplained ALT elevations,anti-HCV
testing every 6 months is recommended for those testing
negative for anti-HCV at the time of admission.
2. Repeat anti – HCV testing if unexplained ALT elevations are
observed. Consider testing for HCV RNA if unexplained ALT
elevations persist in patients who are repeatedly anti-HCV
negative.
F. In the event of a seroconversion, review all other patient’s routine
laboratory test results to identify additional cases. Investigate
potensial sources for infection to determine if transmission might
have occured within the dialysis unit. Consider additional testing.
G. HCV-positive patients should receive medical evaluation

VI. Precautions for dialysis.

A. Strict adherence to infection control precautions recommended
for all hemodialysis patients.
B. Patients who are anti-HCV positive or HCV RNA positive do not
have to be isolated or dialyzed separately on dedicated machines.
They can participate in the dialyzer reprocessing programs.

Hepatitis Delta Virus (HDV)

I. Incidence and prevalance.
 A. Global pattern of HDV infection generally corresponds to the
prevalence of chronic HBV infection.
B. There is a low prevalence of HDV infection in the United States.
C. Rates les than 1% of HBsAg-positive persons in the general
population.
D. Rates greater than 10% of HBsAg-positive persons with
repeated percutaneous exposurres(e.g., injecting drug users).
E. There is limited data on the prevalence among chronic
hemodialysis patients.

II. Characteristics and markers.

A. Small circular RNA virus. Replication is defective and therefore
cannot propagate in the absence of another virus.
B. Requires simultaneous infection with HBV and replicates only in
hepatocytes.
C. HDV and HBV may concurrently infect an individual or
superinfect a chronic HBsAg carrier.
D. Serologic course of HDV infection varies depending on whether
the virus is acquired as a co-infection with HBV or as a
superinfection of a person with chronic HBV infection.
E. Co – infection with HDV and HBV.
1. Both IgM antibody to HDV (anti-HDV) and IgG anti-HDV
are usually detectable during the course of co-infection.
2. Anti-HDV generally declines to subdetectable levels after
the infection resolves and there is no serologic marker that
persists to indicate the patient was ever infected.
3. Hepatitis delta antigen (HDAg) can be detected in serum in
only about 25% of patients.
F. Superinfection. High titers of both IgM and IgG anti – HDV are
detectable. They persist indefinitely.
G. Only a serologic test that measures total antibody to HDV is
commercially available in the United States.
III. Transmission.
A. Only occurs in the presence of hepatitis B infection.
B. Transmitted by blood and blood products; percutaneous
(i.e.,injecting drug use) and permucosal exposure.
C. Risk factors for infection are similar to those for hepatitis B virus
infection.
D. There has been only one reported case of transmission between
hemodialysis patients in the United States.
E. Sexual transmission of HDV is less efficient than for HBV.
F. Perinatal HDV transmission is rare.

IV. Clinical features and disease outcomes.

A. Co-infection.
1. Severe acute disease.
2. Higher risk of fulminant hepatitis (2-20%) compared with
those infected with HBV alone.
3. Low risk of chronic infection.
B. Superinfection.
1. Usually developes chronic HDV infection.
2. Risk of severe chronic liver disease.
3. Over 60% of patients with chronic HDV will develop cirhosis.
C. Clinical symptoms
1. Anorexia.
2. Malaise.
3. Nausea and vomiting.
4. Abdominal pain.
5. Jaundice.
6. Joint pain.
V. Screening.
A. Routine testing of hemodialysis patients is not necessary or
recommended.
B. Screen for delta antibody if a patient is known to be infected
with HDV, or if evidence exists of transmission of HDV in
a dialysis unit.
VI. Precautions for dialysis.
A. Prevention of HBV infection will prevent HDV
infection in a person susceptible to HBV.
B. Patients who are known to be infected with HDV
should be isolated from all other dialysis patients,
especially those who are HBsAg-positive.
Human Immunodeficiency Virus (HIV)
I. Overview.
A. According to national surveillance data, hemodialysis patients
with HIV infection have increased from 0.3% in 1985 to 1.5% in
2002. Only 0.4% of theses patients are reported to have AIDS.

B. There has been no reported health care-associated patient-to-

patient transmission of HIV in U.S. hemodialysis centers.
However, there have been cases of patient to health care worker
transmission due to needlestick injuries.

C. Occupational exposure to bloodborne pathogens from

needlesticks and other sharps injuries is a problem, and it is often
preventable. The centers for disease control and prevention
(CDC) estimates that each year 385,000 needlesticks and other
sharps-related injuries are sustained by hospital-based health care
personnel. Similar injuries occur in other health care settings,
such as nursing homes, clinics, emergency care services, and
private homes.
 D. Sharps injuries are primarily associated with occupational
transmission of hepatitis B virus ( HBV), hepatitis C virus (HCV),
and human immunodeficiency virus (HIV), but they may be
implicated in the transmission of more than 20 other pathogens.

II. General infection control measures.

A. Patients infected with HIV can be dialyzed by either hemodialysis
or peritoneal dialysis.

B. Patients who are HIV-positive do not have to be isolated and can

participate in a dialyzer reuse program. There is no epidemiologic
evidence that dialyzer reuse in the united states had led to either
an occupational or health care acquired infection with HIV. There
have been a few incidents where someone has been dialyzed with
a reprocessed dialyzer belonging to someone else who was
HIV+These events are rare, and to date ther have been no reported
seroconversions as a result of these medical errors in the United
States. In addition, associated diseases does not suggest that reuse
is a risk factor for HIV. Follow the AAMI recommended practices
for reuse of hemodialyzers.
C. Infection control precautions for all diaysis patients apply. There
are no special precautions for patients with HIV or AIDS. There
are several reasons why no special precautions are.
Recommended for these patients receiving care in maintenance
hemodialysis centers.
1. HIV is not efficiently transmitted in the dialysis setting.
2. Standard infection control precautions used for the care off
all hemodialysis patients are sufficient to prevent the
transmission of the virus in the dialysis setting.
3. Transmission from the hemodialysis machine to the patient
has not been observed.
 D. Screening dialysis patients for HIV is not recommended for
infection control purposes since these patients are not treated
differently than other dialysis patients. However, patients with
risk factors for HIV infection should be tested so that, If infected
they can receive proper medical care and counseling on
preventing the transmission of the virus.

E. The CDC has revised recommendations concerning the routine

testing of certain individuals. The recommendations for HIV
testing of adults , adolescents, and pregnant women in health care
settings was published in september 2006. These
recommendations were published to:
1. Increase HIV screening of patients, including pregnant
women, in health care settings.
2. foster earlier detection of HIV infection.
3. Identify and counsel persons with unrecognized HIV
infection and link them to clinical and prevention services.
4. Further reduce perinatal transmission of HIV in the United
States.

F. Per these latest CDC recommendations, diagnostic HIV testing and

opt-out HIV screening should be a part of routine clinical care in all
health care settings. They also preserve the patient’s option to decline
HIV testing and ensure a provider –patient relationship conducive to
optimal clinical and preventive care. The recommendations are
intended for providers in all health care settings, including hospital
emergency departments, urgent-care clinics , inpatient services,
sexually transmitted disease clinics, substance abuse treatment clinics,
other public health clinics, community clinics, correctional health care
facilities and primary care settings. The guidelines address HIV testing
in health care settings only. They do not modify existing guidelines
concerning HIV counseling , testing, and referral for persons at high
risk for HIV who seek or receive HIV testing in nonclinical settings.
G. The other population addressed by these recommendations is
pregnant women. These guidelines reiterate the recommendation for
universal HIV screening early in pregnancy, but advise simplifying the
screening process to maximize opportunities for women to learn their
HIV status during pregnancy. They preserve the woman’s option to
decline HIV testing , and ensure a provider – patient relationship
conducive to optimal clinical and preventive care. All women should
receive HIV screening consistent with the recommendations for adults
and adolescents.
III. Occupational health measures.
A. Develop a culture of safety.
1. Involve personnel in the planning and implementation of
activities that promote a safe health care inveronment.
2. Encourage reporting and removal of sharps injury hazards.
3. Develop feedback systems to increase safety awareness.
4.Promote individual accountability.
5. Have an exposure control plan.
B. Use safety devices.
1. In november of 2000 the needlestick Safety and prevention Act
(the Act) ( pub.L. 106-430 ) was signed into law. This was a
modification to OSHA’S Bloodborne Pathogens Standard (29
CFR 1910.1030) to set forth in greater detail the requirement for
employers to identify, evaluate , and implement safer medical
devices. The Act also mandated additional requirements for
maintaining a sharps injury log and for the involvement of
nonmanagerial health care workers in evaluating and choosing
devices.
2. One study conducted at a hemodialysis center found the use of
standart arteriovenous fistula needles resulted in a needlestick
injury rete of 8/58 per 100,000. The injury rate dropped to less
than 1/100,000 following the introduction and use of a guarded
areteriovenous fistula needle. Studies in other health care settings
have also demonstrated that safety devices, when introduced with
 concomitant training, significantly reduce the number of
needlestick injuries.

C. Actions to take after exposure.

1. Immediately following an exposure to blood:
a. Wash percutaneous injuries with soap and water.
Flush splashes to the nose, mouth , or skin with water
or irrigate eyes with clean water, saline or sterile
irrigants.
b. Report exposure to the department, office, or
individual (e.g.,occupational health, infection
control) responsible for managing health care
worker exposures.
c. If the source individual cannot be identified or
tested, decisions regarding follow-up should be
based on the exposure risk and wheter the source is
likely to be infected with a bloodborne pathogen.
2. For known source.
a. Test Known sources for HBsAg, anti-HCV, and HIV antibody.
(1) Consider using a rapid HIV-antibody test.
(2) Direct virus assay (e.g., Viral Load Assays) for routine
screening of source patients are not recommended.
(3) If the source person is not infected with a bloodborne
pathogen, baseline testing or futher follow-up of the
exposed person is not necessary.
b. For sources whose infection status remains unknown (e.g., the
source person refuses testing), consider the source patient’s
medical diagnoses, clinical symptoms, and history of risk
behaviors.
c. Do not test discarded needles, used syringes, etc., for bloodborne
pathogens.
3. Unknown sources.
 a. For unknown sources, evaluate the likelihood of exposure to a
source at high risk for infection.
b. Consider likelihood of bloodborne pathogen infection among
patients in the exposure setting.

IV. Management of HIV exposure.

A. Health care workers exposed to HIV should be evaluated
within hours ( rather than days ) after their exposure and
should be tested for HIV at base line (i.e., at the time of
exposure).
B. If the source person is seronegative for HIV, further
follow-up of the exposed person is not necessary.
C. For purposes of considering HIV postexposure
prophylaxis (PEP),the evaluation should include
information about medications the exposed person might
be taking and any current or underlying medical
conditions or circumstances(i.e.,pregnancy, breast
feeding, or kidney or hepatic disease) that might
influence drug selection.
D. PEP should be initiated as soon as possible, preferably
within hours rather than days of exposure. For
additional information regarding PEP please refer to the
Update U.S public Heal Service Guidlines for
management of Occupational exposure to HIV and
recommendations for postexposure prophylaxis
(seehttp://www.cdc.gommwr/preview/mmwrhtml/rr540
9al.htm).

Figure 17.3 Acid fast bacteria seen on smear are tubercle bacilli.

Source : centers for disease control and prevention : division of

Tuberculosis Elimination.(2004). Core curriculum on tuberclosis (4th
ed ). Slide sets. Retrieved desember 12, 2007, from
http;//www.cdc.gov/tb/pubs/slidesets/core/html/trans5_slides.htm.Use
d with permission.

Figure 17.4. Colonies of M.tuberculosis growing on media.

Source : Centers for disease control and prevention: Division of
tuberculosis Elimination. (2004). Core curriculum on tuberculosis
(4th ed). Slide sets Retrieved December 12, 2007, from
http://www.cdc
.gov/tb/pubs/slidesets/core/html/trans5_slides.htm.Used with
permission.

Tuberculosis

I. General considerations.
A. Tuberculosis (TB) is a major health concern in the United States.
The growth of TB globally and the presence of a large
immunosuppressed population, in part due to the AIDS epidemic
, contribute to the large number of TB cases.

B. Multidrug resistant strains of TB are emerging that are resistant

to drugs traditionally used treat TB. Chronic kidney disease
(CKD) and diabetes mellitus are risk factors that increase the
chance of developing clinical TB.

II. Etiology.

A. A.Tuberculosis is caused by the tubercle bacillus Mycobacterium

tuberculosis. TB is spread primarily through respiratory means.
While this disease can involve any organ , the lungs remain the
primary site of infection (see figure 17.3).

B. When respiratory droplets are released inti the air, the smallest of
the droplets (droplet nuclei) dry and remain airborne for indefinite
periods of time and may contain one to several mycobacteria.
They are the most dangerous particles because they are smaal
enought to be inhaled and deposited in the alveoli of the
 susceptible host. Larger particle fall to the floor or other surfaces
and are not source of airborne transmission.
C. Infectiousness usually coincides with the number of infectious
organisms in sputum, the extent of pulmonary disease and the
frequency of coughing. When M. Tuberculosis is presented to a
host with a functioning immune system repeated, prolonged
exposure is ussually necessary for infection to occur. When the
immune system is defective, infection can progress to active
disease after short exposure times to small numbers of organisms.

III. Pathophysiology.
A. While M.tuberculosis is similar in many ways to other bacteria,
there are characteristics that are important to remember when
caring for patients with TB.
1. M. Tuberculosis has a mean doubling time of 12 to 24
hours and may require weeks of growth to produce a visible
colony. It can delay identification of the organism, and in
some cases (e.g.,drug resistant strains) can delay
drugsusceptibility testing and drug therapy (see figure
17.4).
2. The cell wall structure of M. Tuberculosis contains an outer
layer of fatty acids and waxes that are toxic to host cells
and tissue and that make the bacilli insoluble in water. This
cell layer contributes to its slow growth rate and also
protects the organism from antimicrobial agents. The layer
also prevents the body’s macrophages from being able to
completely destroy all the invading bacilli, contributing to
the need for prolonged drug therapy.

Figure 17.5 Chest x-ray of a patient with TB ; arrow points to cavity in

patient’s right upper lobe.

Source:centers for Disease control and prevention: Division of

Tuberculosis Elimination.(2004). Core curriculum on tuberculosis (4th
ed). Slide sets. Retrieved December 12,2007 from
http://www.cdc.gov/tb/pubs/slidesets/core/html/trans5_slides
.htm.used with permission.
B. Once an individual inhales tubercle bacilli into the alveoli, how
the body reacts to the bacilli depends in part on host
susceptibility, how many particles were inhaled, and how
virulent the organisms are. The lung responds to the bacilli with
inflammation and the body’s normal defense mechanisms.
Inflammation may lead to development of primary tubercle
nodules. Cells gather around the tubercle and the outer portion
becomes fibrosed. The center becomes necrotic. If the material
is coughed up, it may leave a hole or cavity in the lung issue. On
x-ray, these cavities are suggestive of TB (see figure 17.5).

C. If the host has a competent immune system, multiplication and

spread of the organisms are halted, usually within 2 to 10 weeks.
Alveolar macrophages ingest most of the bacilli, althought some
viable bacilli remain in the macrophages in a dormant state, and
reactivation of the disease at a later time is possible. These
people are considered to have TB infection or latent TB infection
(LTBI). Even thought they have TB , They have no signs or
symptoms of the disease and are not capable of transmitting TB.
These persons will have a positive reaction to a tuberculin skin
test (TST). During their lifetime, these persons have a 10% risk
of developing activeTB. The greatest risk is within 2 years after
the original infection. If the host’s immune system is deficient
and unable to prevent spread of the bacillus, active TB disease
develops. The individual will have clinical symptoms of TB and
is capable of spreading the disease to others.

D. A number of the new cases of TB are seen in older people who

were infected decades earlier (LTBI), and the disease emerges
when the host’s immune system is weakened. Rates of TB are
also increased in racial and ethnic minorities who have other risk
factors for TB, such as birth in a country with high prevalence
rates of TB, in individuals with HIV infection, low
socioeconomic status, or exposure in congregate
settings(i.e.,prisons, shelters). HIV plays a key role in the
resurgence of TB. HIV positive patients have a much higher risk
of developing active clinical disease after initial infection or
 developing disease subsequent to an earlier infection (see Table
17.4 ).

IV. Multidrug-resistamt TB (MDR-TB).

A. There is an increased incidence of TB that is resistant to at
least two of the first-line drugs used to treat TB. In the past,
drug resistance was a result of inappropriate or inadequate
treatment of TB, known as secondary or acquired drug
resistance. Primary drug resistance occurs when only a few
of the organisms present have an inherent resistance to one
or more of the most commonly used antitubercular drugs.
This type of MDR-TB is being spread among patients by
direct exposure, particularly in areas with large populations
of HIV infected patients.

B. To prevent emergences of drug-resistant strains of TB,

appropriate drug regimens must contain several different
drugs to which the organism is susceptible. The dosing
schedule must maintain sufficient concentrations to inhibit
or kill the organisms present. Drugs must be continued long
enough to ensure all organisms are eliminated. Specific
drug therapy for resistant strains of TB depend on whether
the organism is resistant to one or more of the drugs
commonly used to treat TB. Some organism are resistant to
only one drug, while others are resistant to multiple drugs.

V. Signs and symptoms of TB.

A. Pulmonary TB should be suspected in people who complain of
fever, chills, night, sweats, fatigue, weight loss, decreased
appetite, chest pain, prolonged and productive coughing (longer
than 3 weeks) , or hemoptysis.

B. Extrapulmonary TB occurs most often in people with HIV.

Pulmonary TB is the most common form of TB, including those
with HIV. HIV negative patients have a 10% rate of extrapul
monary TB, while those with full blown AIDS have a 70% rate
of TB at sites other than the lung. Patients with HIV and impaired
 immune systems have a 24-45% incidence of extrapulmonary
TB.

C. Patients with HIV and extrapulmonary TB demonstrate

lymphatitis and miliary disease (formation of tubercles)
throughout the body organs from dissemination of bacillus
through the bloodstream. Symptoms include tender lymph
nodes,fever, fatigue and weight loss. People with
extrapulmonary TB are usually not considered infectious unless
they have an open abscess or draining lesion.

D. Anyone suspected of having TB must be immediately placed in

isolation and be referred for futher evaluation consisting of a
physical examination, a Mantoux tuberculin skin test, chest x-
ray and sputum smears and cultures.

VI. Screening for TB.

A. Screening tests in the United States are used to identify
infected people who need preventive therapy and as part of the
workup for those with signs or symptoms of active disease.
1. Screen groups with disease and infection rates in excess of
those in the general population.
2. Institutional screening for staff of health care facilities and
resident of long-term care facilities.
3. The centers for disease Control and Prevention (CDC)
recommend all health care facilities establish a TB
screening program for health care workers. The
Occupational safety and health Administration (OSHA)
mandates that employers develop and follow TB screening
and control programs for staff. To assess the risk for
exposure to TB in the workplace, the risk factors associated
with TB must be identified. While TB can occur in any
population or group, certain subpopulations have been
identified as having a higher-than-average risk for TB:

a. Close contact with infectious tuberculosis cases.

 b. Medically underserved, low-income populations, including
high-risk racial and ethnic groups.
c. c.Foreign-born persons from high-prevalance countries (
Asia, Africa, Latin America).
d. Older adults.

Table 17.4
Medical conditions that increase the risk of developing TB Disease
Once Infection Has Occured
 HIV Infection
 Substance abuse (especially drug injection )
 Sillicosis
 Recent infection with M.tuberculosis within the previous 2 years
 Persons with a history of untreated or inadequately treated TB
disease, including persons with chest radiograph findings with
previous TB disease
 Diabetes mellitus
 Prolonged corticosteroid therapy
 Other immunosuppressive treatments (including tumor necrosis
factor-alpha antaghonists)
 Organ transplants
 Hematologic disorders (for example, leukemia, Hodgkin’s
disease)
 Other malignancies (e.g., carcinoma of the head and neck, or
lung)
 Chronic kidney disease
 Intestinal bypass or gastrectomy
 Chronic malabsorption syndromes
 Being > 10% below ideal body weight

Adapted from centers for Disease Control and Prevention. (2005b).

Guidlines for preventing the transmission of M.tuberculosis in health
care settings.MMWR,54,RR-17.

B. Tuberculin skin tests.

1. Screening programs for TB usually consist of the Mantoux
purified protein derivative. Tuberculin skin test (TST).
 Included in the group of who should be screened are people
who have medical conditions that increase their risk of clinical
disease when exposed to TB.
a. Close contacts of infectious TB cases.
b. Persons with medical conditions that increase the risk of
TB.
c. Foreign-born persons from high prevalence countries.
d. Low-income populations, including high-risk minorities.
e. Alcoholics and intravenous drug users.
f. Residents of long-term care facilities ( Including prisons ).
g. Populations identified locally as being at increased risk for
TB such as health care workers in some settings.

2. CKD is a risk factor for TB. The CDC recommends skin test
screening in this group. Chronic kidney disease is an immuno
compromised condition with cutaneous anergy that can result
in false-negative TB test. Anergy is the absence of a reaction
to a TST that can be seen in dialysis patients. Causes for anergy
include infection , sarcoidosis, poor nutrition , some
medication , vaccinations, and TB disease. The negative test
does not exclude a diagnosis of TB disease or infection with
M. Tuberculosis. Anergy skin testing in conjunction with TST
is no longer recommended routinely for M. Tuberculosis
infection.
3. The Mantoux skin test (TST) provides the most accurate
results. Using a tuberculin syringe with 0.1 mL (5 units ) of
purified protein derivative (PPD), inject intradermally forming
a wheal just under the skin. Trained staff read the test in 48 to
72 hours. Table 17.5 defines how skin tests should be read .
Documentation of skin test results should include:

a. Palpate and measure the area of induraction

(induration is hardness,not redness). Record all results
in millimeters even if they are considered nonreactive.
 b. Interpretation of skin test results are based on risk
factors of the person being tested.
c. False-positive results to TST can be due to infections
with mycobacterium other than M. Tuberculosis or
due to immunization with bacillus Calmette-Guerin
(BCG).
d. False-negative results can occur in people recently
infected with TB. It may take 2 to 10 weeks after
infection to mount an imune response. People who
had a negative skin test after an initial TB infection
may years later manifest a positive reaction.
e. Two-step testing is used in settings where periodic
testing will occur, such as health care workers, nursing
homes, and dialysis units. The first time the person is
tested they are given an initial skin test. If the first test
weeks later. If the first and second test are negative,
then any subsequent positive skin test is more likely
to be due to a recent TB infection (TB conversion).

C. QuantiFERON-TB Gold test (QFTG) is a type of blood assay

for M.Tuberulosis (BAMT).
1. QFTG is an alternative to tuberculin skin tests (TST)
and was approved by the FDA in 2005.
2. QFTG measures the patient’s immune system
reaction to M. Tuberculosis (tuberculosis antingens).
3. Blood samples must be drawn and processed within
12 hours.
4. Interpretation is less subjective than for TSTs.
5. May be less affected by BCG vaccination.
6. Conditions requiring caution in interpreting negative
QuantiFERON-TB Gold test results.
a. Human immunodeficiency virus infection or
acquired immunodeficiency disease.
 b. Immunsuppressive drugs, including those
used for managing organ transplants.
c. Tumor necrosis factor (TNF).
d. Diabetes mellitus.
e. Silicosis.
f. Chronic Kidney disease.
g. Certain hematologic disorders (e.g., leukimia
and lymphomas).
h. Other specific malignancies (e.g.,carcinomas
of the lead, neck, or lung).

VII. Infectivity.
A. Infectiousness of a TB patient is directly related to the number of
bacilli released into the air whenever that person coughs, talks,
sings, or sneezes. Most patients are considered infectious if they:
1. Are coughing, receiving cough-inducing or aerosol-generating
procedures.
2. Have sputum smears that show presence of acid-fast bacilli
and are not receiving therapy have just started therapy, or have
poor clinical or bacteriologic response to therapy.

B. Infectiousness may persist for weeks or even months in patients

with drug-resistant TB.

C. Once effective therapy is begun, patients are no longer considered

infectious as long as they meet all the following criteria:
1. They have been receiving adequate drug therapy for 2-3 weeks.
2. They demonstrate favorable clinical response in therapy.
3. Consecutive sputum smears collected an three separate days are
negative,
VIII. Drug therapy. Antituberculosis chemoterapy is designed to kill
bacilli rapidly, minimize the potential for organisms to develop drug
resistance and sterilize the host’s tissues. Achieving these outcomes
requires multiple combination being administered over a period of
time. Poor follow-throught with the drug regimen is one of the
primary reasons for the current resurgence of TB and increases in
drug resistant strains.

Table 17.5
Classification of TB skin Test Results
*An induration of 5 mm or more is considered a positive reaction in
the following high risk groups. Persons should be treated for LTB1
regardless of age;
Person infected with HIV.
Recent contact of a person with TB disease.
Persons with fibrotic changes on chest x-ray consistent with
previous TB disease.
Organ transplant recipients.

*An induration of 10mm or more is considered positive in the

following persons;
Person with TST or BAMT conversions.
Persons born or who have lived in developing countries with high
incidence of TB disease.
Persons who inject illicit drugs.
Residents and employees in congregate facilities and LTCFs (e.g.,
hospices, skilled nursing facilities, residential settings for persons
with HIV/AIDS or other immunocompromising conditions, and
homeless shelters.
 Personnel from microbiology labs.
Person with any of the following clinical conditions that place them
at high risk:
 Silicosis
 Diabetes melitus
 Chronic kidney failure
 Certain hematologic disorders(e.g.,carcinoma of the head,
neck and lung)
 Unexplained weight loss of ≥ 10% of ideal body weight
 Gastrectomy or jejunoileal by pass
Persons living in areas with high incidence of TB disease.
Children ≥ 4 years of age.
Infants, children and adolescents exposed to adult with high risk for
developing TB.

*. An induration of 15 mm is considered positive for persons who do

not have Any risk factors for TB.
Persons with no known factors for TB disease. HCW who are otherwise
at low risk for TB disease and who received baseline testing at the
beginning of employment as part of a TB screening program.

Adapted from Centers for disease control and prevention.(2005b).

Guidlines for preventing the transmission of M.tuberculosis in health-
care settings.MMWR,54 RR-17.

Table 17.6
TB Drug Frequncy changes for adult patients with reduce Renal
function and Adult patients Receiving Hemodialysis
 A. Preventive therapy is prescribed for people infected with TB
(latent TB) who do not have active disease, to prevent progression
to active clinical TB at later date. Isoniazid (INH) is ussually used
alone for preventive theraphy. Anyone taking INH should be
evaluated for signs of liver disease, neurotoxity( such as
paresthesias of hands and feet ), and adherence to prescribed
therapy.

B. Treatment of active disease includes use of multiple drugs that

the organisms are sensitive to, provision of the safest most
effective therapy in the shortest time possible, and ensuring the
patient adheres fully to the treatment regimen.

C. Extrapulmonary TB treatment follows the basic priciples for

treating pulmonary TB:a 6 to 9 month course of therapy, except
for TB meningitis that requires 9 to 12 months of therapy.

D. Drug-resistant TB diagnosis requires drug susceptibility testing

and prolonged treatment regimens. There have been documented
reports of drug-resistant TB being spread by direct contact. It is
imperative that treatment be started as soon as possible and
adherence to treatment be ensured by whatever means are
necessary.

IX. Chronic kidney disease (CKD)- Implications for TB.

A. Kidney disease complicates the management of TB.
Antituberculosis medications may be cleared by the kidney and
also by hemodialysis. Drugs cleared by the kidneys in patients
with creatine clearance less than 30 mL/minute and those
receiving hemodialysis treatments are managed by changing
closing intervals ( see table 17.6).
 B. Patients with CKD have additional clinical concerns such as
gastroparesis that may affect absorption TB drugs, and
medications that interact with these drugs.

C. There is no data for peritoneal dialysis (PD) patients. Drug

removal mechanisms differ between hemodialysis and PD, so it
cannot be assumed that hemodialysis medication closing
precautions apply to PD.

D. The CDC recommends that after a known exposure to TB,

immunocompromised patients should receive treatment for
presumptive latent TB, regardless of skin testing result.

Vascular Acces infections

I. Overview.
Infection is the second leading cause of death in dialysis patients. Acces
related infection are the leading cause of infection in CKD stage 5
patients. Acces infection may vary from minor infections at the needle
insertion site to massive infections of the entire acces, which may
require graft or catheter removal. Septicemia , a life-threatening
complication, increases morbidity and mortality in these patients.
Acces infection is a preventable complication by following standart
dialysis precautions and infection control practices.

A. Infection can occur from movement of the patient’s normal skin

flora on or into the vascular acces during cannulation or when
accessing the hemodialysis catheter. Failure to follow aseptic
technique or good infection control practices can also result in an
access infection.
B. The primary risk factor to acces infection is the type of access.
C. AV fistulas have a decreased incidence of infection compared to AV
grafts or catheters.
D. Catheters have the highest incidence of infection with a rate of 0.08-
0.7 per 100 catheter days for tunneled catheters.
E. Due to the increased risk of infection and other complications in
catheters, it is recommended by NKF/DOQI guidlines that no more
than 10% of patients be maintained with a permanent catheter and
that 40% of prevalent patients who initiate hemodialysis have a
native AV fistula constructed.
II. Types of infections and common organisms.
Note; Due to immunosuppression in patients with chronic kidney
disease stage 5, these patients may not demonstrate signs and
symtomps of infection normally seen in other patients. For example, a
low grade temperature can be significant and a serious infection can
exist with few signs or symptoms (such as little to no redness or
swelling).
A. Local infection.
1. Local involving blood vessel,graft,or surrounding tissue.
2. Signs and symptoms.
a. Fever of chills.
b. Pain or tenderness of acces or exit site.
c. Rednees.
d. Purulant drainage from access, exit site, or catheter
insertion site.
e. Induration within 2cm of exit site.
f. Inflammation.

B. Systemic infection.
1. Sytemic : sepsis from infection spilling into the blood stream.
2. Signs and symptoms.
a. Malaise.
b. Fever and chills.
c. Presence of local infection symptoms.
d. Septicemia.
C. Common organisms.
1. Gram-positive organisms (staphyloccocus aureus, coagulase
negative staphylococci [CNS], staphylococcus epidermidis).
a. The number of infection caused by S. Aureus is higher among
patients with fistulas or grafts.
b. The number of infections caused by CNS is higher among
patients dialyzed with catheter
2. Gram negative organisms (most commonly Escherichia coli,
Pseudomonas).

III. AV fistula and graft infections.

A. Cause and risk factocrs.
1. Poor personal hygiene.
2. Failure to properly clean access before cannulation.
3. Failure to follow aseptic cannulation technique.
4. Cross contamination.
5. Bacterial seeding from other infected areas.
6. Noncompliance with infection control procedures.
7. Lack of hand washing.
8. Failure to recognize early signs and symptoms of infection.
9. Infection tracking/trending not included in the continous quality
improvement (CQI) process.
a. Inexperienced dialysis staff.
b. Type and location of access.

B. Prevention.
1. Teach patient proper personal hygiene.
2. Strict aseptic cannulation technique.
3. Access care and protection.
4. Train dialysis staff in infection control procedures.
5. Proper hand washing.
 6. Teach patient and staff early identification of signs and symptoms
of infection .
7. Track and trend infections to identify source and allow corrective
action.
8. Early referral for fistula/graft access placement to minimize
catheter use.
9. Improve cannulation skills (i.e.,cannulation camp; mentorship
program).

C. Treatment.
1. Appropriate antibiotics based on culture and sensitivity as
ordered.
2. Antimicrobials at infected acces site.
3. Graft or fistula removal if indicated.
4. Prophylatic antibiotics preoperatively and before dental,
diagnostic or other surgical procedures.
5. Avoid cannulation of infected access.

IV. Catheter-related infections.

A. Infection is the leading cause of chateter loss. Infection in
central venous catheters may occur at the exit site, at the tunnel
track or systemically.
B. Intravascular catheter-related bloodstream infections lead to
increased morbidity, prolonged hospital stays and increased
medical costs.
C. Bacteria can spread from the patient’s skin to the catheter exit
site, along the exterior catheter surface or internally from
external contamination of the catheter lumen or from
colonization of bacteria from other infected areas.
D. Causes and risk factors.
1. Inappropriate catheter care guidlines.
 2. Failure to acces central venous catheter using aseptic
technique.
3. Catheter placement duration.
4. Location of the catheter.
5. Contamination of catheter connenction or lumens.
6. Internal colonization from remote situs during
bacteremia.

E. Prevention.
1. Recommendations for preventing vascular access information
have been developed by the Vascular Access Workgroup of
the national Kidney Foundation-Dialysis Outcomes Quality
Initiative(NKF-DCQI) in 1998. The Clinical practice
guidelines for Vascular Access were updated most recently in
2006. These can be obtained from
http://www.kidney.org/professionals/kdoqi//guidelines.cfm.
2. Selected recommendations for preventing hemodialysis
catheter related infections.
a. Use sterile technique during catheter insertion.
b. Limit the use of noncuffed catheters to 3-4 weeks.
c. Use the catheter solely for dialysis unless there is no other
alternative.
d. Restrict catheter manipulation and dressing changes to trained
personnel.
e. Replace catheter-site dressing at each dialysis treatment or if
damp, loose, or soiled.
f. Disinfect skin before catheter insertion and dressing changes.
g. Ensure that catheter-site care products are compatible with the
catheter material.
h. Wear a surgical mask of face shield (both patient and
caregiver) during connect and disconnect procedures.
i. Use strict aseptic technique when accessing catheters of
performing catheter dressing changes.
 j. Teach patient and staff early identification of signs and
symptoms of infection.
k. Track and trend infections to identify source and allow
corrective action.

F. Treatment.
1. Treat catheter infections with antibiotic therapy based on the
organism isolated.
2. Antimicrobials at infected access site.
3. Catheter lock solutions containing antimicrobial agents used for
systemic therapy.
4. Prophylactic antibiotics preoperatively and before dental,
diagnostic, or other surgical procedures.
5. Catheter removal recommended for noncuffed catheters.
6. Catheter removal for cuffed catheters if not responsive to
treatment.
7. Infected catheters should be exchanged as soon as possible and
within 72 hours of initiating antibiotic therapy in most instances.

Infections Related to Water, Reuse, and/or machine Contamination

Most infection related to water, reuse and/or machine contamination
are caused by organisms either in the water distribution system,
dialysate, or the dialysate effluent. These organisms primarily consist
of gram negative bacteria frequently found in dialysis fluids and fungi.
With the current state of the art and technology, virus (HBV,HCH,and
HIV) transmission either through errors in reuse or contamination of
machines is a rare event in the United States (see Table 17.7).

I. Transmission of bloodborne pathogens.

A. Reuse.
1. No documented transmission of HBV, HCV, or HIV among
facilities that reprocess hemodialyzers in the United States.
2. Transmission of HIV has occurred in Latin America due to reuse
of access needles and reuse of hemodialyzers. In both cases these
device were inadequately disinfected between uses and shared
among different patients.
3. Prevention strategies for preventing the transmission of
bloodborne pathogens in a reuse program include:
a. Exclusion of HBsAg+ patients from participating in a
reuse program.
b. Follow the Association for the Advancement of Medical
Instrumentation (AAMI) recommended practices for the
reuse of hemodialyzers.
c. Label and assign each patient’s dialyzer with a unique
identifier and place warnings on dialyzers with patients
with similar names.
d. Do not reuse access needles.

B. Machine contamination.
1. There has been at least one outbreak of HBV at a dialysis
facility associated with the failure to use external transducer
protectors to protect pressure monitoring equipment in
hemodialysis machines. Transducer protectors can also fail
when wetted, and some have suggested this as a possible
route for HCV transmission. However, there are insufficient
data to suggest that this is a mechanism for HCV
transmission.
2. Contamination of frequently touched external surfaces of
the hemodialysis machine can be a potential environmental
reservoir for HBV and HCV. HBV can persist in an
infectious state for at least 7 days while HCV has been
demonstrated to persist in such a state for 24 hours.
 II. Bacteremia/fungemia.
A. Reuse.
1. Errors in dialyzer reprocessing have historically been
associated with both pyrogenic reactions and
bacteremia.These errors have frequently occured in
facilities performing manual or semiautomated reuse.
The typical errors that have been associated with these
adverse events have include:
a. Failure to prepare dialyzer disinfectant to the correct
concentration.
b. Failure to fill the dialyzers with sufficient concentration
of disinfectant.
c. Failure to mix dialyzer disinfectant.
d. Using disinfectant that is not compatible with the
dialyzer membrane.
e. Using water that did not meet AAMI recommended
microbial and endotoxin limits.
f. Accidentally not refilling the dialyzer with dialyzer
disinfectant.
g. Removing dialyzer header caps without disinfecting the
O-rings, dialyzer header, and caps.
h. Not reprocessing the dialyzer in a timely manner so that
disinfectant has an appropriate contact time.
2. Bacteremia/fungemia can be prevented by:
a. Following AAMI recommended practice for the reuse of
hemodialyzers.
b. Reprocessing dialyzers as soon as possible after the
completion of a treatment session.
c. Preparing dialyzer disinfectant per manufacturer’s labeled
instructions.
d. If manually reprocessing dialyzers, ensuring that the
dialyzers use at least three compartment with an adequate
amount of dialyzer disinfectant. Most outbreaks
 investigated by the Centers for Disease Control and
Prevention have been associated with manual reuse.
e. To prevent sepsis caused by header removal during dialyzer
reprocessing, there are several steps that could be taken.

Table 17.7
Organisms Typically Associated With Infectios Related to
Water, Dialysate,Reuse,and/Machine Contamination.

Figure 17.6. Waste handling option of COBE Centrysystem 3 dialysis

machine.
1) If clots cannot be removed from the header spaces of the
dialyzer consider discarding it.
2) If one removes the head caps from the dialyzer, then rinse
the end of the fibers with a stream of RO water to remove
clots, and then dip the O-ring, end of the dialyzer, and
end cap in disinfectant before reassembling the dialyzer.
3) Use an automated process for removing clots from the
header spaces.
4) Reevaluate heparinization protocols.

B. Machine contamination.
1. Today wish single-pass hemodialysis equipment, infections due
to contamination of machines is not frequent. Patients may be
infected either throught the hands of health care workers, or by
direct contact of the blood lines with the dialysate circuit as in the
waste-handling option of the COBE Centrysystem 3 dialysis
machine (see Figure 17.6).
2. There are several sources of contamination of the internal fluid
pathways of the machine: water delivered to the machine,
powdered bicarbonate concentrates that are prepared with treated
 water at the facillity, and retrograde growth up the effluent line
from the drain.
3. Preventing bacteremia / fungemia associated with contaminated
machines.
a. Follow AAMI recommmended practices for the microbial
quality of water and diaysate.
b. Disinfect water distribution system and hemodialysis
machine at regular time intervals. This should be conducted
at least monthly. Hemodialysis machine may need to be
disinfected more frequently. Some newer equipment allows
for heat disinfection to be performed on a daily basis.
c. Conduct routine environmental monitoring of water and
dialysate (e.g., microbiology and endotoxin testing).
d. Perform preventive maintenance and quality assurance
checks on equipment per manufacturer’s
recomemmendations.
e. If using equipment with the ports to dispose of the dialyzer
priming solution, follow manufacturer’s recommendations.
With regards to peventive mintenance( routine changing of
check valves ), disinfection, and assesment of check valve
competency.

Immunizations
I. Overview.
There is a significant opportunity for improvement in immunization
rates among dialysis patients for influenza, hepatitis B, and
pneumococcal disease. The goal for the Centers for Medicare &
medicaid services (CMS) Healthy People 2010 initiative is that 90% of
adults will be immunized againts pneumococcal disease and receive an
annual infuenza vaccination. However, in 2002, only 54% of dialysis
patients in the U.S. received an influenza vaccination, and only about
12% had received a pneumococcal vaccination. Table 17.8 summarizes
the goals established by the Healthy people 2010 initiative for infuenza,
hepatitis B, and pneumococcal immunizations and the most current
data on imunization rates available for adults in the United States. Table
17.9 summarizes the most current data available for dialysis patients.
The centers for Disease Control and Prevention recommends all three
vaccinations for dialysis patients due to the increased risk of infection
in the CKD population.
II. Recomendations.
Table 17.10 shows a list of vaccines recommended for persons with
chronic kidney disease.
A. Hepatitis B.
1. Each year 78,000 Americans are infected with hepatitis B and
5,000 die from it.
2. Vaccination for hepatitis B is recommended for all pre-CKD
stage 5 patients before they start dialysis.
3. Vaccination is recommended for all chronic dialysis patients.

Table 17.8
Healthy People 2010 Goals and Current Status of Immunizations
4. Hepatitis B vaccines are given in a three or four dose series. Table
17.11 shows the schedules for both series.
5. Serologic testing should be performed 1-2 months after
administration of the last dose of the vaccine series.
6. Patients with anti-HBs level of less than 10mIU/mL after the
vaccine series should be revaccinated followed by serologic
testing.
7. Patients who do not respond to revaccination should be tested for
HBsAg. If the HBsAg is positive, the patient should be
considered infected and managed appropriately to prevent the
spread to others. If the HBsAg is negative, the patient should be
considered susceptible to infection and counseled on precautions
to prevent infection.
 8. Patients who have responded to the vaccine should have annual
anti-HBs testing. A booster dose should be administered when
anti-HBs levels are less than 10 mIU/mL.

Table 17.9
Immunization Rates for Dialysis patients
B. Influenza.
1. Every year 5-20% of the population is infected with influenza,
more than 200,000 people are hospitalized from complications,
and 36,000 people die from the flu. People with chronic medical
conditions (like chronic kidney disease) are at higher risk of
developing serious flu complications such as pneumonia and
bacterial infections, respiratory and cardiac ailments, Reye’s
syndrome, and death.
2. Inactivated influenza vaccine is recommended for all persons
with impaired kidney function.
Table 17.10
Recommended Vaccinations For Persons with Chronic Kidney Disease
3. The live, attenuated influenza vaccine is not recommended for
persons with impaired kidney function.
4. Vaccination for influenza is recommended annually at the
beginning of the flu season (October-November).
C. Pneumococcal.
1. In 2002, approximately 65,000 people died of pneumonia: 90%
of these deaths were in persons 65 years or older.
2. Complications of pneumococcal pneumonia include empyema,
pericarditis, endobronchial obstruction, and death.
3. Vaccination for pneumococcal disease is recommended for
persons with chronic kidney failure.
4. The pneumococcal polysaccharide vaccine (PPV) protects
against 23 types of pneumococcal bacteria.
 5. Revaccination every 5 years is recommended for chronic kidney
failure patients over 2 years of age.

Regulations and Recommendations: What’s the Difference?

Infection control practices in dialysis and kidney transplant settings
are influenced by the federal end-stage renal disease (ESRD)
regulations , any applicable state licensing rules, Occupational
Safety and Health Agency (OSHA) regulations, and
recommendation of professional associations and state and federal
agencies.
I. Regulations are mandatory requirements that must be met to
practice within the “law.”
A. Implement statutes passed by legislative bodies and
signed into law by the governor, for state laws, or the
president, for federal laws.
B. The public can influence the content and sructure of the
law during the legislative process by contacting their
congresspersons to educate and influence the vote.
C. Once a bill has been passed and signed into statute, the
applicable state or federal agency is charged with
developing regulations to implement the law.
D. Statutes are typically broad, outlining the intent of the
legislature. The specifics are usually found in regulation.
E. Regulations are subject to public influence as well.

Table 17.11
Dose schedules for Hepatitis B Vaccine
1. Proposed state and federal regulations are published for
public comment before being finalized.
2. Comments received are taken into consideration in
developing the final regulations.
 3. Examples of current regulations : Federal regulations
require ESRD facilities to prevent the transmission of
infection. Essentially this requires that facilities follow
the guidance issued by the centers for Disease Control
for infection control in hemodialysis facilities. These
recommendations are discussed in more detail in a
different section of this chapter.

II. Recommendations are voluntary and frequently

Come about as the result of critical incidents or research evidence,
rather than law. Recommendations, by themselves, do not carry
the weight of “law.’’
a. May be developed via a consensus process.
b. Professional organization that have developed
recommendations addressing infection control topics include:
1. ANNA: Nephrology Nursing Standards of practice and
Guidlines for Care.
2. National Kidley Foundation (NKF): kidney Disease
Outcomes Quality Improvement (KDOQI) Practice
Guidelines.
3. Association for the Advancement of Medical
Instrumentation (AAMI): Recommended Practice Dialysate
for Hemodialysis.
c. The federal agency that provides direction in the area of
infection control is the centers for disease Control and
Prevention (CDC). Their documents are designated as
either‟Guidelines” or ‟Recommendations.”
1. Recomendations are based on findings from CDC
investigations of critical incidents, research or review of
data and developed via expert opinion. There is an internal
review process, and public comments may be solicited, but
there is no requirement to incorporate such comment into
the final recommendation.
 2. Guidlines are usually developed by CDC and external
partners, based on evidence, and require public review and
are published in the federal register for comment. Public
comments have to be addressed by incorporation into the
guideline or by providing a reason why the comment was
not accepted. The completed document undergoes a final
peer review process before being published as a guidelines.

III. Recommendations adopted as regulations.

Recommendations may sometimes be formally adopted as
regulations.

A This allows the state or federal government agency to use the

work of professional organizations and other agencies,
preventing the potential development of conflicting standards
and reducing duplicate efforts.

B For example, the Centers for medicare and medicaid Services

(CMS) formally adopted the AAMI document” Reuse of
Hemodialyzers” as part of the ESRD regulations,mandating
that facilities that reprocess dialyzers comply with the
“Voluntary” guidelines that AAMI developed.

C CDC recommendations for infection control are currently

referenced in the CMS ESRD guidance to surveyors as the
standard for infection control practices in dialysis. State
surveyors are instructed to expect facilities to follow the CDC
recommendations for standard precautions and the specific
precautions related to hemodialysis.

D . The changes to the CM’s ESRD regulations proposed in 2005

included language to incorporate the CDC recommendations
for infection control as regulations.
 IV. Practice gidelines and standards are more and more
commonly used as a way to organize and prioritize care
delivery, and to evaluate the care deliverd.

A. In this context, recomendations are sometimes used as an

expected standard.

B. For example, the KDOQI guidelines for dialysis adequancy

is commonly used as the expected standard of care for
hemodialysis and peritoneal dialysis. State surveyors are
instructed to compare a facility’s patient outcomes in
dialysis adequancy with the KDOQI minimum target ,
those minimum targets might be included as support for the
finding of a deficient practice.

C. Currently, KDOQI guidance has not been adopted as

regulation. Thus ,if a facillity had evidence that their targets
for adequancy were based on a similar scientific process,
the surveyor would consider that evidence in determining
whether a deficient practice existed.

CDC Recommedations for infection control in Hemodialysis Settings

I. General considerations,
A. Standard precautions are designed to protect health care
workers and service users from occupational exposure to
blood or other potentially infectious materials. All human
blood and certain human body fluids are treated as if known
to be infectious for HIV, HBV, and other bloodborne
pathogens.

B. The occupational safety and Health Administration

mandates that each employer having an employee(s) with
occupational exposure establish a written Exposure Control
 plan designed to eliminate or minimize employee exposure.
The components of the plan must include, but are not
limited to:
1. Engineering and work practice controls to eliminate or
minimize employee exposure (i.e., safety needles,
needleless systems).
2. Personal protective equipment (PPE) (e.g., gowns,
gloves, face shields).
3. Hepatitis B vaccination and postexposure evaluation and
follow-up.
4. Communication of hazards to employees.

C. Standard precautions synthesize the major featues of

universal precautions designed to reduce the risk of
transmission of bloodborne pathogens, and body subtance
isolation designed to reduce the risk of transmission of
pathogens from moist body substances, and applies them to
all patients receiving care in hospitals, regardless of their
diagnosis or presumed infection status; recommended for
the inpatient hospital setting.

D. In addition to standard precautions, more stringent

precautions have been recommended by the CDC for the
hemodialysis setting due to the increased potential for
contamination with blood and pathogenic microorganisms
and are the focus of this section on infection control.

II. Recommendations for preventing transmission of infections

among chronic hemodialysis patients.
A. Published by the Centers for Disease Control and
Prevention (CDC) MMWR, April 27, 2001, Vol.50,
No.RR-5.
 B. These recommendations replace previous
recommendations for the prevention of bloodborne virus
infections in hemodialysis centers.
C. They provide additional recommendations for the
prevention of bacterial infections in the hemodialysis
setting.
D. Provides recommendations for comprehensive infection
control program.
1. Infection control precautions specifically designed to
prevent transmission of bloodborne viruses and
pathogenic bacteria among patients.
2. Routine serologic testing for hepatitis B and C.
3. Vaccination of susceptible patients and staff.
4. Isolation of patients who test positive for hepatitis
surface antingen (HBsAg).
5. Surveillance and education.
E. Implementation of the recommendations will reduce
opportunities for patient-to-patient transmission of
infectious agents, directly or indirectly via contaminated
devices, equipment and supplies, environmental surfaces,
or hands of staff.
F. Must be carried out routinely for all patients in the
hemodialysis center.
G. Includes additional measures to prevent HBV
transmission.

III. Infection control precautions for all hemodialysis patients.

A. Wear gloves whenever caring for a patient or touching the
patient’s equipment at the dialysis station. Remove gloves and
wash hands between patient or stations or more often if gloves
become contaminated.
B. Wash hands after gloves are removed and between patient
contacts, as weel as after touching blood, body fluids, secritions,
excretions, and contaminated items.
C. If hands are not visibly contaminated, a waterless antiseptic hand
rub can be substituted for hand washing.
D. Items taken to a patient’s dialysis station , including those placed
one top of dialysis machines, should either be disposed of,
dedicated for use only on a single patient, or cleaned and
disinfected before being returned to a common clean area or
used for other patients.
E. Unused medications or supplies (e.g.,syringes, alcohol swabs)
taken to the patient’s station should not be returned to a common
clean area or used on other patients.
F. Multiple dose vials must not be carried from station to station.
G. Common carts should not be used to prepare or distribute
medications. If trays are used to distribute medications, the tray
must be cleaned before using for a different patient.
H. Common supply carts that are used to store clean supplies in the
treatment area should remain in a designated area at a sufficient
distance from patient stations to avoid contamination with
blood.
I. Residual medication from two or more vials should not be
pooled into a single vial.
J. Staff members should wear gowns, face shields, eye wear, or
masks when performing procedures during which exposure to
blood might occur.
K. After each patient treatment, a low level disinfectant should be
used to clean environmental surfaces at the dialysis station,
including the bed or chair, countertops, equipment, blood
pressure cuffs, clamps, external surfaces of the dialysis machine,
and containers used for prime waste.
L. Blood spills must be immediately cleaned with a cloth soaked
with a tuberculocidal disinfectant or a 1:100 dilution of
household bleach.
M. Venous pressure transducer protectors should be changed
between patients and not reused.
N. External transducer protectors that become wet should be
replaced immediately and inspected.
 1. If fluid is visible on the side of the transducer protector
that faces the machine, qualified personnel should open
the machine after the treatment is completed and check
for blood contamination of the internal pressure sensing
port.
2. If contamination has occurred, the machine must be
taken out of service and disinfected, using either 1:100
dilution of bleach or EPA registered tuberculocidal
germicide before further use.
O. Wastes generated by the hemodialysis treatment should be
considered infectious and placed in leakproof containers for
disposal according to local and state reguations.

Continuous Quality improvement and Infection Control

I. Continuous quality improvement (CQI).
Assesing and improving quality is an important part of professional
care. CQI has been shown to improve clinical outcomes and
processes that can lead to improved morbidity, mortality,quality of
life, and patient satisfaction.
II. Quality improvement plan (QIP).
A. Aquality improvement plan (QIP) is a process to promote
continuous quality improvement in all aspects of patient
care. The plan is like a road map.That leads in the right
direction. The road ,ap requires the participation off all
members of the care team including patients, physicians,
nurses, technicians, dietitians, social workers, vendors,
housekeeping, and other customers of the dialysis unit.
B. Each dialysis unit must maintain its own specific quality
improvement plan. The plan is used to identify areas for
continous monitoring that includes all areas of the
organization, from the board of directors (or governing
body) to staff providing patient care. The team must
 agree on aspects of care that need improvement and
develop and adopt quality indicators. The group then
collects data to determine the need for improvement.then
steps are devised and carried out to bring about change
through improving the system of care. Use the indicators
to measure successes.
C. Elements of a good QIP.
1. Identfy and measure key areas of care in the
facilitiy.
2. Measure those indicators identified by CMS,
KDOQL,CDC,AAMI, and OSHA.
3. Assess facility care processes and look for areas
that could be improved.
4. Develop a system for monitoring these processes.
5. Evaluate the changes and recommend
improvements.
6. Always monitor outcomes over time.

III. Infection control practices.

A. Key aspects of the QIP include monitoring the following
infection control issues:
1. Dialysis specific infection control precautions (CDC).
2. Dialyzer reuse processes.
3. Water used for dialysis and reuse.
4. Hepatitis testing for staff and patients.
5. Hepatitis vaccination for staff and patients.
6. Isolation of hepatitis B patients.
7. Influenza vaccination for patients.
8. Tuberculosis surveillance.
9. Pyrogenic reactions.
10. Peritonitis exit site and peritonitis rates.
11. Sepsis episodes.
12. Access infection rates.
13. Specific staff identified to monitoring infection rates.
 B. The facility’s infection control strategis should cover the
following at minimum:
1. A written plan that is reviewed and updated as necessary.
2. A requirement for use of personal protective equipment
such us as gloves, gowns, and face protection when
exposure to blood or body fluids is likely.
3. A requirement for housekeeping procedures that ensures the
environment is clean and sanitary.
4. A requirement for efficient and save infectious waste
procedures.
5. A requirement for effective handling of blood
contaminated linens and clothing.
6. Development and implementation of an effective training
program for the use of infection control practices.
7. Maintenance of employee’s training records related to
infection control training.
8. Disinfection policies and procedures for medical equipment
and medical devices, including periodic bacteriologic
testing of a random sample of dialysis machines.
9. Procedures for maintaining a long of adverse patient
reactions.
10. Procedure for monthly surveillance of dialysate and
water cultures.
11. Surveillance and reporting of access infections.
12. Disinfection of equipment.
13. Rinsing , cleaning, disenfection, preparation, and
storage of reused dialyzers.

IV. Surveillance and reporting.

A. For each indicator, data will be collected and reported in a way
that allows for identification of outliers (e.g., those patients not
meeting the standard or threshold set for a given indicator). An
example might be the number of a new tunneled catheter systemic
infections in the facility. The number of infections in new
 catheters would be collected over a designated period of time (for
example, 3 months). Compare the number of infections against
other sources ( sometimes referred to as benchmarks). In addition
to a single facility’s threshold ( goal or standard ), examples of
comparative data may include the number of new tunneled
catheter infections in other facilities within the organization and
the 2006 KDOQI Vascular Acces Infection Clinical Practice
Guidelines for tunneled catheters. Using comparative data assists
in identifying areas needing improvement.

B. Steps for collecting and reporting data include identification of:

1. Who is best qualified to collect the data.
2. The source or sources of the data.
3. How the data is to be collected and the frequency of collection.
4. Who will organize the data.
5. How the data will be displayed and how comparative data will
be used in the report.

V. Evaluation of outcomes.
A. At regular meetings, those individuals responsible for evaluating
specific outcomes report to the quality improvement team. The
team will evaluate and determine whether there is an opportunity
for improvement.
B. The team should record in meeting minutes the outcomes,
assements,conclusions, and recommendations for each indicator.

VI. Action steps.

A. If the evaluation of an indicator suggests a need for improvement,
actions must be specified and recommendations carried out.
Actions may include:
1. Knowledge issues needing in-service education and sharing of
information. An example might be the technique used to
 cleanse and prepare catheter exit sites. Are KDOQI guidelines
being used for prevention of catheter infections? Are staff
following the designated procedure?
2. Behavior issues needing counseling or disciplinary action.
3. System issues requiring changes in how information is shared,
staffing issues, equipment problems, and procedures.For
example, does the procedure for cleansing and dressing
catheters need to be changed?

B. Identify who will implement the changes and how the changes
will be monitored for effectiveness.

C. Set up a pilot project. It is often better to start small than to

implement a unit-wide change unless the severity of the problem
indicates otherwise. Select the study group (e.g., every other new
tunneled catheter patient). The study group will use a new
cleaning and dressing procedure.

D. Identify what data needs to be collected and how long the data
will be collected. For example, collect the number of systemic
catheter infection in the patients included in the pilot study for 3
months.

VII. Assess effectiveness of pilot project.

A. Review outcome of action steps. If care and service improved
and agreement is reached to change the process, write new
procedures and educate all involved staff and patients as
needed. For example, if the percentage of infections in the pilot
study group was 3% versus 6% in the nonstudy group, a
change in procedure may be warranted.

B. If care and service did not improve , futher evaluation is

needed to determine whether further interventions are needed.
 Additional data collection may be necessary to determine if the
initial plan can produce change. For example, if no changes
were seen in infection rates between the pilot and general
group, it may mean that data needs to be collected for a longer
period of time to show results. Re-examine the changes made
to the current work process. Does it need revision? Are staff
involved in the pilot following the new process?

VIII. Make the change.

A. If it is clear that the pilot project has produced positive
change, communicate process changes to staff and patients.
B. Educate staff as needed and implement the changes unit-
wide.
C. Continue collecting data over time to ensure positive
outcomes.
D. Changes in policies and procedures must be approved by
and adopted by the facility’s governing body/organization.