Infection Control Connie Cavenaugh UAMS’ Infection Control Practitioner.
Infection Control in Dialysis Overview - Webber Training Control in Dialysis Dr. Charmaine Lok, ......
Transcript of Infection Control in Dialysis Overview - Webber Training Control in Dialysis Dr. Charmaine Lok, ......
Infection Control in DialysisDr. Charmaine Lok, University of Toronto
A Webber Training Teleclass
Hosted by Paul Webber [email protected] Page 1
Infection Control in DialysisCatheter related infections
Charmaine Lok, MD, FRCPC, MScUniversity of Toronto
Hosted by Paul [email protected]
www.webbertraining.com
Overview
Focus on hemodialysis catheter-related infections
BackgroundPathogenesis & Risk FactorsEpidemiology - Clinical studiesManagement
HICSConclusions
Infection
Most common cause of morbidity2nd most common cause of death75% of infectious deaths due to bacteremiaVascular access = main source of bacteremia Central venous catheters (CVC) = highest risk≈ 50% with have CRB by 6 mosSepsis related hospitalizations ↑50% (decade)Cost = $22 000 USD /bacteremia Multiple organisms involved
Pathogenesis
Distribution of Culprit OrganismsMajority are Gram Positive organisms
Lok, CE., Advances in Chronic Kidney Disease:13(3):225; 2006
Staphylococcus Aureus
Binds to nasal mucoproteinsProduces glycocalyxToxins lead to abscess formationMuch more toxic than S. epidermidis
Infection Control in DialysisDr. Charmaine Lok, University of Toronto
A Webber Training Teleclass
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Staphylococcus Epidermidis
Common organism that colonizes skinLess toxic than S. aureusEnveloped by amorphous slimy materialHost serum proteins aid in productionBiofilm provides environment for increased bacterial growth
Pathogenesis
Bacteria
Patient Catheter
Skin Contamination (Extraluminal)
Touch contamination (Intraluminal)
Bacterial attachment to catheter
Biofilm Formation
More Biofilm Formation
BACTEREMIA
Nasal Carriage - S. aureus Skin surface – S. Epidermidis Pathogenesis
Sources of infection:
Skin contamination (early)Hub contamination (later)Hematogenous seeding (uncommon)Infected infusate (rare)
Extraluminal: Skin contamination Early Infection
Bacteria from exit site track down the catheter into the catheter tip
Quantitative skin cultures show increased risk of infection with increased cfu/cm2
Bertone S, Inf Cont Hosp Epi 1994
Infection Control in DialysisDr. Charmaine Lok, University of Toronto
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Intraluminal: Hub contamination Later Infection
Caused by touch/hub contamination
Develops later in course
Frequent problem with hemodialysis catheters
Biofilm on a Catheter
S. Aureus
emu.arsusda.gov/typesof/images/staph.jpg
Anton van Leeuwenhoek
“SCURF” and “Animalculi” Biofilms
Infection Control in DialysisDr. Charmaine Lok, University of Toronto
A Webber Training Teleclass
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The Biofilm Micro-cosm
Skin Contamination (Extraluminal)
Touch contamination (Intraluminal)
Bacterial attachment to catheter
Biofilm Formation
More Biofilm Formation
BACTEREMIA
Nasal Carriage - S. aureus Skin surface – S. Epidermidis
Bacterial attachment to catheter
Lessons from Peritoneal Dialysis
Instructions for PD exchange & catheter access:
Remove petsShut doorPut on maskCut off circulating air – cover or close ventsWash hands for 3 minutes
What precautions do your nurses, technicians, patients and colleagues follow in the Hemodialysis unit?
Epidemiology
Staphylococcal Infection
Annual incidence of SA bacteremia ≈ 6- 27%S. aureus bacteremia in HD ≈ 0.6- 3.9/1000 days23% hospitalized in ICU21% require re- admission within 3 months
70% of due to recurrent bacteremiaDeath at 12 weeks: 13%- 20% 88%: Vascular access is the source of bacteremia Avg Cost = $22 000 /uncomplicated bacteremia Avg Cost = $32 000 /complicated bacteremia
Costs and complications increase when MRSA +veEngemann,et. al. Infect Control Hosp Epidemiol, 2005; n=210, 1994-2001; Kaech Clin Microb Infect, 2006
Staphylococcal Infection
3%Stroke
31%Any
35%19%Mortality (12 weeks)
5%Septic Emboli
5%Septic Arthritis
6%Osteomyelitis
17%Infective endocarditis
MRSASAComplication
Engemann,et. al. Infect Control Hosp Epidemiol, 2005; n=210, 1994-2001
Reed,et. al. Infect Control Hosp Epidemiol, 2005; n=54 (143 total) 1996-2001
?
Nissensen, AJKD, 2005, n=11572, USRDS
Infection Control in DialysisDr. Charmaine Lok, University of Toronto
A Webber Training Teleclass
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US HD Patient Mortality 2002-2003
Annual mortality 23.5 /100 pt-years
Cardiac arrest 5.5Septicemia 2.6MI 1.9Stroke 1.2
Table H.29 Unadjusted Mortality.
USRDS 2005 Annual Report
Mortality & Bacteremia
In the USA in 2004308000 HD patientsCatheter rate ≈25% (now 1/3)81,000 pts with CVCCRB rate average 2/1000 days (0.5-5.5/1000 days)
(0.73 infection/pt- year)Mortality from bacteremia 10% (up to 20%)5913 deaths/year from bacteremia
Mortality and Sepsis
Foley et. al, JASN 15:1038, 2004
N=393 451MI
Sepsis
No Sepsis
Morbidity, Cost, Mortality
USRDS retrospective study (1996-2001)S. aureus vs. other bacteria11,572 S. aureus admissions
<.0013.8%13.5%Mortality
<.001$15,965$17,307Cost(Index admission)
<.0019 ± 1013 ± 13LOS
P valueOtherS. Aureus
Nissenson AR, AJKD 2005
Increase in Staphylococcal Infections
Foley et. Al, JASN, 2004
N=393,451
11%/1st yr
Of HD ↑51%
↑39%
Dialysis Surveillance Network (CDC)
1999Volunteer outpatient dialysis centersInternet-based systemData from 321,519 patient-months
Finelli, Semin Dial 2005
76%40%MRSA
30%12%VRE
20021995Centres with at least 1 case
Klevens, RM. NN&I 2005
Infection Control in DialysisDr. Charmaine Lok, University of Toronto
A Webber Training Teleclass
Hosted by Paul Webber [email protected] Page 6
Dialysis Surveillance Network (CDC)
Purposes
To provide a method for HD centers to record & track rates of vascular access infections, other bacterial infections, & IV antimicrobial startsTo provide rates for comparisons among various dialysis centers (benchmarking); Rate: 1.5/1000To use these data to motivate practice changes & to prevent infections, especially those caused by antimicrobial resistant organisms
ww.cdc.gov/ncidod/dhqp/index.html for protocols
Canada
Canadian Nosocomial Infection Surveillance ProgramNetwork of Canadian hospital that carries our surveillance examining the frequency & risk factors for hosp acquired infectionsMultiple publicationsHD units
Catheter related bacteremia (CRB)
8%Enteroccoci
10%Gram Negative
8%Mixed
40%Coag Neg Staph
32%S. Aureus
82%Gram Positive
PercentageOrganism
Taylor, G. Infect Control Hosp Epidemiol 23:716-720, 2002
CRB Risk factors
Catheter site: Femoral>IJ > subclavianCatheter characteristic: Non- cuffed vs. cuffed, Non- tunneled vs. tunneledProlonged duration of catheter usePrevious bacteremiaThrombosis of the catheterPatient “stressed state”
Recent surgeryDiabetesImmunocompromised
Poor hygiene
Epidemiology:
Clinical Prevention Trials
Extraluminational CRB prophylaxisElimination of Nasal Colonization:
Single courses of intranasal mupriocin +/- other
Problem: Effective but recurrence after 3 mos
Multiple, intermittent coursesProblem: Mupirocinresistance
Infection Control in DialysisDr. Charmaine Lok, University of Toronto
A Webber Training Teleclass
Hosted by Paul Webber [email protected] Page 7
Skin Contamination (Extraluminal)
Touch contamination (Intraluminal)
Bacterial attachment to catheter
Biofilm Formation
More Biofilm Formation
BACTEREMIA
Nasal Carriage - S. aureus Skin surface – S. EpidermidisMupirocin
Extraluminal CRB prophylaxis
Elimination of Exit Site Colonization:Prevention of hemodialysis subclavian vein catheter infections by topical proviodine–iodine (Levin, A. et. al. KI1991, RCT)
Prophylaxis of HD CVC with mupirocin (Sesso R. et. al., JASN 1998; Johnson DW et. al, Nephrol Dial Transplant 2002, nonblindedRCTS)
Prophylaxis of HD CVC with Honey (Medihoney)(Johnson D.W., JASN 2005; nonblinded RCT-no difference vs mupirocin)
Only selected honeys have activity: manuka honey (New Zealand) & Leptospermum honey (Australia)γ Sterilization (Clostridium botulism found in honey)
Death
Bacteremia
16%
2.48
Placebo
4%
0.63
PT
78%
60%
RRR
P=0.0048
P<0.00047
P valueNNT
* Number of events/1000 catheter days
A Reduction in catheter exchanges & hospitalizations
seen in PT group (P< 0.05)
Extraluminal CRB prophylaxis
DB RCT Prophylaxis of HD CVC with Polyantibiotic (Lok C.E., JASN 2003)
Skin Contamination (Extraluminal)
Touch contamination (Intraluminal)
Bacterial attachment to catheter
Biofilm Formation
More Biofilm Formation
BACTEREMIA
Nasal Carriage - S. aureus Skin surface – S. EpidermidisMupirocin
Topical Antimicrobial
Topical Antimicrobial
Intraluminal CRB Prophylaxis
Antibiotic Lock Prophylactic Therapy (ABL)Developed in late 1980’s for TPN ptsVancomycin and amikacin
[luminal] 40- 80 & 60- 120 x systemic peak [blood] with conventional dosing[ ]Maintained 8- 12 hrs, stable & active 12 hrs
HD patients: ↓ CRB (interdialytic lock)
Prophylaxis with ABL solutions: RCT
0.44/1000 (Gent-Cit) vs.3.12/1000 (hep)
Cefazolin 10 mg/ml, Gentamicin 5 mg/ml +hep 1000 U/ml vs. hep only
N=120 TCCRB- 2 cultures pos same org (tip, CVC or periph)
Kim (KI 2006)
0% CRB (minoc-EDTA)8.3% (hep) NS;9.1% vs. 64.3% colonizn
Minocycline 3 mg/ml & EDTA 30 mg/ml vs.Heparin (concentration?)
N=57 TCCRI; thrombosis; both
Bleyer(ICHE 2005)
0.31/1000 (gent-hep) vs.
4.0/1000 (hep)
Gentamicin 5 mg/ml & heparin 5000 u/ml vsheparin 5000 u/ml
N=50 PCCRI by CDC definitions
McIntyre(KI 2004)
0/1000 CRB (Gent-cit) vs.2.6/1000 (hep)
Gentamicin 40mg/ml & Citrate 3.13% vs. heparin 5000 u/ml (+ intranasal mupriocin)
N=112 PC (83 pts)
CRI by CDC definitions
Dogra(JASN 2002)
ResultsStudy RxN/ EndpointAuthor
Infection Control in DialysisDr. Charmaine Lok, University of Toronto
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Concerns with ABL
Microbial resistanceSystemic leakage of Abx
Ototoxicity with AMGsIf lumen colonized with intrinsically R strains, overgrowth of resitant strains may occur when Abx susceptible organisms are suppressed
Physical & chemical compatibilityAnticoagulantCatheter material
Are ABL Indicated?
Artificial Heart ValvesPacemakerInternal defibrillatorsFemoral cuffed cathetersRecurrent infections with limited access
Anti-microbial Locks
Double blind trial: Citrate vs. HeparinNewly inserted catheters291 HD patients with CVC randomized
WeijmerJASN 2005
.00528%46%Catheter Removal
.02805Patient Deaths
<.0011.14.1CRB
P ValueCitrateHeparin
Taurolidine & citrate ↓ CRB (Betjes NDT 2004; Allon CID, 2003)
Skin Contamination (Extraluminal)
Touch contamination (Intraluminal)
Bacterial attachment to catheter
Biofilm Formation
More Biofilm Formation
BACTEREMIA
Nasal Carriage - S. aureus Skin surface – S. EpidermidisMupirocin
Topical Antimicrobial
Topical Antimicrobial
Catheter Locking Solution
Catheter Locking Solution
Catheter Locking Solution
What can I do?
Get rid of those catheters!Educate patientsMeasure and monitor bacteremia rate in your unitFollow universal infection control precautionsPharmacy)
Topical antimicrobial usagePrescribe anti- microbial or ABL solutions (from Pharmacy)
Appropriate antibiotic use & avoid resistance
Overriding Management Principles
Avoid CVC as much as possiblePreserve anatomy for permanent access placement
Always culture first before administering antibiotics → be clear and specific in ordersAlways follow up with sensitivitiesCatheter specific strategies dependent on clinical situation
Infection Control in DialysisDr. Charmaine Lok, University of Toronto
A Webber Training Teleclass
Hosted by Paul Webber [email protected] Page 9
Management Strategies for CVC Related Bacteremias
Catheter “salvage” Salvage + adjunctive antibiotic lockCatheter exchangeCatheter removal + delayed replacement
Concurrent IV antibiotics for all strategies
HICS
Hemodialysis Infection Control Subcommittee
HICSVA Coordinator
NephrologistInfection Control
Practitioner
Pharmacist
Student HICData Manager
Microbiologist
HICS: What we do
HD infection surveillanceSpecifically Vascular AccessExpanding
Identify & confirm suspected infectionsFU cultures, clinically exam patients prnHealth Canada guidelines
Guidance for managementBenchmarkingDevelop procedures & protocolsEducate nurses, physicians, patients
Identifying causative organisms
0
20
40
60
80
100
Percentage
Gram-positive Gram-negative Polymicrobial
Organism Type
Bacteremia
Exit Site Infection
Tracking Management Outcomes
36.0%Hospitalization for infection56.1%Catheter salvage43.9%Catheter removal
4.4%Recurrence at 3 months
1.8%Death
3.5%Infectious complications (septic arthritis)3.5%Recurrence at 6 months
77.2%Successful treatment
Treatment Outcomes
Infection Control in DialysisDr. Charmaine Lok, University of Toronto
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Duration of Treatment
0 5 10 15 20 25 30 35
S. aureus
CoNSt
Gram-negative
Fungal
Days of therapy
Organism
Duration of treatment required for maximum cure
Tracking Antibiotic Resistance
0%0%Resistance to Resistance to tobramycintobramycin
(1/11) 9.1%(1/11) 9.1%
(30/44) 68.2%(30/44) 68.2%
Resistance to Resistance to cefazolincefazolin
Resistance to vancomycin
GramGram--negative negative organismsorganisms
0%Staphylococcus aureusStaphylococcus aureus
0%CoagCoag--negneg. . StaphylococciStaphylococci
Selected Pathogen Resistance
Tracking Infection Rates
Catheter Related Infection Rates
00.20.40.60.8
11.21.41.6
2000 2001 2002 2003 2004 2005 2006*
Year
Even
t/100
0 CV
C da
ys
BacteremiaESITotal
* Jan-July only
CQI: Track Outcomes & RectifyBlood Stream Infection Rates
00.2
0.40.6
0.81
1.21.4
2003 2004 2005Year
Infe
ctio
n R
ates
/ 100
0 lin
e da
ys
BSI definite+Probable+PossibleBSI Definite+ Probable
PST
Problem
Follow guideline recommendation to have database to track VA use & outcomes
Non-access related infections
Lower/upper respiratory tract infectionsHIV infectionCentral Nervous system infectionGI tract infectionGenitourinary infectionCellulitis and osteomyelitisInfections due to highly drug- resistant organismsTuberculosis (new and reactivated)
Summary
Staphyloccocal infections are associated with great morbidity, mortality & costMonitoring & benchmarking infections in your own unit is important (DSN)The pathogenesis involves an intraluminaland/or extraluminal sourceOrganism attachment & biofilm formation =common pathwayPreventative strategies should targeted to pathophysiologyGet rid of those catheters!
Infection Control in DialysisDr. Charmaine Lok, University of Toronto
A Webber Training Teleclass
Hosted by Paul Webber [email protected] Page 11
AVOID THIS!
The Next Few TeleclassesMay 17 Ethics of Care During a Pandemic
… with Dr. Eric Wasylenko, Calgary Health Board
May 24 Importance of Vaccination Among Dialysis Patients… with Dr. Matthew Arduino, CDC
May 31 Evaluation and Management of Infectious Disease Outbreaks in Nursing Homes… with Dr. Chesley Richards, CDC
June 7 Infection Control in the Living and the Dead: The Angola Marburg Outbreak… with Dr. Adriano Duse, University of the Witwatersrand
June 20 Central Venous Lines and Prevention of Infection… with Dr. Steven Chambers, Australia
For the full teleclass schedule – www.webbertraining.comFor registration information www.webbertraining.com/howtoc8.php