Preventing Infections in Patients Undergoing Hemodialysis

Alexander J Kallen; Matthew J Arduino; Priti R Patel

Disclosures

Expert Rev Anti Infect Ther. 2010;8(6):643-655. 

In This Article

Abstract and Introduction

Abstract

Infections continue to be a major cause of morbidity and mortality in patients with end-stage renal disease. While rates of all-cause hospitalization of prevalent end-stage renal disease patients receiving hemodialysis reported by the United States Renal Data System fell from 1993 to 2007, rates of hospitalization for infections rose by 26%. Developing a better understanding of the reasons for this rise and employing strategies to reverse it have become a priority for patients, providers and regulatory agencies in the USA. In addition, recent episodes of transmission of bloodborne hepatitis viruses in outpatient healthcare facilities, including hemodialysis centers, related to suboptimal infection control and injection safety practices, have raised concerns about patient safety. In this article, we review many of the current infection control challenges facing outpatient dialysis centers and discuss recommended infection control policies and practices aimed at combating these challenges.

Introduction

In the 1970s, the CDC's Study on the Efficacy of Nosocomial Infection Control (SENIC) suggested that hospitals could decrease their rates of healthcare-onset infections by about one-third if they had an infection control program that had four components.[1] These components included an emphasis on surveillance and control activities, at least one infection preventionist for every 250 inpatient beds, a trained hospital epidemiologist and a system to make individual surgeons aware of their rates of surgical site infections. In the decades since the publication of that study, organized and effective infection control programs with the components highlighted in SENIC have become the standard in inpatient healthcare facilities. In outpatient healthcare facilities, however, organized infection control programs are still continuing to evolve and in many respects lag behind those found in inpatient facilities.

There are more than 5000 outpatient dialysis centers in the USA, providing care to approximately 340,000 hemodialysis patients.[2] These facilities, which are the primary focus of this article, are a prime example of a healthcare setting in which rigorous attention to infection control has the potential to greatly influence the infection-related outcomes of its patients. However, there are challenges in implementing aspects of infection control programs in dialysis centers that are not seen in acute-care hospitals. First, most (>80%)[2] dialysis centers are not hospital-based and therefore they frequently do not have access to the trained infection preventionists that provide infection control expertise in hospitals. Second, dialysis technicians, who provide a large amount of care in dialysis settings, generally receive limited formal training in infection control and aseptic technique. Third, dialysis surveillance is limited nationally. The United States Renal Data System (USRDS) follows a large number of important dialysis-related measures but the information it collects is generally based on claims data and is subject to many of the problems found with this type of data, including reduced timeliness and sensitivity. In addition, data in USRDS related to infections are limited and some important infectious outcomes are not captured.

There is little doubt that infections remain a major problem in patients undergoing hemodialysis. USRDS has shown that while rates of hospitalizations for many problems remain relatively stable, rates of hospitalization for infection have increased by 26% since 1993, although there has been a decrease in infectious hospitalizations since 2005.[2] Of particular note, however, is the increase in hospitalizations for bacteremia/septicemia from approximately 8.2 per 100 patient-years in 1999–2000 to 10.5 per 100 patient-years in 2005–2007.[2]

In the USA, both the CDC and the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQITM) have provided evidence-based guidance on aspects of infection control in hemodialysis patients.[3–7,101–103] Guidance from these organizations covers a large number of topics, including the prevention of vascular access infections,[3–6] environmental disinfection,[3,102] hand hygiene,[7] the prevention of transmission of multidrug-resistant organisms,[3,103] vaccinations[3,101] and the prevention of transmission of bloodborne viruses.[3] In addition, the Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage for end-stage renal disease (ESRD) facilities have also required adherence to certain infection control practices based upon national guidelines.[104] These requirements, which were developed in conjunction with the CDC, focus on three areas: providing infection control training and education for staff; surveillance for infections and other adverse events; and the use of specific infection control measures that are intended to prevent transmission of and infections with bloodborne viruses and pathogenic bacteria in outpatient dialysis settings. Both the CMS requirements and the guidance described above have formed a framework upon which infection control programs in dialysis facilities can be based.

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