Infection Protection

Infection Protection is a monthly column dedicated to education about infection control issues. Every fourth issue includes a Q&A forum to answer questions you have about the infection control information presented here. We are pleased to publish your questions and hope you find the responses useful.To submit questions to Infection Protection, contact us by email at jakridge@hpnonline.com or call (941)927-9345 ext. 202.
Cynthia T. Crosby
Vice President, Clinical Affairs Medi-Flex, Inc.

Q: What infection control issues should caregivers be aware of when treating dialysis patients?

A: Your question is very important due to the high risk of infection among dialysis patients. Factors that increase infection risk include more frequent use of catheters, poor personal hygiene among dialysis patients, and inexperience or inadequate training among dialysis staff who manage access sites.1,2 Epidemiology also plays a role: the incidence of end-stage renal disease has doubled in the last decade, resulting in more dialysis patients and, consequently, a higher incidence of bloodstream and other infections.3

Figure 1: Bloodstream infections (BSIs) per patient-month7

Legend: Bloodstream infections increased from 0.7 to 4.2 per 100 patient-month at an outpatient hemodialysis center. An intervention program was initiated to reduce infections. Education of staff and patients, use of chlorhexidine for skin antisepsis and gauze for dressings, and discontinuation of antimicrobial ointments containing polyethylene glycol at catheter exit sites resulted in a decline in infections to less than 1 per 100 patient-months.

Guidelines

Guidelines for the use of catheters for interventional radiology state that hemodialysis catheters are the most common factor contributing to bloodstream infections.4 Relative risk for bloodstream infection among patients with dialysis catheters versus arteriovenous (AV) fistulas was 7.6 in one study of chronic hemodialysis patients.5 As a result, AV fistulas and grafts are preferred over catheters.4 These guidelines also reflect recommendations by the Centers for Disease Control and Prevention (CDC) for reducing intravascular catheter-related infections, including using a 2% chlorhexidine gluconate preparation for skin antisepsis.4,6

Guidelines published by the National Kidney Foundation’s Kidney Disease Outcome Quality Initiative (K/DOQI™) include additional infection control measures for dialysis patients.2 (See the references for the web addresses to download guidelines.) Patients with poor hygiene habits should be taught how to improve and maintain their hygiene. K/DOQI™ skin preparation guidelines are being updated with revised aseptic techniques for all cannulation and catheter accession procedures. Updated recommendations include cleansing the skin by applying 2% chlorhexidine gluconate/70% isopropyl alcohol or 70% alcohol and/or 10% povidone iodine, according to manufacturer’s instructions. The recommendation to use chlorhexidine gluconate plus isopropyl alcohol was added based on its rapid and persistent antimicrobial activity on the skin. Catheter care recommendations are summarized in Table 1.

Table 1.
Catheter care and accessing circulation2

• Hemodialysis catheter dressing changes and catheter manipulation that access the patient’s bloodstream should only be performed by trained dialysis staff.

• The catheter exit site should be examined at each hemodialysis treatment for signs of infection.

• Catheter exit site should be changed at each hemodialysis treatment for signs of infection.

• Catheter exit site dressings should be changed at each hemodialysis treatment.

• Use of dry gauze dressing combined with skin disinfection, using either chlorhexidine or povidone iodine solution, followed by povidone iodine ointment or mupirocin ointment at the catheter exit site are recommended after catheter placement and at the end of each dialysis session.

• Manipulating a catheter and accessing the patient’s bloodstream should be performed in a manner that minimized contamination.

• During catheter connect or disconnect procedures, nurses and patients should wear a surgical mask or face shield. Nurses should wear gloves during all connect and disconnect procedures.

Clinical Intervention

In addition to guideline recommendations, data from clinical studies also provides useful information about methods to reduce infection rates. A study was undertaken to investigate and control an increase in bloodstream infections in an outpatient hemodialysis center.7 The baseline infection rate was 0.7 per 100 patient-months, but the rate increased to 4.2 per 100 patient-months over 14 months. Approximately 30 species of infectious microbes were identified during the outbreak. To reduce the infection rate, several intervention steps were taken, including discontinuing the use of prepackaged central venous catheter (CVC) dressing kits and biweekly infection control monitoring, replacing povidone-iodine with chlorhexidine for cutaneous antisepsis, replacing transparent dressings with gauze, and discontinuing the use of polyethylene glycol antimicrobial ointments at CVC exit sites. Staff and patient received cutaneous hygiene education. After the intervention, the bloodstream infection rate decreased to less than 1 per 100 patient-months (Figure 1).

Conclusion

Guidelines for dialysis and catheter care provide several steps to reduce the risk of infection. Clinical studies confirm these steps and offer additional insights into infection control. Education of staff and patients is particularly important. The effort to reduce and control infections associated with dialysis is ongoing. Periodic review of information provided by the K/DOQI™ and the CDC is a good way to stay informed of the most current recommendations for infection control among dialysis patients.

Q: I read your article in the March 2005 issue about identifying truth and myths in infection control. I knew the importance of moisturizing, but I did not realize that certain moisturizing lotions can deteriorate gloves. Can you tell me which ingredients to avoid when choosing a lotion to avoid glove deterioration?

A: The authors made the point that healthcare staff should use the moisturizing products provided by the facility, rather than bringing their own from home. One responsibility of the purchasing staff is to work with product suppliers to ensure that there is compatibility among products. However, it is always advisable for healthcare staff to understand the issues behind purchasing decisions.

Latex gloves are used most often. Ingredients that can cause deterioration of latex include petroleum-based products, mineral oil, and lanolin. A quick review of glove manufacturer websites confirmed this information. Readers are invited to provide additional information about products that might adversely affect glove integrity. HPN

References

1. Kokales P. Prevention of intravascular catheter-related infections using chlorhexidine gluconate antiseptic. Presented at the 35th annual meeting of the American Nephrology Nurses’ Association; April 15-18, 2004; Washington, DC.

2. Guidelines for Vascular Access. National Kidney Foundation. Kidney Disease Outcome Quality Initiative (K/DOQI™). Available at: http://www.kidney.org/
professionals/kdoqi/
guidelines_updates/
doqiupva_iii.html. Accessed on January 6, 2006.

3. Tokars JI. Bloodstream infections in hemodialysis patients: getting some deserved attention. Infect Control Hosp Epidemiol. 2002;23(12):713-715.

4. Miller DL, O’Grady NP. Guidelines for the prevention of intravascular catheter-related infections: recommendations relevant to interventional radiology. J Vasc Interv Radiol. 2003;14(2 Pt 1):133-136.

5. Hoen B, Paul-Dauphin A, Hestin D, Kessler M. EPIBACDIAL: a multicenter prospective study of risk factors for bacteremia in chronic hemodialysis patients. J Am Soc Nephrol. 1998;9(5):869-876.

6. Centers for Disease Control and Prevention. Guidelines for the Prevention of Intravascular Catheter-Related Infections. MMWR. 2002;51(RR-10). Available at: http://www.cdc.gov/
mmwr/preview/
mmwrhtml/
rr5110a1.htm.
Accessed on January 6, 2006.

7. Price CS, Hacek D, Noskin GA, Peterson LR. An outbreak of bloodstream infections in an outpatient hemodialysis center. Infect Control Hosp Epidemiol. 2002;23(12):725-729.

February
2006