Do we have your email?
Click here to sign up for MARC news & updates.
Need to update facility staff who receive MARC mail?
Click here to submit changes.


Search
	WWW MARC Website

Contact

Site Map

ADMISSION OF VRE / MRSA COLONIZED OR POSITIVE PATIENTS TO NETWORK 5 DIALYSIS FACILITIES

Recommendations:

1. OUTPATIENT/FREESTANDING dialysis centers should NOT restrict admission of patients colonized or infected with VRE and/or MRSA. Administrative staff of facilities that currently have restrictive admission policies should review all reference sources and implement an open admission policy.(2, 4)

2. VRE/MRSA patients should be cared for using Centers for Disease Control and Prevention (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients, published in the April 27, 2001 MMWR (SEE ATTACHMENTS). Patient cohorting, by dialysis shift and chair location, should be used aggressively to facilitate treatment of this patient population. (Patients positive for VRE and MRSA should NOT be cohorted together.)

3. INPATIENT/HOSPITAL-BASED dialysis units should follow their hospital infection control polices. The Centers for Disease Control and Prevention (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients (2) state the following:

"Hemodialysis in Acute-Care Settings. For patients with acute renal failure who receive hemodialysis in acute-care settings, Standard Precautions as applied in all healthcare settings are sufficient to prevent transmission of bloodborne viruses. However, when chronic hemodialysis patients receive maintenance hemodialysis while hospitalized, infection control precautions specifically designed for chronic hemodialysis units (see Recommended Practices at a Glance) should be applied to these patients. If both acute and chronic renal failure patients receive hemodialysis in the same unit, these infection control precautions should be applied to all patients."

Background:

Some Network 5 dialysis facilities have refused to admit, as well as re-admit patients who are colonized or positive for Vancomycin Resistant Enterococcus (VRE), and/or methicillin-resistant Staphylococcus aureus (MRSA).

Federal regulations require dialysis units to have written operational objectives that include "admission criteria that insure equitable access to services are adopted by the facility and are readily available to the public."(1)

These policies must be applied equitably to all patients (i.e., new, patients returning from hospitalizations, transient). Based on the increase in the percentage of patients known to be colonized or infected with these or similar bacterial infections, policies which restrict patients from returning to their unit after hospitalization leave patients without a source for chronic, out-patient dialysis services and may constitute patient abandonment.

Analysis:

The Centers for Disease Control and Prevention (CDC) reports that antimicrobial-resistant bacteria are more common in patients with severe illness. These patients have often had multiple hospitalizations or surgical procedures and have received prolonged courses of antimicrobial agents. In health care settings and in dialysis units, such patients can serve as a source for transmission (2). The following risk factors have been identified for both colonization and infection by blood-borne pathogens:

severity of illness
previous exposure to antimicrobial agents
underlying diseases or conditions, particularly:
- chronic renal disease
- insulin-dependent diabetes mellitus
- peripheral vascular disease
- dermatitis or skin lesions
invasive procedures, such as:
- dialysis
- presence of invasive devices
- urinary catheterization
repeated contact with the healthcare system
previous colonization by a multidrug-resistant organism
advanced age (3)

Identification of known and unknown colonization or infection with VRE and/or MRSA in the dialysis community has been reported in recent professional journals. In a 1997 study, done by the CDC and Mid-Atlantic Renal Coalition, rectal cultures were obtained from volunteer hemodialysis patients to explore the prevalence and incidence of VRE colonization at seven Network 5 dialysis units. In the seven centers (five free standing and two hospital affiliated), 478 cultures were performed; 4.2% were positive for VRE with prevalence of positive cultures varying from 1.0% to 7.9% in the seven facilities). Of the 346 patients cultured, 5.8% (20) were VRE positive on either the first or second culture. The study found that VRE-colonized patients were present in all seven study units. Since stool or rectal cultures are rarely performed routinely in dialysis centers, study authors concluded that VRE colonization in patients will often be unknown to staff members (4). A study conducted in Kasukabe Shuwa Hospital, Japan explored preventive tools to reduce the prevalence and incidence of MRSA. It was found that 4.5% of treated hemodialysis patients were suffering from MRSA nasal and throat colonization. The use of "isolating hemodialysis" (separated rooms and gown technique), seasonal surveillance of MRSA carriers (use of nasal cultures and monitoring of WBC and serum C-reactive protein levels), and treatment (gentian violet or mupirocin ointment and povidone-iodine gargle), reduced the frequency of MRSA infection to 2.9%.(5)

Contact-transmission is the most important route by which pathogens are transmitted. This most commonly occurs when microorganisms from the patient are transferred to the hands of health-care workers who DO NOT comply with infection control precautions. In addition, environmental surfaces may become contaminated and serve as an intermediate reservoir for future transmission. The infection control practices recommended for hemodialysis units 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 personnel. (SEE ATTACHED: Recommended Infection Control Practices for Hemodialysis Units at a Glance, and Infection Control Practices for Hemodialysis Units.)

Preventing transmission of bloodborne viruses and pathogenic bacteria from both recognized and unrecognized sources of infection, requires the implementation of a comprehensive infection control program such as the CDC Recommendation published in the April 2001 MMWR.

Components of a comprehensive infection control program to prevent transmission of infections among chronic hemodialysis patients include:

Infection control practices for hemodialysis units.
- Infection control precautions specifically designed to prevent transmission of bloodborne viruses and pathogenic bacteria among patients.
- Routine serologic testing for hepatitis B virus and hepatitis C virus infections.
- Infection control precautions specifically designed to prevent transmission of bloodborne viruses and pathogenic bacteria among patients.
- Vaccination of susceptible patients against hepatitis B.
- Isolation of patients who test positive for hepatitis B surface antigen.
- Surveillance for infections and other adverse events.
- Infection control training and education.

Prevention and Management of Bacterial Infections:

Units should follow published guidelines for judicious use of antimicrobials, particularly Vancomycin, to reduce selection for antimicrobial-resistant pathogens. Infection control precautions recommended for all hemodialysis patients are adequate to prevent transmission for the majority of patients infected or colonized with pathogenic bacteria, including antimicrobial-resistant stains. However, additional infection control precautions should be considered for treatment of patients who might be at increased risk for transmitting pathogenic bacteria. Such patients include those having either of the two following syndromes: (a) an infected skin wound with drainage that is not contained by dressings (the drainage does not have to be culture positive for VRE, MRSA of any specific pathogen) or b) fecal incontinence or diarrhea uncontrolled with personal hygiene measures. For these patients consider using the following additional precautions: (a) staff members treating the patient should wear a separate gown over their usual clothing and remove the gown when finished caring for the patient; and (b) dialyze the patient at a station with as few adjacent stations as possible (e.g., at the end or corner of the unit).

The Medical Review Board emphasizes the following:

The CDC Surveillance of Dialysis Associated Diseases statistics reveal that 35.4% of Network 5 units reported treating 1-4 VRE+ patients; 70.0% reported treating 1 or more MRSA+ patients during 2000.
The percentage of U.S. hemodialysis centers reporting > 1 patients infected or colonized with VRE increased from 11.5% in 1995 to 32.7% in 2000. (6)
The percentage of U.S. hemodialysis centers reporting > 1 patients infected or colonized with MRSA increased from 40% in 1995 to 71% in 2000. (6)
It is possible to effectively treat this patient population and reduce the incidence of VRE and MRSA through the use of infection control training and education, strict adherence to CDC Infection Control Practices for Hemodialysis Units, and surveillance for infections and other adverse events. (2)
Since stool, rectal, or nasal cultures are rarely performed routinely in dialysis centers, VRE and/or MRSA colonization in patients will often be unknown to staff members.(4)
Long Tern Care Facilities (nursing homes) have sought to deal with the problem of antimicrobial resistant pathogen colonization by restricting admission of diagnosed patients with VRE and MRSA. There is no evidence to indicate that this strategy was effective and it was noted to possibly lead to a false sense of security on the part of management who thought that their facility was free of resistant organisms.(7)

Attachments:

1. Recommended Infection Control Practices for Hemodialysis Units at a Glance. Centers for Disease Control and Prevention. Recommendation for preventing transmission of infections among chronic hemodialysis patients. MMWR 2001; 50 (No.RR-5): 20-21.

2. Infection Control Practices for Hemodialysis Units. Centers for Disease Control and Prevention. Recommendation for preventing transmission of infections among chronic hemodialysis patients. MMWR 2001; 50 (No.RR-5): 19, 22-23.

3. Suggested Reading. Centers for Disease Control and Prevention. Recommendation for preventing transmission of infections among chronic hemodialysis patients. MMWR 2001; 50 (No.RR-5): 42-43.

References:

1. Title 42 Subpart U - Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services. Ch. IV (10-1-99 Edition). Section 405.2136 (b)(3)

2. Centers for Disease Control and Prevention. Recommendation for preventing transmission of infections among chronic hemodialysis patients. MMWR2001; 50 (No.RR-5):17-23.

3. Multidrug-Resistant Organisms in Non-Hospital Healthcare Settings. CDC, Division of Healthcare Quality Promotion.
Available on the internet at: http://www.cdc.gov/ncidod/hip/ARESIST/nonhosp.htm

4. Tokars JI, et al. Vancomycin-resistant Enterococci colonization in patients in seven hemodialysis centers. Kidney International, Vol. 60 (2001):1511-1516.

5. Osono E, et al. Effects of "isolating hemodialysis on prevention of methicillin-resistant Staphylococcus aureus cross-infection in a hemodialysis unit. Clinical Nephrology; Vol. 54 -No 2/2000: 128-133.\

6. Tokars JI, et al. Summary, National Surveillance of Dialysis -Associated Diseases in the United States, 2000:1-2.

7. SHEA Position Paper, Strausbaugh LF, et al: Antimicrobial resistance in long-term-care facilities. Infection Control and Hospital Epidemiology, Vol.17 No. 2/1996: 129-140

ATTACHMENT 1

Recommended Infection Control Practices for Hemodialysis Units at a Glance

Vol. 50 / No. RR-5, MMWR, Pages 20-21, April 27, 2001

(Immunization tables from original document are not included.)

Infection Control Precautions for All Patients

Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station; remove gloves and wash hands between each patient or station.
Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient.
Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth-covered blood pressure cuffs) should be dedicated for use only on a single patient.
Unused medications (including multiple dose vials containing diluents) or supplies (e.g., syringes, alcohol swabs) taken to the patient's station should be used only for that patient and should not be returned to a common clean area or used on other patients.
When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis station and deliver separately to each patient. Do not carry multiple dose medication vials from station to station.
Do not use common medication carts to deliver medications to patients. Do not carry medication vials, syringes, alcohol swabs, or supplies in pockets. It trays are used to deliver medications to individual patients, they must be cleaned between patients.
Clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to where used equipment or blood sample are handles.
Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines' pressure monitors. Change filter/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients.
Clean and disinfect the dialysis station (e.g., chairs, beds, tables, machines) between patients.
Give special attention to cleaning control panels on the dialysis machines and other surfaces that are frequently touched and potentially contaminated with patients' blood.
Discard all fluid and clean and disinfect all surfaces and containers associated with the prime waste (including buckets attached to the machines).

For dialyzers and blood tubing that will be reprocessed, cap dialyzer ports and clamp tubing. Place all used dialyzers and tubing in leakproof containers for transport from station to reprocessing or disposal area.

ATTACHMENT 2

Recommendation for Preventing Transmission of Infections Among Chronic Hemodialysis Patients

MMWR, Vol. 50 No. RR-5 Pages 19, 22-23

In each chronic hemodialysis unit, policies and practices should be reviewed and updated to ensure that infection control practices recommended for hemodialysis units are implemented and rigorously followed (see Recommended Infection Control Practices for Hemodialysis Units at a Glance). Intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices.

Infection Control Precautions for All Patients

During the process of hemodialysis, exposure to blood and potentially contaminated items can be routinely anticipated; thus, gloves are required whenever caring for a patient or touching the patients equipment. To facilitate glove use, a supply of clean non-sterile gloves and a glove discard container should be placed near each dialysis station. Hands always should be washed after gloves are removed and between patient contacts, as well as after touching blood, body fluids, secretions, excretions, and contaminated items. A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. If hands are not visibly soiled, use of a waterless antiseptic hand rub can be substituted for hand washing.

Any item taken to a patient's dialysis station could become contaminated with blood and other body fluids and serve as a vehicle of transmission to other patients either directly or by contamination of the hands of personnel. Therefore, items taken to a patient's dialysis station, including those placed on 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. 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.

Additional measures to prevent contamination of clean or sterile items include a) preparing medications in a room or area separated from the patient treatment area and designated only for medications; b) not handling or storing contaminated (i.e., used) supplies, equipment, blood samples, or biohazard containers in areas where medications and clean (i.e., unused) equipment and supplies are handled; and c) delivering medications separately to each patient. Common carts should not be used within the patient treatment area to prepare or distribute medications. If trays are used to distribute medications, clean them before using for a different patient.

Intravenous medication vials labeled for single use, including erythropoietin, should not be punctured more than once. Once a needle has entered a vial labeled for single use, the sterility of the product can no longer be guaranteed. Residual medication from two or more vials should not be pooled into a single vial.

If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies.

Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Such protective clothing or gear should be changed if it becomes soiled with blood, body fluids, secretions, or excretions. Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. However, patients can be served meals or eat food brought from home at their dialysis station. The glasses, dishes, and other utensils should be cleaned in the usual manner; no special care of these items is needed.

Cleaning and Disinfection. Establish written protocols for cleaning and disinfecting surfaces and equipment in the dialysis unit, including careful mechanical cleaning before any disinfection process (Table 2). If the manufacturer has provided instructions on sterilization or disinfection of the item, these instructions should be followed. For each chemical sterilant and disinfectant, follow the manufacturer's instructions regarding use, including appropriate dilution and contact time.

After each patient treatment, clean environmental surfaces at the dialysis station, including the dialysis bed or chair, countertops, and external surfaces of the dialysis machine, including containers associated with the prime waste. Use any soap, detergent, or detergent germicide. Between uses of medical equipment (e.g., scissors, hemostats, clamps, stethoscopes, blood pressure cuffs), clean and apply a hospital disinfectant (i.e., low-level disinfection); if the item is visibly contaminated with blood, use a tuberculocidal disinfectant (i.e., intermediate-level disinfection).

For a blood spill, immediately clean the area with a cloth soaked with a tuberculocidal disinfectant or a 1:100 dilution of household bleach (300-600 mg/L free chlorine) (i.e., intermediate-level disinfection). The staff member doing the cleaning should wear gloves, and the cloth should be placed in a bucket or other leakproof container. After all visible blood is cleaned, use a new cloth or towel to apply disinfectant a second time.

TABLE 2. Disinfection procedures recommended for commonly used items or surfaces in hemodialysis units

Item or Surface	Low-Level Disinfection*	Intermediate-Level Disinfection *
Gross blood spills or items contaminated with visible blood		x
Hemodialyzer port caps		x
Interior pathways of dialysis machine		x
Water treatment and distribution system	x	x^t
Scissors, hemostats, clamps, blood pressure cuffs, stethoscopes	x	x^§
Environmental surfaces, including exterior surfaces of hemodialysis machines	x

* Careful mechanical cleaning to remove debris should always be done before disinfection.
^tWater treatment and distribution systems of dialysis fluid concentrates require more extensive disinfection if significant biofilm is present within the system.
^§If item is visibly contaminatedwith blood, use a tuberculocidal disinfectant.

Published methods should be used to clean and disinfect the water treatment and distribution system and the internal circuits of the dialysis machine, as well as to reprocess dialyzers for reuse (see Suggested Readings). These methods are designed to control bacterial contamination, but will also eliminate bloodborne viruses. For single-pass machines, perform rinsing and disinfection procedures at the beginning or end of the day. For batch recirculating machines, drain, rinse, and disinfect after each use. Follow the same methods for cleaning and disinfection if a blood leak has occurred, regardless of the type of dialysis machine used. Routine bacteriologic assays of water and dialysis fluids should be performed according to the recommendations of the Association for the Advancement of Medical Instrumentation (see Suggested Readings).

Venous pressure transducer protectors should be used to cover pressure monitors and should be changed between patients, not reused. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing part. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Frequent blood line pressure alarms or frequent adjusting of blood drip chamber levels can be an indicator of this problem. Taken separately, these incidents could be characterized as isolated malfunctions. However, the potential public health significance of the total number of incidents nationwide make it imperative that all incidents of equipment contamination be reported immediately to the FDA (800-FDA-1088).

Housekeeping staff members in the dialysis facility should promptly remove soil and potentially infectious waste and maintain an environment that enhances patient care. All disposable items should be placed in bags thick enough to prevent leakage. Wastes generated by the hemodialysis facility might be contaminated with blood and should be considered infectious and handled accordingly. These solid medical wastes should be disposed of properly in an incinerator or sanitary landfill, according to local and state regulations governing medical waste disposal.

Hemodialysis in Acute-Care Settings. For patients with acute renal failure who receive hemodialysis in acute-care settings, Standard Precautions as applied in all healthcare settings are sufficient to prevent transmission of bloodborne viruses. However, when chronic hemodialysis patients receive maintenance hemodialysis while hospitalized, infection control precautions specifically designed for chronic hemodialysis units (see Recommended Practices at a Glance) should be applied to these patients. If both acute and chronic renal failure patients receive hemodialysis in the same unit, these infection control precautions should be applied to all patients.

Regardless of where in the acute-care setting chronic hemodialysis patients receive dialysis, the HBsAg status of all such patients should be ascertained at the time of admission to the hospital, by either a written report from the referring center (including the most recent date testing was performed) or by a serologic test. The HBV serologic status should be prominently placed in patients' hospital records, and all health-care personnel assigned to these patients, as well as the infection control practitioner, should be aware of the patients' serologic status. While hospitalized, HBsAg-positive chronic hemodialysis patients should undergo dialysis in a separate room and use separate machines, equipment, instruments, supplies, and medications designated only for HBsAg-positive patients (see Prevention and Management of HBV Infection). While HBsAg-positive patients are receiving dialysis, staff members who are caring for them should not care for susceptible patients.

ADMISSION OF VRE / MRSA COLONIZED OR POSITIVE PATIENTS TO NETWORK 5 DIALYSIS FACILITIES

ATTACHMENT 1

Infection Control Precautions for All Patients

ATTACHMENT 2

ATTACHMENT 3

Suggested Readings