Infection prevention in dialysis patients

Infections are common among people receiving dialysis and can be very serious. It is important to remember that germs can be spread between people through direct contact when someone is sick or by breathing in respiratory droplets after a sick person coughs or sneezes. Germs can also spread within the dialysis facility through the surfaces of equipment or through unclean hands. Different types of infections during dialysis are:

Bloodstream Infections (BSI)
A bloodstream infection (BSI) is a serious infection. Most BSI’s occur through central line catheters which have a higher risk of infection than fistulas or grafts. Symptoms may include:
•    Fever
•    Chills
•    Low blood pressure

Chronic Viral Infections
Infections caused by viruses are also a concern for people receiving dialysis. Viruses in the blood spread when an infected person’s blood enters the body of someone who is not infected. This could happen in a variety of ways, including through surfaces and equipment in the dialysis facility. Symptoms of viral infections vary. Examples of viral infections are:
•    Hepatitis B
•    Hepatitis C
•    HIV

Other Infections
People receiving dialysis may also be at risk for infections that are not related to the blood and can lead to serious outcomes. These infections may include intestinal and respiratory infections

Reasons for Infection in Dialysis
Patients who undergo dialysis treatment have an increased risk of getting an infection due to the following reasons:
•    Hemodialysis patients are at high risk for infection because the process of hemodialysis requires frequent use of catheters or insertion of needles to access the bloodstream.
•    Hemodialysis patients also have weakened immune systems, which increases their risk of infection.

Vein Access and Infection Risk
A vein access, also known as a vascular access, is needed to move blood between your body and the dialysis machine during hemodialysis treatments. An arteriovenous (AV) fistula or graft should be placed before hemodialysis treatments begin. However, if you have damaged veins and arteries, this type of access may not be possible and a central line catheter may be used. Central line catheters are designed for short-term use and can be placed quickly.

Any of the three access types (AV Fistula, AV Graft, or central line catheter) could develop an infection, but AV fistulas have the lowest risk of infection, while central line catheters have the highest risk of infection.

Ways to Prevent Infections During Dialysis Treatments
You can be a safe patient and take action to help prevent infections.
•    Wash your hands often or use hand sanitizer.
•    Cover your nose and mouth when you cough or sneeze.
•    Learn about the dialysis process and know what to expect during treatment.
•    Learn about things staff do to protect you from infections
•    Watch the Speak Up Video and ask questions during your dialysis treatments.
•    Check your access daily and notify staff if you notice any of these signs of infection:
    o    Redness
    o    Pus or unusual drainage
    o    Swelling
•    If your catheter bandage gets dirty or wet, notify staff.
•    If you have a central line catheter, ask staff if you can use a fistula or graft for your dialysis treatment.
•    Make sure all staff clean their hands before and after caring for you or your access.
•    In some cases, you may be asked to take additional actions to prevent infections. For example, during the COVID-19 pandemic.

Infection Prevention Tools
Core Interventions
These Core Interventions have been proven to reduce dialysis bloodstream infections (BSIs). Apply these interventions when using the audit tools and checklists.

Hand Hygiene Observations
Perform observations of hand hygiene opportunities monthly and share results with clinical staff.

Catheter/vascular Access Care Observations
Perform observations of vascular access care and catheter accessing quarterly. Assess staff adherence to aseptic technique when connecting and disconnecting catheters and during dressing changes. Share results with clinical staff.

Staff Education and Competency
Train staff on infection control topics, including access care and aseptic technique. Perform competency evaluation for skills such as catheter care and accessing every 6-12 months and upon hire.

Patient Education/Engagement
Provide standardized education to all patients on infection prevention topics including vascular access care, hand hygiene, risks related to catheter use, recognizing signs of infection, and instructions for access management when away from the dialysis unit.

Chlorhexidine for Skin Antisepsis
Use an alcohol-based chlorhexidine (>0.5%) solution as the first line skin antiseptic agent for central line insertion and during dressing changes. Povidone-iodine (preferably with alcohol) or 70% alcohol are alternatives for patients with chlorhexidine intolerance.

Catheter hub Disinfection
Scrub catheter hubs with an appropriate antiseptic after cap is removed and before accessing. Perform every time catheter is accessed or disconnected. If a closed needleless connector device is used, disinfect connector device per manufacturer’s instructions.

Antimicrobial Ointment
Apply antibiotic ointment or povidone-iodine ointment to catheter exit sites during dressing change.

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