CDC: Use standard precautions, not contact isolation in dialysis

CDC: Use standard precautions, not contact isolation in dialysis

IC measures deemed sufficient despite increase

In highlighting the growing problem of drug-resistant bacteria in hemodialysis settings the Centers for Disease Control referenced its existing infection control guidelines for dialysis.¹ Those 2001 guidelines primarily emphasize the risk of bloodborne transmission of hepatitis, but do address the rise of pathogens such as methicillin-resistant Staphylococcus aureus (MRSA).² Key points about infection control of drug-resistant bacteria in dialysis settings are summarized as follows:

• Standard precautions are used on all patients and include use of gloves, gown, or mask whenever needed to prevent contact of the health care worker with blood, secretions, excretions, or contaminated items. In addition to standard precautions, more stringent precautions are recommended for hemodialysis units because of the increased potential for contamination with blood and pathogenic microorganisms. For example, infection control practices for hemodialysis units restrict the use of common supplies, instruments, medications, and medication trays and prohibit the use of a common medication cart.

• For certain patients, including those infected or colonized with MRSA contact precautions are used in the inpatient hospital setting. Contact precautions include isolating a patient and using gloves and gowns whenever entering the patient's room. However, contact precautions are not recommended in hemodialysis units for patients infected or colonized with pathogenic bacteria for several reasons. First, although contact transmission of pathogenic bacteria is well documented in hospitals, similar transmission has not been well documented in hemodialysis centers. Transmission might not be apparent in dialysis centers, possibly because it occurs less frequently than in acute care hospitals or results in undetected colonization rather than overt infection. Also, because dialysis patients are frequently hospitalized, determining whether transmission occurred in the inpatient or outpatient setting is difficult. Secondly, contamination of the patient's skin, bedclothes, and environmental surfaces with pathogenic bacteria is likely to be more common in hospital settings (where patients spend 24 hours a day) than in outpatient hemodialysis centers (where patients spend approximately 10 hours a week). Third, the routine use of infection control practices recommended for hemodialysis units, which are more stringent than the standard precautions routinely used in hospitals should prevent transmission by the contact route.

• Standard precautions are adequate to prevent transmission for most patients infected or colonized with pathogenic bacteria, including antimicrobial-resistant strains. 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 with either:

— an infected skin wound with drainage that is not contained by dressings (the drainage does not have to be culture-positive for MRSA, or any specific pathogen); or

— 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).

Reference

1. Centers for Disease Control and Prevention. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR 2001; 50:(RR05)1-43.