Campaign To Prevent Antimicrobial Resistance: Dialysis Patients

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
Campaign to Prevent
Antimicrobial
Resistance
Dialysis Patients
Centers for Disease Control and Prevention
National Center for Infectious Diseases
Division of Healthcare Quality Promotion
Department of Health and Human Services
 Link to: Campaign to Prevent Antimicrobial Resistance Online

 Link to: Federal Action Plan to Combat Antimicrobial Resistance
Clinicians
Hold the
Solution!
 Link to: Campaign to Prevent Antimicrobial Resistance Online

 Link to: Federal Action Plan to Combat Antimicrobial Resistance
Emergence of Antimicrobial Resistance

Susceptible Bacteria
Resistant Bacteria
Mutations
XX
Resistance Gene Transfer

New Resistant Bacteria
Selection for Antimicrobial-resistant Strains
xx
xx
Resistant Strains
xx
Rare
xx
Antimicrobial xx
Exposure xx
Resistant Strains
Dominant
Antimicrobial Resistance:
Key Prevention Strategies
Antimicrobial-Resistant
Susceptible Pathogen
Pathogen
Pathogen
Prevent Prevent
Transmission Infection
Antimicrobial Infection
Resistance
Effective
Optimize Diagnosis
Use & Treatment
Antimicrobial Use
Key Prevention Strategies
 Prevent infection
 Diagnose and treat
infection effectively
 Use antimicrobials wisely
 Prevent transmission
Clinicians hold the solution!

Campaign to Prevent Antimicrobial

Resistance in Healthcare Settings
 General health communication strategy

 Goals:
- inform clinicians, patients, and other stakeholders
- raise awareness about the escalating problem of
antimicrobial resistance in healthcare settings
- motivate interest and acceptance of interventional
programs to prevent resistance
12 Steps To Prevent Antimicrobial

Resistance
 Targeted intervention programs for clinicians caring for high risk
patients
- hospitalized adults - dialysis patients
- hospitalized children - surgical patients
- long - term care residents
 Goal: Improve clinician practices & prevent antimicrobial resistance
 Partnership with professional societies; evidence base published in
peer-reviewed specialty journals
 Educational tools – web-based / didactic learning modules, pocket
cards, slide presentations, etc.
12 Steps to Prevent Antimicrobial Resistance: Dialysis Patients
12 Steps to Prevent Antimicrobial

Resistance: Dialysis Patients
12 Partner with your patients

11 Practice hand hygiene Prevent Transmission
10 Follow infection control precautions
9 Stop antimicrobial treatment
8 Treat infection, not contamination or colonization Use Antimicrobials
7 Know when to say “No” to Vanco Wisely
6 Use local data
5 Access the experts Diagnose & Treat
4 Target the pathogen Effectively
3 Optimize access care
2 Get the catheters out Prevent Infection
1 Vaccinate staff and patients
Disease Burden for Dialysis Patients

 The number of patients with end-stage renal disease treated by
maintenance hemodialysis in the US has increased during the past 30
years.¹
 In 2001 more than 3,000 hemodialysis centers had greater than 250,000
chronic hemodialysis patients.2
 Annual mortality rate among hemodialysis patients is 23% and infections
are the second most common cause, accounting for 15% of deaths.¹
 Hemodialysis patients are immunosuppressed and require frequent
hospitalization and surgery, which increases their risk for resistant
infections.¹
 Vascular access infections (in hemodialysis patients) and peritonitis (in
peritoneal dialysis patients) are the most common infections.¹
1
CDC, MMWR 2001; 50 (5):13
2
Unpublished data, Dialysis Surveillance Network
Step 1: Vaccinate staff and patients
Prevent Infection
Step 1: Vaccinate
staff and patients
Fact:
Influenza and pneumococcal vaccine given to both staff
and patients will help to prevent infections requiring
antimicrobial therapy.
Vaccination Rates of Dialysis Patients,

1999-2001*
100
90
80
70 Influenza Vaccine
60
Pneumococcal
50
Vaccine
40
Healthy People 2010
30
Goal
20
10
0
1999 2000 2001
* Unpublished data, Dialysis Surveillance Network

 Link to: Influenza recommendations...CDC, MMWR 2003; 52 (RR08):1-36
Need for Healthcare Personnel Immunization

Programs: Influenza Vaccination Rates (1996-
97)
% Vaccinated
All adults > 65 yrs. of age 63%
Healthcare personnel at high risk 38%
All healthcare personnel 34%
Source: 1997 National Health Interview Survey

Walker FJ, et al., Infect Control Hosp Epidemiol 2000; 21:113
 Link to: ACIP Influenza Immunization Recommendations

Prevent Infection
Step 1: Vaccinate staff & patients
Fact: Influenza and pneumococcal vaccine given to both

staff and patients will help to prevent infections requiring
Actions:
 Get influenza vaccine
 Give influenza / pneumococcal vaccine to patients
in addition to routine vaccines (e.g., hepatitis B)
 Link to: ACIP Influenza immunization recommendations

 Link to: CDC facts about influenza and pneumococcal vaccine
 Link to: ACIP: Vaccine standing orders
Step 2: Get the catheters out
Prevent Infection
Step 2:
Get the catheters out
Fact:
Indwelling catheters are the single most important
factor contributing to bacteremia in hemodialysis
patients.
 Link to: NNIS Online at CDC

Epidemiology of Catheter Associated

Infections
 Estimated attributable mortality for catheter-
associated bloodstream infections ranges from 0%
to 35%, depending on study design.
 Primary risk factor for access infection is access
type (catheters>grafts>fistulas).
 The relative risk for bacteremia in patients with
dialysis catheters is sevenfold the risk for patients
with primary arteriovenous fistulas.
CDC, MMWR 2002, 51 (RR-10); p.10

Biofilm on Intravenous Catheter Connecter

24 Hours After Insertion
Scanning Electron Micrograph
 Link to: Biofilms and device-associated infections

Rates of Bacteremia Infection by Access Type -

Dialysis Surveillance Network
10/99-05/02
Rate per 100 patient-months
10.0 8.7
8.0
6.0 4.8
4.0
2.0
0.3 0.5
0.0
Fistula Graft Cuffed Noncuffed
Catheter Catheter
Tokars et al., Am J Infect Control 2002;30:288-295.

Prevent Infection
Fact: Indwelling catheters are the single most important
factor contributing to bacteremia in hemodialysis patients.
Actions:
Hemodialysis:
 Use catheters only when essential
 Maximize use of fistulas/grafts
 Remove catheters when they are no longer essential
Peritoneal Dialysis:
 Remove/replace infected catheters
 Link to: Urinary catheter infection prevention

Coming soon…guidelines for preventing catheter-associated bloodstream infections
Step 3: Optimize access care
Prevent Infection
Step 3:
Optimize access care
Fact: Careful infection control prevents

peritoneal dialysis related infections.
 Link to: NNIS Online at CDC

Peritoneal Catheter Insertion and

Management
 Catheter insertion should be performed under operating
room, sterile conditions.
 Adherence to the principles of catheter insertion,
management, and care remain the cornerstone of successful
peritoneal dialysis access.
 Despite improvements in catheter survival over the last few
years, catheter-related complications still occur, causing
significant morbidity and often forcing the removal of the
catheter.
Gokal et al., Peritoneal Dialysis International 1998;18:11-33.

Prevent Infection
Fact: Careful infection control prevents peritoneal

dialysis-related infections.
Actions:
 Follow established guidelines for access care
 Use proper insertion and catheter-care protocols
 Remove access device when infected
 Use the correct catheter
 Link to: Peritoneal Catheters and Exit-Site Practices 1998 Update

Guidelines for preventing catheter-associated bloodstream infections, CDC, MMWR 2002 51 (RR10)
Step 4: Target the pathogen
Diagnose & Treat Effectively

Step 4:
Target the pathogen
Fact: Identifying the pathogen using
microbiologic cultures and antimicrobial
susceptibility testing allows for targeted
Importance of Utilizing Cultures and

Antimicrobial Susceptibility Testing Results
No. (%) Susceptible

___________________________________________________
Cefazolin Vanco Cefazolin and Vanco and
Gentamicin Gentamicin
___________________________________________________
Blood Cultures 14 (78) 16 (89) 16 (89) 17 (94)
(n=18)
Clinically Significant
Cultures (n=146) 87 (60) 100 (68) 132 (90) 142 (97)
Fogel et al., Am J Kidney Dis 1998;32:401-409

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
CDC’s
M.A.S.T.E.R.
Improving
Antimicrobial
Susceptibility
Testing
Proficiency

Fact: Identifying the pathogen using microbiologic cultures and
antimicrobial susceptibility testing allows for targeted
Actions:
 Obtain appropriate cultures
 Target empiric therapy to likely pathogens
 Target definitive therapy to known pathogens
 Optimize timing,regimen,dose,route and duration
 Link to: IDSA guidelines for evaluating fever in critically ill adults
Step 5: Access the experts

Step 5:
Access the experts
Fact:
Input from infectious diseases experts
improves the outcome of serious
infections.
Infectious Diseases Expert Resources
Infectious Diseases
Specialists
Healthcare Infection Control
Epidemiologists Professionals
Clinical Optimal
Pharmacists Patient Care
Clinical
Clinical Pharmacologists
Microbiologists
Surgical Infection
Experts

Fact: Input from infectious diseases experts

improves the outcome of serious infections.
Action:
 Consult the appropriate experts for
complicated infections
 Link to: SHEA / IDSA: Guidelines for the Prevention of Antimicrobial Resistance
in Hospitals
Step 6: Use local data
Use Antimicrobials Wisely

Fact:
The prevalence of resistance varies by locale
Percent of S. aureus Blood Isolates Resistant to

Methicillin, by Dialysis Center
11 Centers, 10 Centers,
Number of Dialysis Centers
10 Canada, 10%1 Connecticut, 43%2

8
6
4
2
0
10 20 30 40 50 60 70 90
Percent Resistant to Methicillin
Dialysis Surveillance Network 1999-20023

1
Taylor et al., Infect Control Hosp Epidemiol 2002;23:716-720
2
Dopirak et al., Infect Control Hosp Epidemiol 2002;23:721-724
3
Unpublished data, Dialysis Surveillance Network

Fact: The prevalence of resistance varies by locale.
Actions:
 Know your local antibiogram
 Get previous microbiology results when
patients transfer to your facility
 Link to: NCCLS Proposed Guidance for Antibiogram Development

Step 7: Know when to say “No” to Vanco

Step 7: Know when to
say “No” to vanco
Fact:
Reduction of vancomycin use is one of the most
important strategies to limit the emergence,
selection, and spread of vancomycin resistant
bacteria.
Step 7: Know when to say “ No” to Vanco
Evolution of Drug Resistance in S. aureus

Penicillin
Methicillin
S. aureus [1944] Penicillin-resistant Methicillin-resistant
S. aureus [1962] S. aureus (MRSA)
[2002] [1997] Vancomycin
[1990s]
Vancomycin Vancomycin-resistant
Vancomycin- intermediate enterococci (VRE)
resistant S. aureus
(VISA)
S. aureus
CDC, MMWR 2002;51(26):565-567

Step 7: Know when to say “ No” to Vanco
VRE Colonization Among Dialysis Patients

Who Received Vancomycin
Received Vancomycin Developed VRE

No 0/29 (0%)
Yes 16/61 (26%)
p<.001
Atta et al., Kidney International 2001;59:718-724

First Case of Vancomycin - Resistant

S. aureus (VRSA)
 First fully vancomycin resistant clinical isolate of S. aureus
 Michigan, June 2002
 40-year old black female with diabetes mellitus, peripheral
vascular disease,on chronic hemodialysis
 VRSA from foot ulcer and catheter exit site
 During the 6 months preceding VRSA:
 patient experienced 6 hospitalizations, totaling 18 days
 patient received multiple antimicrobial therapy, including
 5.5 weeks of vancomycin
Chang S et al, New England J of Med 2003; 348:14,1342-3447

Vancomycin- Intermediate S. aureus (VISA)
State, Year Site PD/HD*

Michigan, 1997 Peritonitis Chronic PD
New Jersey, 1997 Blood Recent PD
New York, 1998 Blood Chronic HD
Illinois, 1999 Endocarditis Chronic HD
Minnesota, 2000 Bone Chronic HD
Nevada, 2000 Liver -----
PD=peritoneal dialysis , HD=hemodialysis
Fridkin, Clin Infect Diseases 2001;32:111

Guidelines for Appropriate Vancomycin Use

(HICPAC/CDC)
 Selected situations in which the use of vancomycin is
appropriate or acceptable:
 For treatment of serious infections caused by beta-lactam-
resistant gram-positive microorganisms.
 For treatment of infections caused by gram-positive
microorganisms in patients who have serious allergies to beta-
lactam agents.
 When antibiotic-associated colitis fails to respond to
metronidazole therapy or is severe and potentially life-
threatening.
CDC, MMWR 1995;44(RR12):1-13

Guidelines for Appropriate Vancomycin Use

(HICPAC/CDC)
 Selected situations in which the use of vancomycin should be discouraged:
 Treatment in response to a single blood culture positive for coagulase-negative
staphylococcus, if other blood cultures taken during the same time frame are
negative.
 Continued empiric use for presumed infections in patients whose cultures are
negative for beta-lactam resistant gram-positive microorganisms.
 Eradication of MRSA colonization.
 Systemic or local prophylaxis for infection or colonization of indwelling central or
peripheral intravascular catheters.
 Primary treatment of antibiotic-associated colitis.
 Routine prophylaxis for patients on continuous ambulatory peritoneal dialysis or
hemodialysis.
 Treatment (chosen for dosing convenience) of infections caused by beta-lactam-
sensitive gram-positive microorganisms in patients who have renal failure.

Step 7: Know when to say “No”
to vanco
Fact: Reduction of vancomycin use is one of the most
important strategies to limit the emergence, selection, and
spread of vancomycin resistant bacteria.
Action:
 Follow CDC guidelines for vancomycin use
 Consider 1st generation cephalosporins instead of
vancomycin
 Link to: Methods to improve antimicrobial use and prevent resistance

Step 8: Treat infection, not contamination or colonization

Step 8: Treat infection,
not contamination or
colonization
Fact:
A major cause of antimicrobial
overuse is treatment of contamination
or colonization.
Step 8: Treat infection, not contamination or colinization
Interpreting a Positive Blood Culture

True Bacteremia:
Unlikely Uncertain Likely
• Corynebacterium spp. • coagulase-negative • S. aureus

• Non-anthracis Bacillus spp. staphylococci • S. pneumoniae
• Propioniobacterium acnes • Enterobacteriaceae
• P. aeruginosa
pre-test probability post-test probability • C. albicans
patient risk factors # positive / # cultures
prosthetic devices compare antibiograms
clinical evidence compare genotypes
Kim SD, et al., Infect Control Hosp Epidemiol 2000;21:213-217
Step 8: Treat infection, not contamination or colonization

Step 8: Treat infection, not
contamination or colonization
Fact: A major cause of antimicrobial overuse is treatment of
contamination or colonization.
Actions:
 Use proper antisepsis for drawing blood cultures
 Get one peripheral vein blood culture, if possible
 Avoid culturing vascular catheter tips
 Treat bacteremia, not the catheter tip
 Culture the blood, not the skin or catheter hub
 Link to: CAP standards for specimen collection and management
Step 9: Stop antimicrobial treatment

Step 9: Stop
antimicrobial treatment
Fact:
Stopping empiric therapy when cultures are negative
can significantly reduce antimicrobial use.
Short-course Antimicrobial Treatment of New

Pulmonary Infiltrates in an ICU
Standard Experimental
Variable Therapy (n=42) Therapy (n=39)
Regimen clinician discretion ciprofloxacin 400mg
(all treated; 18 drugs) (IV bid x 3 days)
Treatment > 3 days 97% 28%
Antimicrobial resistance 35% 15%
Length of stay
mean/median 14.7/9 days 9.4/4 days
Mortality (30 day) 31% 13%
Antimicrobial cost
mean/total $640/$16,004 $259/$6,484
 Link to: Singh N, et al.,Am J Respir Crit Care Med 2000;162:505-511

Fact: Stopping empiric therapy when cultures are

negative can significantly reduce antimicrobial use.
Actions:
 Stop when infection is treated
 Stop when clinical and laboratory data
rule out infection
 Link to: IDSA guideline for evaluating fever in critically ill adults
Step 10: Follow infection control precautions
Prevent Transmission
Step 10: Follow infection
control precautions
Fact:
Following the recommended infection control
precautions for hemodialysis patients can prevent
transmission of infections from patient to patient.
Step 10: Follow infection control precautions
Infection Control Precautions for

Hemodialysis Patients
 In the hemodialysis setting, contact transmission plays a major role in transmission of
bloodborne and other pathogens.
 Infection Control Precautions for hemodialysis patients include:
 Strict attention to hand hygiene
 using gloves for patient care and when handling patients medical equipment and devices.
 Dedicating nondisposable items for use on a single patient.
 Cleaning and disinfection of items taken into a dialysis station that will be used for more than one
patient.
 For patients at increased risk for transmission of pathogenic bacteria, including antimicrobial-
resistant strains, additional precautions also might be necessary in some circumstances. For
example, staff treating the patient should a) wear a separate gown over their usual clothing
and b) dialyze the patient at a station with as few adjacent stations as possible.
Step 11: Practice hand hygiene
Step 10: Follow infection control
procedures
Fact: Following recommended infection control
precautions for hemodialysis patients can
prevent transmission of infections from patient
to patient.
Actions:
 Use standard infection control precautions
for dialysis centers
 Consult local infection control experts
 Link to: A VRE prevention success story
 Link to: CDC isolation guidelines and recommendations
Step 11: Practice hand
hygiene
Fact:
Hand hygiene is the single most important
infection control measure for preventing the
spread of antimicrobial resistant organisms.
Hand Hygiene Adherence in Hospitals

Year of Study Adherence Rate Hospital Area
1994 (1) 29% General and ICU
1995 (2) 41% General
1996 (3) 41% ICU
1998 (4) 30% General
2000 (5) 48% General
1. Gould D, J Hosp Infect 1994;28:15-30 2. Larson E, J Hosp Infect 1995;30:88-106

3. Slaughter S, Ann Intern Med 1996;3:360-365 4. Watanakunakorn C, Infect Control Hosp
Epidemiol 1998;19:858-860 5. Pittet D, Lancet 2000;356:1307-1312
% log Time after disinfection
99.9 3.0 0 60 180 minutes
Effectiveness
of Hand
Hygiene Agents
Bacterial Reduction
99.0 2.0
Alcohol-based
in Reducing handrub
(70%
Bacteria on Isopropanol)
Hands 90.0 1.0

Antimicrobial
soap
(4%
Chlorhexidine)
0.0 0.0
Baseline
Plain soap
Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, Philadelphia: Lippincott & Williams,1999.
Fact: Hand hygiene is the single most important

infection control measure for preventing the spread
of antimicrobial resistant organisms.
Actions:
 Wash your hands or use alcohol-based
handrub
 Set an example!
 Link to: Health guidelines for healthcare personnel

 Coming soon…new guidelines for hand hygiene
Step 12: Partner with your patients
Step 12: Partner with
your patients
Fact:
Dialysis patients share in the responsibility
for preventing access-related infections
Poor Patient Hygiene is a Risk Factor

for Infection
No.(%) with Poor Hygiene
Patients Patients not p-value

Infected Infected
All Infections 17/23 (74%) 12/48 (25%) 0.0004
Access site
Infections 8/9 (89%) 21/62 (34%) 0.002
Kaplowitz et al., Infect Control Hosp Epidemiol 1988;9:534-541

Educating Patients About Infection

Control Practices
• Patients should be educated about the

importance of their role in infection control upon
admission to a dialysis center/hospital and at least
annually thereafter.
• Educational materials should include personal
hygiene, hand hygiene, proper care of access
lines, and recognition of signs of infection.
CDC, MMWR 2001;50 (5): 31

Step 12: Partner with your
patients
Fact: Dialysis patients share in the responsibility for
preventing access-related infections.
Actions:
 Educate patients about proper access care
and infection control measures
 Re-educate regularly
 Link to: Health guidelines for healthcare personnel

 Coming soon…new guidelines for hand hygiene
PREVENTION
IS PRIMARY!
Protect patients…protect healthcare personnel…
promote quality healthcare!

Campaign To Prevent Antimicrobial Resistance: Dialysis Patients

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Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Department of Health and Human Services

 Link to: Campaign to Prevent Antimicrobial Resistance Online

 Link to: Campaign to Prevent Antimicrobial Resistance Online

Emergence of Antimicrobial Resistance

Resistance Gene Transfer

Selection for Antimicrobial-resistant Strains

Key Prevention Strategies

Clinicians hold the solution!

Campaign to Prevent Antimicrobial

 General health communication strategy

12 Steps To Prevent Antimicrobial

12 Steps to Prevent Antimicrobial

12 Partner with your patients

Disease Burden for Dialysis Patients

Vaccination Rates of Dialysis Patients,

* Unpublished data, Dialysis Surveillance Network

Need for Healthcare Personnel Immunization

All adults > 65 yrs. of age 63%

Healthcare personnel at high risk 38%

All healthcare personnel 34%

Source: 1997 National Health Interview Survey

 Link to: ACIP Influenza Immunization Recommendations

Fact: Influenza and pneumococcal vaccine given to both

 Link to: ACIP Influenza immunization recommendations

 Link to: NNIS Online at CDC

Epidemiology of Catheter Associated

CDC, MMWR 2002, 51 (RR-10); p.10

Biofilm on Intravenous Catheter Connecter

Scanning Electron Micrograph

 Link to: Biofilms and device-associated infections

Rates of Bacteremia Infection by Access Type -

Tokars et al., Am J Infect Control 2002;30:288-295.

 Link to: Urinary catheter infection prevention

Fact: Careful infection control prevents

 Link to: NNIS Online at CDC

Peritoneal Catheter Insertion and

Gokal et al., Peritoneal Dialysis International 1998;18:11-33.

Fact: Careful infection control prevents peritoneal

 Link to: Peritoneal Catheters and Exit-Site Practices 1998 Update

Diagnose & Treat Effectively

Importance of Utilizing Cultures and

No. (%) Susceptible

Fogel et al., Am J Kidney Dis 1998;32:401-409

Diagnose & Treat Effectively

Diagnose & Treat Effectively

Infectious Diseases Expert Resources

Diagnose & Treat Effectively

Fact: Input from infectious diseases experts

Use Antimicrobials Wisely

Percent of S. aureus Blood Isolates Resistant to

10 Canada, 10%1 Connecticut, 43%2

Dialysis Surveillance Network 1999-20023

Use Antimicrobials Wisely

 Link to: NCCLS Proposed Guidance for Antibiogram Development

Use Antimicrobials Wisely

Evolution of Drug Resistance in S. aureus

[2002] [1997] Vancomycin

CDC, MMWR 2002;51(26):565-567

VRE Colonization Among Dialysis Patients

Received Vancomycin Developed VRE

Atta et al., Kidney International 2001;59:718-724