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2. It should be noted that the antibody response rate in these patients is lower than in
the general population and hence the vaccination dose and schedule should follow those recommended for haemodialysis patients refer vaccine.
6.4.7 Connection to dialysis machine in HIV patients
1. It is necessary to have a dedicated machine for HIV-positive patients but all venous
pressure transducers must be changed between patients. 2.
Disposable dialysers should be used and dialysers should not be reprocessed. 3.
Staff should wear eye glasses or visors to protect against the spray of blood that may occur when inserting needles into the patient.
6.4.8 Disinfection and disposal at the end of haemodialysis
1. Staff must take care to avoid accidents with re-useable sharp instruments.
2. Gloves and an apron must be worn.
3. On completion of the haemodialysis treatment, all used dialysers and blood lines
should be placed in a leak proof containersbags when transporting them from the dialysis station to the reprocessing or disposal area.
4. All machines should be cleaned with a 0.1 hypochlorite solution.
5. Normal cleaning is adequate for the beds, mattresses, lockers and other furniture,
unless contaminated by blood or other body fluids in which case the spillage procedure is followed.
6. Blood-stained linen must be placed in a special bag which is labeled “Biohazard’.
7. Heavily blood-soaked linen should be placed in yellow bag for incineration.
6.4.9 Infection Control Precautions for all Patients
1. Disposable gloves MUST be worn whenever caring for the patient or when touching
the patient’s equipment including the haemodialysis machine at the haemodialysis station. The disposable gloves MUST be removed and hands MUST be washed
between patients or dialysis stations.
2. Items taken into a dialysis station should be disposed of, dedicated for a single
patient or cleaned and disinfected before using on other patients. 3.
Dialysis chairs, table, haemodialysis machines etc MUST be cleaned and disinfected between patients.
4. Clean area should be clearly designated for handling and storage of medications,
unused disposables, equipments and machines. 5.
Venous and arterial pressure transducers filterprotector should be used and these should be changed between each patient and should not be reused.
6. Common cart should not be used to deliver medications or food to patients. If common
cart has to be used, the cart must not be moved from one dialysis station to another and should remain in a designated area of sufficient distance from dialysis stations.
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6.4.10 Management of Hepatitis B positive patients
1. Requires the same infection control precautions recommended for all haemodialysis
patients. 2.
Hepatitis B Ag positive patients should be dialysed in separate room using separate machines, equipment and supplies.
3. Staff caring for Hepatitis Bs Ag positive patients MUST not care for hepatitis B
susceptible patients anti Hepatitis Bs antibody negative at the same time 4.
Dialysers may be reprocessed but this MUST be done at dedicated reprocessing area and dedicated reprocessing machines
6.4.11 Management of Hepatitis C positive patients
1. Requires the same infection control precautions recommended for all haemodialysis
patients 2.
Hepatitis C positive patients should be dialysed in separate room using separate machines, equipment and supplies.
3. Staff caring for Hepatitis C positive patients MUST not care for Hepatitis C negative
patients at the same time 4.
Dialysers may be reprocessed but this MUST be done at dedicated reprocessing area and reprocessing machines
5. Hepatitis C positive patients who acquired sustained response after antiviral treatment
should continue to be dialysed with machines at dialysis station dedicated for Hepatitis C positive patients. However it is preferred that these patients are dialysed during
the first shift.
6.4.12 Other infection control procedures
1. Standard ‘no-touch’ dressing changes and care of intravascular catheters should be
performed according to the ward nursing procedures. 2.
Patients with temporary or cuffed tunneled dialysis catheters should be screened for carriage of Staphylococcus aureus, particularly methicillin-resistant strains MRSA,
and MRSA eradication should be attempted with a short course of nasal mupirocin and topical chlorhexidine.
B. CONTINUOUS AMBULATORY PERITONEAL DIALYSIS CAPD
6.4.13 Catheter insertion
1. Patients should be screened for staphylococcus nasal swab before surgical insertion
of the catheter. 2.
Carriers of Staph aureus MSSA or MRSA should be treated with nasal mupirocin and topical antiseptics in order to clear staphylococcal carriage before the catheter
is inserted.
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3. On the day of catheter insertion, the patient should shower using 4 aqueous
chlorhexidine applied to their whole body to reduce skin flora. 4.
Prophylactic antibiotics are indicated, at the discretion of the renal physician, before insertion of the catheter.
5. If the patient has concurrent skin sepsis, insertion must be delayed until the skin is
normal. 6.
If this is not possible, an antibiotic active against the causative organism should be administered just before catheter insertion and continued for 24 hours.
7. The intra-abdominal catheter must be inserted with full aseptic precautions.
6.4.14 Care of the CAPD system
1. The patient must receive adequate instruction on how to change the dialysis bags
and how to maintain the exit with aseptic precautions at all times. 2.
Patients should not immerse or wet the exit site during bathing. It is easier to keep the exit site dry by showering.
3. Only sterile pyrogen-free dialysate fluid designed for CAPD must be used.
4. If dialysis bags must be warmed, it should be done in a dry heating system and
water baths must not be used. 5.
Hands must be cleaned with chlorhexidine skin cleanser or alcoholic chlorhexidine. 6.
The exit site must be cleaned and dressed daily using 10 aqueous providon iodine or 0.5 chlorhexidine. The exit site should be patted dry after cleansing. Gentamicin
cream should be applied to the exit site after cleansing. 7.
All dried blood and secretions must be removed using fresh gauze swabs before each application of skin disinfectant. However it is important not to forcibly remove
crusts or scabs during cleansing as this would cause a break in the skin and may lead to exit site infection.
8. The exit site is covered with a sterile non-occlusive dressing.
9. The connecting tubing and connectors must be changed approximately 6 monthly
by the renal unit staff. 10. The catheter and proximal tubing must be securely anchored to the abdominal wall
to prevent unnecessary movement around the exit site.
Recurrent CAPD infection
1. Patients who develop more than two to three infections per year should have their infection
control techniques review and receive additional instruction in the prevention of peritonitis. 2.
Infection with unusual environmental pathogens may require a review of those procedures carried out at the patient’s home.
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ADDITIONAL GUIDELINES ADAPTED FROM THE DOQI and CDC
MANAGEMENT OF THE INFECTIVE PATIENT HBV, HCV, HIV
Due to the nature of haemodialysis treatment and the likelihood of receiving multiple blood transfusions, long term haemodialysis patients have a higher risk of acquiring Hepatitis B virus
HBV and Hepatitis C virus HCV infections compared to the normal population. Once infected these patients are more likely to become chronic carriers. Hence, the
seroprevalence of HBV and HCV in haemodialysis patients is higher than in the general population. Even with meticulous and regular sterilization procedures for haemodialysis machines and
disposable components and practice of standard precautions against infections from blood products and body fluids, the risk of acquitting HBV and HCV with haemodialysis treatment
remains.
Therefore it is prudent to adopt additional measures to reduce the risk: 1
All patients subjected to chronic haemodialysis treated must have their blood tested for HBV, HBC and HIV every 3 months.
2 Patients who are positive for HbsAg should be dialyzed with separate machines at separate
haemodialysis station and not shared by seronegative patients. 3
The following roomsfacilities used for Hepatitis B sAg positive patients should be separated from HbsAg negative patients:
a Reprocessing area for disposable
b Dialysis treatment room.
4 Patients who are Hepatitis C positive should also be dialysed with dedicated machine at
dedicated haemodialysis station and not to be shared with Hepatitis C negative patients. The dialysis treatment room and the reprocessing area should be separated from Hepatitis
C negative patients.
5 For HIV positive patients, disposable should not be re-used and a separate room or
home haemodialysis is preferred. The disposal of blood lines, dialysers and dialysate is made according to the recommendation of the Ministry of Health.
6 Seronegative patients should be immunised against hepatitis B if HbsAb-ve using 40ug
of vaccine at 0, 1 and 6 months with Recombivax HB
®
or at 0,1,2 and 6 months with Engerix B
®
. Staff of haemodialysis units are routinely immunized. 7
Monitoring for patients who are Hepatitis BsAg positive;—3 monthly LFT, HbsAg; 6 monthly alpha-fetoprotein; yearly ultrasound of the liver.
8 Monitoring for patients who are Hepatitis C positive: 3 monthly LFT; 6 monthly alpha-
fetoprotein; yearly ultrasound of the liver.
PREVENTION OF COMPLICATIONS : INFECTION Infections Control Measures
Staff and patient education should include instruction on infection control measures for all haemodialysis access sites.
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RATIONALE
In haemodialysis patients, poor personal hygiene is a risk factor for vascular access site infec- tions. Therefore, haemodialysis patients with poor personal hygiene habits should be taught how
to improve and maintain their personal hygiene. In additional, there is a higher rate of infections in haemodialysis patients when new or inexperi-
enced dialysis staff manipulates the patient’s vascular access. Because of this, all dialysis staff should be trained in infection control procedures. Documenting educational materials and objec-
tives must be part of patient’s records and staff orientation records.
Tracking the occurrence of infections can help identify the source and allow corrective action to be taken. Ongoing quality assurance, risk management, or CQI efforts should be in place to
monitor the incidence of infections, to evaluate the response to patient and staff education, and identify future educational needs.
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6.5.1. Introduction
In the Dental Clinic, standard infection control precautions are taken. These precautions are procedure-specific and not patient-specific. This means that the same set of precautions are
taken for each type of procedure irrespective of whether the patient is known to be infected with a blood-borne virus. Refer to standard precaution section.
6.5.2 Personal Protective Equipment PPE
1. Gloves
• Clean examination gloves must be worn when examining or performing any non
surgical dental procedures •
Examination gloves preferably double layer may also be worn when performing extraction of teeth.
• Sterile gloves preferably double layer must be worn when performing surgical
procedures •
Heavy-duty utility gloves must be worn when cleaning contaminated instruments and when cleaning clinical contact surfaces must be puncture and chemical
resistant - preferably nitrile. •
Heavy-duty gloves can be reused but must be considered contaminated and handled appropriately until properly disinfected.refer to CSSD chapter.Gloves
must be discarded if their barrier properties become compromised. 2.
Masks, Protective Eyewear, Face Shields and Protective Clothing •
When performing procedures that are likely to generate debris, sprays and splashes both the operator and the assistant must use;
o surgical masks which cover both the mouth and nose o appropriate protective eyewear goggles or face shields
o protective gowns which are fluid resistant preferably disposable •
Single and 2-ply masks should no longer be used. •
Protective eyewear or face shields must be cleaned with soap and water and disinfected with an appropriate disinfectant after use on each patient
6.5.3 Patient Protection 1.
Only sterile instruments must be used on patients during oral procedures 2.
All clinical contact surfaces must be disinfected appropriately before the patient sits on the dental chair
3. All patients must wear clean bibs ideally disposable when undergoing non surgical
procedures.
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4. For surgical procedures, sterile drapes should be used.
5. Patients should wear protective eyewear against physical damage to the eye from
propelled and dropped objects. Protective eyewear must be cleaned with soap and water and disinfected with an appropriate disinfectant after use on each patient.
6.5.4. Cleaning, Disinfection and Sterilization of Dental Equipment and Instruments 1. Methods refer disinfection section
•· Critical instruments contacts non intact oral tissue examples include forceps, scalpels, bone chisels, scalers and burs must be packaged and heat sterilized.
• Semi-critical instruments contacts the oral environment and intact oral mucosa
examples include amalgam condensers, mouth mirrors, dental hand pieces and digital radiography sensors should also be packaged and heat sterilized. If heat
sterilisation is not possible - should receive minimum of high level disinfection.
• Non-critical instruments contacts only intact skin examples include x-ray cone,
position indicator device for x-ray cone, and face bow, should be cleaned and disinfected appropriately after each use
2. Instrument processing area in the dental clinic
• Instruments must moved in a single loop from dirty through clean to sterile without
doubling back and should therefore be divided into 3 areas: o decontamination area for receiving, cleaning, and decontamination,
o packaging area for sorting and packaging, o sterilising area for sterilization and storage.
3. Instrument cleaning refer to CSSD chapter
• Instruments should be wiped of visible blood immediately after use in the surgery
before transporting to the instrument processing area. •
Instruments should be soaked in holding solution in a puncture-resistant container if cleaning is not performed immediately.
• Instruments to be washed by hand instruments should be soaked in a disinfectant
solution at least intermediate level before washing. •
Appropriate PPE which includes utility gloves, masks, protective eyewear and protective clothing must be worn during cleaning.
• Hand cleaning is the least desirable method because there is direct hand contact
with contaminated sharp instruments. Clean only 1 or 2 instruments at a time using a long-handled brush and scrub instruments while submerged to minimise
splashing.
• Automated cleaning equipment such as washer-disinfectors and ultrasonic cleaners
do not require hand cleaning of instruments and they also do not require pre- cleaning disinfection if disinfectant solutions or heat disinfection is used in the
cleaning process. These methods are therefore safer and more efficient than manual cleaning. Use recommended solutions and follow manufacturers’ instructions
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• It is advisable to soak the instruments in a lubricant and a rust and corrosion
inhibitor before packing. Follow the manufacturer’s instructions for this. •
Before final sterilization, instruments should still be handled as though contaminated and handled using gloves.
4. Packaging
Critical and semi-critical instruments that are heat sterilized, must be packaged, or placed into container systems to maintain sterility of the processed item after
sterilization
5. Sterilization
• When processing any of the following items a vacuum autoclave Type S or Type
B will be required packaged items i.e. for storage purposes hollow items, such as dental hand pieces or cannulae porous items, such as drapes or gowns.
• When processing only solid, un-packaged instruments and none of the above
items, a Type N downward displacement autoclave will be sufficient. •
Sterilization of unwrapped instruments is usually only for flash sterilization i.e. sterilization of items for immediate use
6. Storage
• After sterilization instruments must be stored in an enclosed area.
• Packages must be inspected before use to verify barrier integrity and dryness.
• First in, first out system should be observed.
6.5.5. Cleaning and Disinfection of Treatment Room 1.
Clinical contact surfaces
• Clinical contact surfaces are surfaces that might become contaminated with
blood and during a procedure and include the dental chair, light handles, dental chair controls, dental radiographic equipment, chair side computers etc.
• Avoid contact with non-working surfaces once treatment has commenced
• For disinfection of clinical contact surfaces use:
low level disinfectants when the surfaces are not visibly contaminated, intermediate level disinfectants when the surfaces are visibly contaminated
with blood. high level disinfectants are usually not used as they may be toxic to the
personnel or damage the surfaces. •
Because of the risks associated with exposure to chemical disinfectants and contaminated surfaces chemical and puncture resistant gloves and other PPE
must be worn during the cleaning process.
