See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/306383042

Hand Hygiene in Haemodialysis Units

Article in Open Access Library Journal · January 2016

DOI: 10.4236/oalib.1102953

CITATIONS READS

3 2,190

1 author:

Ayman Karkar
Baxter International
103 PUBLICATIONS 1,495 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

It’s a new published article. View project

Dialysis perspectives and Complications View project

All content following this page was uploaded by Ayman Karkar on 20 November 2016.

The user has requested enhancement of the downloaded file.

Open Access Library Journal

Hand Hygiene in Haemodialysis Units

Ayman Karkar
Department of Nephrology, Kanoo Kidney Centre, Dammam Medical Complex, Dammam, KSA

Received 5 August 2016; accepted 18 August 2016; published 22 August 2016

Copyright © 2016 by author and OALib.

This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/

Abstract
Healthcare-associated infections are a major risk to patient safety. Infection is the first cause of
hospitalisation and the second most common cause of mortality among haemodialysis (HD) pa-
tients. HD patients, as well as the dialysis staff, are vulnerable to contracting healthcare-associated
infections due to frequent and prolonged exposures to many possible contaminants in the dialysis
environment. The extracorporeal nature of the therapy, the associated common environmental
conditions, and the immune compromised status of HD patients are major predisposing factors.
HD patients are exposed to different types of infections which include bloodstream infections and
localized infections of the vascular access, blood-borne infections with hepatitis B virus, hepatitis
C virus, and/or human immunodeficiency virus, and airborne infections. Sources of infections in-
clude contaminated water, equipment, environmental surfaces, and infected patients. The evident
increased potential for transmission of infections in the HD settings led to the creation and im-
plementation of specific and stricter infection prevention and control measures in addition to the
usual standard precautions. Contaminated hands of healthcare workers are among the most
common modes of transmission of healthcare-associated infections. Hand hygiene is singled out as
the most important infection prevention intervention. Hand hygiene compliance can be improved
by continuous education and monitoring, providing a sufficient number of sinks with soap dis-
pensers, paper towels, hand lotions and alcohol-based hand rub placed at each patient station, and
regular feedback of surveillance results. Education and training and full awareness of infection
control policies and procedures should be provided to all Healthcare workers and to be repeated
regularly. The patient and/or caregiver should also be educated on hand hygiene and the care of
new vascular access.

Keywords
Hand, Hygiene, Haemodialysis, Healthcare, Infection, Vascular Access

Subject Areas: Infectious Diseases, Nephrology

1. Introduction
Healthcare-associated infections are a potential risk to patient safety and constitute a major cause of morbidity

How to cite this paper: Karkar, A. (2016) Hand Hygiene in Haemodialysis Units. Open Access Library Journal, 3: e2953.
http://dx.doi.org/10.4236/oalib.1102953
 A. Karkar

and mortality. In healthcare settings, there are three major types of healthcare-associated infections: surgical-site
infections, central-line-associated bloodstream infections, and catheter-associated urinary tract infections. In di-
alysis units, infection is the first cause of hospitalization and the second most common cause of mortality among
haemodialysis (HD) patients after cardiovascular disease [1]-[3]. HD patients are exposed to different types of
infections which include bloodstream infections and localized infections of the vascular access (catheters and
grafts), blood-borne infections with hepatitis B virus (HBV), hepatitis C virus (HCV), and/or human immunode-
ficiency virus (HIV), and airborne infections like tuberculosis. Sources of infections could be contaminated wa-
ter, equipment, environmental surfaces in the treatment area, and patients with infections who pose a risk to oth-
er nearby patients being treated in the dialysis unit. The increased risk for contracting healthcare-associated in-
fections (HAIs) among HD patients are mainly due to 1) immune compromised status, 2) frequent and pro-
longed blood exposure during HD treatments through the vascular access and extracorporeal circuit (with many
ports and connections), 3) close proximity to other patients during treatment in the HD facility, 4) frequent con-
tact with healthcare workers who frequently move between patients and between machines, 5) frequent hospita-
lization and surgery, and most importantly 6) non-adherence or a break in implementation of recommended
practices, including hand hygiene and use of personal protective equipment.
The break in implementation of recommended practices may sometimes occur inevitably as a result of one or
more of the following factors: 1) understaffing with poor nurse to patient ratio [4]-[6], 2) frequent turn-over of
nursing staff [4]-[9], 3) lack of or inadequate training and lower level of competency among HD staff [5] [9]-
[11], 4) inadequate or lack of patient/family education, 5) inadequate provision of necessary supplies/equipment,
including adequate clean sinks and/or alcohol-based hand rubs, soap and towels [10] [11], 6) poor design of HD
unit lay-out (congested and inadequate segregation/isolation) [11], and 7) the urgency associated with dialysis
complications (sometimes life-threatening situation) which may sacrifice adherence to standard precautions [9]
[12] [13].
Healthcare Infection Control Practices Advisory Committee (HICPAC) and Centers for Disease Control and
Prevention (CDC) recommended two-level approach precautions to prevent the transmission of infectious agents
in healthcare settings. These are 1) Standard Precautions and 2) Transmission-Based Precautions. Standard
Precautions are the basic level of infection control practices to be applied in the care of all patients and in all
healthcare settings, regardless of the suspected or confirmed infection status. Standard Precautions were based
on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous
membranes may contain transmissible infectious agents [14]. The elements of Standard Precautions include: 1)
hand hygiene, 2) use of personal protective equipment (PPE) such as gloves, gown, mask, eye protection (eye
goggles or face shield), and 3) handling of equipment or items including surfaces in the patient environment in a
manner that prevent transmission of infectious agents. CDC added new elements to be considered as a standard
of care which include: a) respiratory hygiene/cough etiquette; b) safe injection practices; and c) use of masks for
insertion of catheters [14].
Transmission-Based Precautions are usually applied for patients who are known or suspected to be infected
or colonized with infectious agents, including certain epidemiologically important pathogens that require addi-
tional control measures to effectively prevent transmission. Transmission-Based Precautions have three catego-
ries: 1) contact precautions, 2) droplet precautions, and 3) airborne precautions [14].
In addition to Standard Precautions and Transmission-Based Precautions, CDC recommended more stringent
measures for HD settings, which include non-sharing of supplies, instruments, medications and medication trays
between patients, and prohibit the use of a common medication cart [15]-[18]. Unlike the conditions in general
hospital wards, the typical lay-out and associated conditions in most HD units (wherein multiple patients receive
extracorporeal treatment with prolonged blood exposures in the same area and usually with one healthcare
worker (HCW) caring for more than one patient at the same time) are potential factors that may increase the
transmission of infections. Therefore, strict implementation of Standard Precautions and in particular hand hy-
giene constitutes an essential measure of infection prevention and control. The aim of this narrative review is to
mainly focus on hand hygiene and other related Standard Precautions in a HD facility, where the importance of
implementation of such precautions is shared with other healthcare settings. Other more specific hemodialysis-
related infection control measures, which include cleaning and disinfection of HD machine’s external surfaces,
disinfection of internal fluid pathway of HD machines, handling of disposable supplies and reusable items in HD
units, purity and testing of treated water, screening and routine serologic testing and patient placement, and im-
munization of patients and healthcare personnel are all reviewed in [19].

OALibJ | DOI:10.4236/oalib.1102953 2 August 2016 | Volume 3 | e2953

 A. Karkar

2. Hand Hygiene
Contaminated hands of HCW are among the most common modes of transmission of healthcare-associated in-
fections. Pittet and colleagues [20] described a five-step sequence resulting in microbial transmission through
contaminated hands during healthcare delivery. These are “1) pathogens shed by infected patients can contami-
nate surrounding environments, 2) HCW’s hands get contaminated by contact with patient skin or surrounding
environment, 3) pathogen remains viable on the HCW’s hands for at least several minutes 4) HCW may omit
hand decontamination or use inappropriate product or procedure, and 5) HCW’s contaminated hands can either
transfer the pathogen directly to another patient or indirectly on a medical device or objects within the patient’s
immediate vicinity”.
Different studies have confirmed that transiently contaminated hands of the HCW are the main route of
transmission of healthcare-associated infections [21]-[29]. Hand hygiene, therefore, is singled out as the most
important infection prevention intervention. However, the compliance rates of HCWs in hand hygiene is very
poor, with an overall average of 40% or less [30] [31]. Based on hand hygiene indications per recommendations
from Association for Professionals in Infection Control and Epidemiology (APIC) [32], CDC [15] and World
Health Organization (WHO) [33] (Table 1), the estimated number of times a single dialysis staff is required to
perform hand hygiene per HD session per patient is shown in Table 2. The estimated number can be a minimum
of 60 to 100 times when multiplied by the number of patients assigned per staff (e.g., 2 - 3 patients). The large
number of times an HD staff is required to perform hand hygiene could be a reason for lack of compliance.
However, compliance can be improved by continuous education, supervision and monitoring of hand hygiene
behaviors, where the latter represents the most effective method in improving performance [34].
Monitoring hand hygiene compliance is crucial and direct observation is the current gold standard method.
However, direct observation has several limitations, among which are being labor intensive, small sample size
(may cover only 1% of total hand hygiene activity), and not standardized. A new model device application de-
veloped by the Computational Epidemiology Research Group at the University of Iowa (the “iScrub Lite”,
which is available for free download on the Apple iTunes store for Apple® iPhone or iPod), can facilitate the
work of the Infection Preventionist (IP) by recording the observations, which can be loaded to an excel spread-
sheet for ready analysis. Advanced technologies, with automated electronic devices and software (Real Time
Location System), can monitor the number of hand hygiene activity (10 to 50 thousands per month) in each de-
partment, floor or unit, and identify the HCW performing the hand hygiene through badge or wristband detec-
tion, with indication of the time of day and day of the week hand hygiene is performed, and even provide feed-
back/cueing to encourage proper hand hygiene [35].
Compliance can also be improved by providing, in convenient locations, a sufficient number of sinks with

Table 1. Hand hygiene indications as recommended by APIC, CDC, and WHO.

WHO-“My Five Moments for Hand

APIC [32] CDC [15]
Hygiene” [33]
1. Before touching a patient, even if gloves
1. Before touching a patient
will be worn
1. Just before touching a patient
2. Prior to performing an aseptic task (e.g.,
2. Before clean/aseptic procedure
placing an IV, preparing an injection)

2. After touching blood, body fluids,

3. After contact with blood, body fluids,
secretions, excretions and contaminated 3. After body fluid exposure risk
excretions, or wound dressings
items (including front of the HD machine)

4. Before exiting the patient’s care area after 4. After touching a patient
3. Before leaving a patient station touching the patient or the patient’s
immediate environment 5. After touching patient surroundings

5. If hands will be moving from a

4. Before accessing or restocking supplies contaminated-body site to a clean-body
site during patient care

5. After gloves are removed 6. After glove removal

APIC = Association for Professionals in Infection Control and Epidemiology, CDC = Centers for Disease Control and Prevention, WHO = World
Health Organization.

OALibJ | DOI:10.4236/oalib.1102953 3 August 2016 | Volume 3 | e2953

 A. Karkar

Table 2. Estimated minimum number of times where hand hygiene is required per dialysis session per patient [19] (regard-
less of gloves use).

SN Activity Before After Total

1 Accessing supplies from common clean storage area 1 - 1
*
2 Preparing/setting-up the HD machine 1 1
3 Preparing/administering medications (including for anticoagulation) 1 1 2
*
4 Pre-dialysis: measuring vital signs/weighing 1 1
*
5 Preparing trolley/tray for cannulation 1 1
*
6 Palpating clean cannulation sites 1 1
*
7 Skin preparation & cannulation of arteriovenous access (AVF, AVG) 1 1
8 Preparing trolley for catheter dressing** *
1 1
**
9 Removing old dressing over catheter site - 1 1
** *
10 Catheter exit site dressing 1 1
11 Connection for HD 1 1 2
12 Handling blood samples and other specimens - 1 Minimum 1
13 Checking blood pressure (every 1/2 - 1 hour for 4 hours) 1 1 Minimum 8
14 Catheter/blood lines manipulation 1 1 Minimum 2
15 Adjusting machine parameters and/or attending machine alarms - 1 Minimum 1
16 Attending to patient’s incidents/assisting patient 1 1 Minimum 2
17 Prepare trolley for dialysis disconnection 1 - 1
18 Disconnection of HD 1 1 2
*
19 Post-dialysis: measuring vital signs/weighing 1 1
*
20 Cleaning/disinfection of dialysis equipment 1 1
21 Leaving the dialysis unit 1 - 1
Total estimated minimum number of times hand hygiene is required per dialysis per patient ~30
*
Most of the time, the activity is recently preceded by a hand hygiene performed at the end of one procedure/activity (between two different activities).
Therefore, repetition of hand hygiene prior to an activity (wherein performance of hand hygiene is indicated per recommendation) is unnecessary.
**
Not included for patients with permanent arteriovenous (AV) access.

soap dispensers, paper towels, hand lotions (e.g., one for every 2 - 4 dialysis station), and alcohol-based hand
rub (ABHR) placed at each patient station [32]. Because of the proven superior efficacy in decontamination,
better skin tolerability and ease of use, ABHR is recommended to be used in all clinical situations if hands are
not visibly soiled. If exposure to bacterial spores (i.e., bacillus anthracis and/or clostridium difficile) is suspected
or proven, hand washing with soap and water is recommended, because spores are resistant to most antiseptic
agents and requires physical removal by washing and rinsing [36]. Other preventive measures include restriction
of having long nails and wearing of artificial fingernails or extenders by healthcare personnel who provide direct
patient care, as artificial nails could harbor gram negative bacilli and yeasts [30] [32] [36]-[40].

3. Personal Protective Equipment

Personal Protective Equipment (PPE) refers to a variety of barriers and respirators used alone or in combination
to protect mucous membranes, airways, skin, and clothing from contact with infectious agents, which includes:
gloves, gowns, masks, eye goggles, face shields, and respirators [36]. In the HD setting, gloves are recommend-
ed to be worn whenever caring for a dialysis patient; whether touching patient’s intact skin (e.g., taking blood
pressure) or patient’s equipment at the dialysis station. Gloves should be removed and followed by hand hygiene
between patients or stations [16] [32]. The recommended practice of glove use for every contact with the pa-
tient(s) and equipment(s) at the dialysis station requires an enormous amount of glove supply, which is not al-

OALibJ | DOI:10.4236/oalib.1102953 4 August 2016 | Volume 3 | e2953

 A. Karkar

ways realistic in many HD units. However, when visible soil is present and/or contact precautions are indicated,
wearing gloves is a must. Sterile gloves must be used during procedures requiring sterile aseptic technique, such
as during catheter insertion or at any time a dialysis catheter is handled/manipulated [41]-[43]. Wearing gown
(fluid-resistant with full coverage of the arms and body front and preferably disposable ones) over the uniform,
and use of face mask and eye goggles or face shield is recommended when performing procedures wherein
splashes of blood can be anticipated, especially during initiation and discontinuation of dialysis [16] [32] [36]. If
a face shield is used during catheter handling, a surgical mask should be worn underneath to protect patient from
HCW’s respiratory droplets [32]. Equally important is that patient should also wear a mask and asked to turn
his/her face away from the catheter site to reduce contamination from infectious droplets [32] [43]-[45]. Fur-
thermore, wearing a mask is important when a staff member, a patient or a visitor is experiencing cold or cough
[32] [36]. A respirator should be used by HCWs only when taking care of a patient with an airborne infection.
HCWs uniforms can be colonized with potentially pathogenic bacteria for up to 60% [46]-[51] and therefore
should be laundered and changed daily in order to decrease the bacterial load.

4. Cleaning and Disinfection of Environmental Surfaces

In the healthcare setting, contamination of environmental surfaces with various pathogens and the persistence of
these pathogens on surfaces [52]-[58] can be an important and frequent source of transmission of infectious
agents through the frequent hand touching of HCWs [59] [60]. The environment in HD units is particularly
prone for contamination with blood-borne pathogens such as HBV, HCV and HIV, and other infectious agents
such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and
Clostridium difficile (C. difficile). Microorganisms can survive on environmental surfaces for varying periods of
time ranging from few hours to days and months. Low temperature, high humidity and high inoculums favor the
long persistence of pathogens on inanimate surfaces [52]. In order to prevent and control spread of environmen-
tally transmitted pathogens, cleaning and disinfection of the external surfaces of equipment (i.e., HD machine,
dialysis chair or bed, procedure trolley) and other environmental surfaces inside HD units, especially those that
are frequently touched by patients and staff, should be performed between all patient treatments (irrespective of
the patient diagnosis) [16] [32] [43]. The application of friction during cleaning is emphasized since some or-
ganisms like C. difficile are not easily inactivated by most surface disinfectants (except bleach) and require re-
moval by friction [32] [36].

5. Cleaning and Disinfection of Auxiliary Equipment

Auxiliary equipment used in HD may include reusable jugs for mixing bicarbonate solution, reusable priming
buckets, and external pressure transducers. As per recommendation, any reusable item should be cleaned and
disinfected prior to being used on another patient, and external pressure transducers should be changed between
patients’ uses. Nowadays, many units have shifted to use the more hygienic automated process of mixing bicar-
bonate powder in cartridge on the individual machines eliminating the use of reusable bicarbonate jugs. If bi-
carbonate solution in a jug is used, any “left-over” solution must be discarded and opened jugs should not be
used after 24 hours because sodium bicarbonate solution substitute a good media for bacterial growth [32].
Reusable priming buckets are now seldom used since most dialysis companies include a disposable prime col-
lection bag in each pack of sterile bloodline set, and also with pre-attached external pressure transducers. With
improved and better technology in some latest model of HD machines, prime collection bags or transducer pro-
tectors are not even required, because drainage of priming solutions can be done by connecting the bloodline to
a drainage port in the machine, and blood pressure sensors are completely non-invasive without using transducer
connections and protectors.

6. Handling of Disposable Supplies and Reusable Items in HD Units

Both CDC and APIC recommended specific measures which include the following: 1) items taken into an indi-
vidual patient’s HD station should be used only for that patient and be disposed of after use, 2) unused item(s)
should be cleaned and disinfected before returning to a common clean area or used on another patient, or be
disposed of if it cannot be disinfected, and 3) non-disposable items that cannot be comprehensively cleaned and
disinfected (e.g., adhesive tape, cloth-covered blood pressure cuffs) should be dedicated for use on a single pa-

OALibJ | DOI:10.4236/oalib.1102953 5 August 2016 | Volume 3 | e2953

 A. Karkar

tient [16] [32]. In reality, allocating a blood pressure cuff for each patient may not be practical as too frequent
detachment and re-attachment of the cuff can cause imminent damage to the line connections. Reusable blood
pressure cuffs that are covered with waterproof material with smooth surface (instead of cloth-covered cuffs)
can be an attractive alternative, as they can be comprehensively cleaned and disinfected between patient uses.
There should also be a clear separation for storage and handling of clean supplies and medications from conta-
minated items (i.e., used supplies/equipment, blood samples, biohazard containers).

7. Safe Injection Practices

Aside from the basic principles of aseptic technique, there are specific complementary recommendations for HD
published by the CDC and APIC, which include the following: 1) all single-use injectable medications and solu-
tions should be dedicated for use on a single patient and be entered one time only, 2) medications packaged as
multi-dose should be assigned to a single patient whenever possible, 3) medication preparation should occur in a
clean area away from the patient treatment area, and be delivered separately for each patient, 4) not to carry
multi-dose vials from station to station or carry medication vials, syringes, alcohol swabs or supplies in pockets,
5) unused medications or supplies 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, 6) not to use common medication carts to de-
liver medications to patients, and if trays are used to deliver medications to individual patients, they must be
cleaned between patients [16] [32] [61]. CDC’s full recommendations on safe injection practices are shown in
Table 3.

8. Vascular Access: Care and Prevention of Infection

Infection rates with tunneled dialysis catheters has been estimated to be 10 times higher than that of arterioven-
ous fistula (AVF) or AV graft [32], and found to be the leading risk factor of bacteremia in chronic HD patients
[62]. The international bodies are in concert with the guidelines that vascular access should be a native AV fis-
tula whenever possible, AV graft as the next preferred option, and the use of catheters to be avoided as much as
possible [17] [32] [42]-[45]. Vascular access infection prevention measures unanimously recommended by the
international bodies are outlined in Table 4, and varying messages on dialysis catheter recommendations are
outlined in Table 5. The relevance of “rubbing and soaking the catheter hub with the cap on with a povidone
iodine swab for 3 - 5 minutes before the cap is removed” (as recommended by KDOQI) is understandably to
disinfect the outside surface thereby preventing inadvertent contamination of the inner hub and ultimate blood-
stream contamination. In the 2011 update of CDC Guidelines for the Prevention of Catheter-Related Infections,

Table 3. Key recommendations on safe injection practices in ambulatory care settings.

SN Recommendations
1 Use aseptic technique when preparing and administering medications
2 Cleanse the access diaphragms of medication vials with 70% alcohol before inserting a device into the vial
Never administer medications from the same syringe to multiple patients, even if the needle is changed or the injection is
3
administered through an intervening length of intravenous tubing
4 Do not reuse a syringe to enter a medication vial or solution

Do not administer medications from single-dose or single-use vials, ampoules, or bags or bottles of intravenous solution to more
5
than one patient

6 Do not use fluid infusion or administration sets (e.g., intravenous tubing) for more than one patient
Dedicate multidose vials to a single patient whenever possible. If multidose vials will be used for more than one patient, they
7 should be restricted to a centralized medication area and should not enter the immediate patient treatment area (e.g., operating
room, patient room/cubicle, patient HD station)
8 Dispose of used syringes and needles at the point of use in a sharps container that is closable, puncture-resistant, and leak-proof
9 Adhere to “national” requirements for protection of HCW from exposure to blood borne pathogens

Content source: CDC. Guide to Infection Prevention for Outpatient Settings: Minimum Expectation for Safe Care.
http://www.cdc.gov/HAI/pdfs/guidelines/standards-of-ambulatory-care-7-2011 [15].

OALibJ | DOI:10.4236/oalib.1102953 6 August 2016 | Volume 3 | e2953

 A. Karkar

Table 4. Common recommendations on vascular access infection prevention.

Vascular Access Infection Prevention Measures References

Catheter insertion: (Not addressed in KDOQI 2000/2006 guidelines)

• Avoid the use of femoral veins in adult patients [17] [32] [41]
• Catheters should be inserted under strict aseptic technique [17] [32] [41]-[43]
• Maximal barrier precautions (use of mask, cap, sterile gown and sterile gloves by the inserter, and [17] [32] [43]
large sterile drape to cover the patient)
Catheter care:
• Only trained dialysis staff should perform catheter dressing changes and catheter manipulations [17] [32] [43]-[45]
• The catheter exit-site should be examined for proper position and absence of infection by [17] [32] [41] [44] [45]
experienced personnel before accessing the bloodstream at each HD session
• Aseptic technique should be used to prevent contamination of the catheter system [17] [32] [41] [43] [44]
• Use of a surgical mask for staff and patient for all catheter system connect, disconnect, and [32] [43] [44]
dressing procedures
• Catheter manipulation should be kept at a minimum [32] [43] [44]
Skin preparation technique for permanent AV access:
• The patient’s access arm should be washed with antimicrobial soap and water prior to skin [32] [43]-[45]
preparation with antiseptic solution
• To locate and palpate the needle cannulation sites prior to skin preparation [32] [43]-[45]
• To cleanse the skin by applying antiseptic solution before cannulation (alcohol-based [32] [43]-[45]
chlorhexidine, or 10% povidone iodine solution and/or 70% alcohol)

KDOQI = Kidney Disease Outcomes Quality Initiative.

scrubbing of the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70%
alcohol) was recommended for needleless intravascular catheter systems [17]. The routine scrubbing of dialysis
catheter hubs (after cap removal before accessing, and before replacing a new cap) with an appropriate antiseptic
was included as part of a recent CDC’ score interventions for dialysis bloodstream infection (BSI) prevention
(Table 6) [18]. Dialysis providers are cautioned to avoid introduction of the used antiseptic solution into the
bloodstream [63]. In an in vitro study by Salzman et al. [64], the potential for the antiseptic used in cleaning the
open catheter hub as well as few strands of cotton fibers to enter the bloodstream (simulated), and the effective-
ness of normal saline solution (used as control) to reduce the microbial load at a level greater than 99% of the
total number of microorganisms (suggesting mechanical removal) was demonstrated. The cumulative effect of
minute residues of toxic antiseptics and foreign substance that may get into the patient’s bloodstream when ap-
plied repeatedly on open catheter hubs among chronic HD patients have not, and may not be studied. Therefore,
it is prudent to choose a safe and non-toxic solution for cleaning open catheter hubs and to emphasize the appli-
cation of friction while cleaning (scrubbing not just wiping).
Since HD patients are more immune compromised than other surgical patients, pre-surgical infection preven-
tion measures are recommended, which include: 1) pre-surgical shower/bath with an antiseptic agent such as
chlorhexidine, the night before and morning of surgery, 2) if hair removal is necessary, to use clippers instead of
razors to prevent infection associated with micro-abrasions resulting from razor use, and 3) avoiding intravenous
placements and phlebotomy in the arm where access is to be placed (helps prevent infection and maintains vas-
culature integrity) [32]. Screening and decolonization for MRSA before an elective surgery may be used as an
additional measure.

9. Tracking Infections
Surveillance for infections (outcome measures), and monitoring adherence to recommended infection prevention
practices (process measures) are important components of an infection prevention program [65]. To enable
safety, accurate comparison and analyses of monthly rates within the same facility, or meaningful benchmarking
with other units/centers, it is important that a standardized and validated surveillance protocol be used uniformly
by all dialysis facilities [66] [67]. A centralized surveillance system for healthcare-associated infections like the
CDC’s national healthcare safety network (NHSN) which requires all participating facilities to strictly follow
very specific surveillance criteria, can provide accurate and reliable data that can be used to identify problem
areas as well as measure progress of prevention efforts. Implementation of CDC’s NHSN Dialysis Event Proto-
col (accessible online: www.cdc.gov/nhsn/dialysis) by other dialysis facilities outside the United States have

OALibJ | DOI:10.4236/oalib.1102953 7 August 2016 | Volume 3 | e2953

 A. Karkar

Table 5. Varying messages on catheter-related infection prevention strategies.

NKF/KDOQI EBPG/ERBP APIC CDC

Chlorhexidine for skin antisepsis
“Chlorhexidine 2% with 70% “Use an alcohol-based
alcohol is the preferred solution “For patients older than 2 chlorhexidine (>0.5%)
for cleansing of long-term months, a skin preparation solution as the first line skin
catheter sites. For patients with The importance of skin solution containing >0.5% antiseptic agent for central
sensitivities to chlorhexidine antisepsis before catheter chlorhexidine gluconate and line insertion and during
2% with 70% alcohol, placement is indicated 70% isopropyl alcohol dressing changes.
chlorhexidine aqueous may be without mention of preferred should be applied to the Povidone-iodine (preferably
used instead. For patients with antiseptic solution [41] insertion site and allowed to with alcohol) or 70% alcohol
sensitivities to chlorhexidine dry before the skin is are alternatives for patients
aqueous, povidone solution punctured.” [32] with chlorhexidine
may be used.” [44] intolerance” [18]
Technique for all connect, disconnect, dressing procedures, catheter manipulations
“Wear either clean or sterile
Clean aseptic technique Sterile aseptic technique Clean aseptic technique gloves when changing the
(use of clean gloves) [44] (use of sterile materials) [41] (use of clean gloves) [32] dressing on intravascular
catheters” [17]
Soaking and cleansing the catheter hub connection site with the cap on, with an antiseptic pad/swab
“Cleanse hub connection site
“The hub of HD catheters can
and cap vigorously with the
Not mentioned in ERBP 2010 be soaked in povidone-iodine
first swab” [44]. “The catheter Not mentioned in CDC/
position statement on diagnosis, solution or wrapped with
hub caps or bloodline HICPAC
prevention and treatment of gauze saturated with
connectors should be soaked guidelines/recommendations
haemodialysis CRBSI, and in povidone-iodine solution
for 3 - 5 minutes in povidone [16] [17]
2007/2002 guidelines [41]-[43] for 5 minutes prior to
iodine and then allowed to dry
removing the caps” [32]
prior to separation” [45]
Disinfection of catheter hub after cap removal
Not mentioned in ERBP 2010 “Scrub catheter hubs with an
position statement on diagnosis, “After removing the cap, the appropriate antiseptic after cap
Not mentioned in 2000
prevention and treatment of hub should be wiped with is removed and before
Vascular Access Guidelines
haemodialysis CRBSI, in 2007 chlorhexidine, alcohol, or accessing. Perform every time
and in 2006 update [44] [45]
and 2002 vascular access povidone iodine” [32] catheter is accessed or
guidelines [41]-[43] disconnected” [18]
Catheter exit-site dressing
“Use either sterile gauze or
“With long-term catheters, sterile, transparent,
“Changing the catheter exit-site
gauze is the preferred choice. semipermeable dressing.
dressing at each HD treatment, “The catheter exit-site
The catheter exit-site should be Replace dressings on short-term
using either a transparent dressing should be changed
covered by a dressing as long as CVC sites every 2 days for
dressing or gauze and tape” every 3 days (after each HD
the catheter remains in place. gauze dressings, and every 7
[44] “Use of dry gauze session) if gauze/tape, or
The exit-site should be days for transparent dressings.
dressing… at the catheter every 7 days if transparent
inspected at every HD session, Replace transparent dressings
exit-site are recommended after dressing is used in addition to
and the exit-site dressing should on tunneled or implanted CVC
catheter placement and at the whenever the dressing is wet
be replaced on a routine basis if sites no more than once per
end of each dialysis session” or soiled” [32]
it is no longer clean or intact” week (unless the dressing is
[45]
[41] soiled or loose), until the
insertion site has healed” [17]

Application of antimicrobials or antiseptics on the catheter exit-site

“Use povidone iodine
“…combined with skin
antiseptic ointment or
disinfection using povidone
bacitracin/gramicidin/polymixin
iodine ointment or mupirocin “Application of antibiotic
Recommended routine B ointment at the hemodialysis
ointment at the catheter exit ointment at the exit-site should
application of povidone catheter exit site after catheter
site are recommended after be considered after catheter
iodine or triple antibiotic insertion and at end of each
catheter placement and at placement until site has healed
ointment at the time of dialysis session only if this
the end of each but should be discontinued after
dressing change [32] ointment does not interact with
dialysis session” [45] healing” [41]
the material of the HD catheter
Not mentioned in
per manufacturer’s
2006 update [44]
recommendation” [17]

OALibJ | DOI:10.4236/oalib.1102953 8 August 2016 | Volume 3 | e2953

 A. Karkar

Continued
Antibiotic lock prophylaxis

Preventive use is advocated to

“Use prophylactic antimicrobial
reduce the risk of CRBSI, but
Prophylactic use of lock solution in patients with
with caution to balance the
antimicrobial catheter long term catheters who have a
No recommendation for routine benefits against the associated
locking solution as a history of multiple CRBSI
prophylactic use [44] [45] risk, and should not replace
“plus measure”-unresolved despite optimal maximal
hygienic standards with
issue [32] adherence to aseptic
regard to catheter
technique” [17]
care and handling [41]

KDOQI = Kidney Disease Outcomes Quality Initiative, EBPG/ERBP = European Best Practice Guidelines/European Renal Best Practice, APIC =
Association for Professionals in Infection Control and Epidemiology, CDC/HICPAC = Centers for Disease Control and Prevention/Healthcare Infec-
tion Control Practices Advisory Committee.

Table 6. The CDC core interventions for dialysis bloodstream infection (BSI) prevention.

Surveillance and feedback using NHSN

1 Conduct monthly surveillance for BSIs and other dialysis events using CDC’s National Healthcare Safety Network (NHSN).
Calculate facility rates and compare with rates in other NHSN facilities. Actively share results with frontline clinical staff.

Hand hygiene observations

2
Perform observations of hand hygiene opportunities monthly and share results with clinical staff.

Catheter/vascular access care observations

3 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
4 Train staff on infection control topics, including access care and aseptic technique. Perform competency evaluation for skills
such as catheter care and accessing upon hire and every 6 - 12 months.

Patient education/ engagement

5 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.

Catheter reduction
6 Incorporate efforts (e.g., through patient education, vascular access coordinator) to reduce catheters by identifying and
addressing barriers to permanent vascular access placement and catheter removal.

Chlorhexidine for skin antisepsis

7 Use an alcohol-based chlorhexidine (>0.5%) solution as the first-line skin antiseptic agent for central line insertion and during
dressing changes.a

Catheter hub disinfection

8 Scrub catheter hubs with an appropriate antiseptic after cap removal and before accessing. Perform every time catheter is
accessed or disconnected.b

Antimicrobial ointment
9
Apply antibiotic ointment or povidone-iodine ointment to catheter exit sites during dressing change.c
a
Povidone-iodine (preferably with alcohol) or 70% alcohol by itself are alternatives for patients with chlorhexidine intolerance. bIf closed needleless
connector device is used, disinfect connector device as per manufacturer’s instructions. cSee information on selecting an antimicrobial ointment for
hemodialysis catheter exit sites on CDC website. Use of chlorhexidine-impregnated sponge dressing might be an alternative. Adapted from CDC.
CDC Approach to BSI Prevention in Dialysis Facilities (i.e., the Core Interventions for Dialysis Bloodstream Infection (BSI) Prevention [18].

been demonstrated to be feasible. Dialysis Events that should be reported include: 1) intravenous antimicrobial
starts, 2) positive blood cultures, and 3) evidence of local access site infection (pus, redness, or increased swel-
ling at the vascular access site), and data collected from these three events can generate four other types of Di-
alysis Events: bloodstream infection (BSI), local access site infection (LASI), access-related bloodstream infec-
tion (ARB), and vascular access infection (VAI). The number of maintenance HD outpatients who received HD
in the unit/center during the first two working days of the month (including transient HD patients but excluding
inpatients and peritoneal dialysis patients) should be reported on monthly basis and according to their vascular
access type. This will serve as the denominators for rate calculation. Each patient is counted only once; if the
patient has multiple vascular accesses, that patient is counted with the vascular access type of highest infection

OALibJ | DOI:10.4236/oalib.1102953 9 August 2016 | Volume 3 | e2953

 A. Karkar

risk. Rates are calculated by dividing the number of events by the number of patient-months and multiplying the
result by 100 [68].
As a means to reduce infection transmission, each dialysis facility should also monitor other parameters like
dialysis water and dialysis fluid cultures and endotoxin results, incidence of drug-resistant infections, hospitali-
zations, as well adherence to Standard Precautions (hand hygiene, glove use and other PPE, equipment and en-
vironmental cleaning, safe injection practices, etc.), and other recommended practices (screening for HBV, HCV,
HIV and tuberculosis infections, and immunizations) [19]. Regular feedback of surveillance results to everyone
involved in the healthcare delivery (especially the frontline staff) would help to stimulate and encourage active
engagement and improve compliance with infection prevention efforts. At least one designated person with
training in infection control and epidemiology (infection preventionist) should be responsible for oversight of
the program as well as education of staff and patients related to infection prevention and control [15] [32].
Steps that should be taken to control spread of infection, especially if there is an incidence of a positive sero-
conversion or outbreak in the HD unit, include the following: 1) revision of the laboratory test results of all pa-
tients dialyzing in the same unit to identify any additional case(s), 2) performance of additional testing as indi-
cated in Table 7, 3) determination/tracking of potential sources for infection, which includes a) revision of
newly infected patients’ recent history of blood transfusion, invasive procedure(s) and/or hospitalization, and b)
high risk behavior such as history of injection drug use and sexual activity, and 4) revision of HD unit’s practic-
es and procedures of infection control [16].

10. Staff and Patient/Family Education

Education and training in infection prevention and control should be provided to all HCWs upon hire and to be
repeated regularly (at least once yearly). Basic principles and practices, including hand hygiene and wearing
PPE, for preventing the spread of infections should be covered and monitored, and staff competencies should be
assessed and documented upon orientation to the facility and to be repeated as appropriate for the specific staff
and position [15] [69]. The patient(s) and/or caregiver(s) should also be educated on hand hygiene and the care
of new vascular access and whenever there is a change in access type and repeated at least every year [70] [71].
Key areas for patient education as outlined by CDC are shown in Table 8.

Table 7. Additional testing to be performed in case of positive seroconversions.

HBsAg Seroconversions [16] Anti-HCV Seroconversions [72]

In patients newly infected with HBV, HBsAg is the only serologic • If a new HCV infection in a hemodialysis unit is suspected to
marker initially detected. be nosocomial, testing with NAT should be performed in all
• 1 - 2 months later: repeat HBsAg testing and test for anti-HBc patients who may have been exposed.
(including IgM anti-HBc) • Repeat testing with NAT is suggested within 2 - 12 weeks in
• 6 months later: repeat HBsAg testing and test for anti-HBs initially NAT-negative patients

Content source: 2001 CDC recommendations for preventing transmission of infections among chronic haemodialysis patients [35], and 2008 KDIGO
clinical practice guidelines for the prevention, diagnosis, evaluation and treatment of hepatitis c in chronic kidney disease [72]. HBsAg: Hepatitis B
surface Antigen; HCV: Hepatitis C Virus; NAT: Nucleic Acid Amplification.

Table 8. Key areas for patient education.

Patients with Catheters Patients with Permanent AV Access
1 Hand hygiene 1 Hand hygiene
2 General access care at home (e.g., bathing with a catheter) 2 Washing the access site prior to treatment
General access care at home
3 Signs and symptoms of infection 3
(e.g., don’t scratch or pick at the site)
How to respond if problems with
4 4 Signs and symptoms of infection
catheter develop outside of the dialysis center
Risks associated with How to respond if problems with
5 5
catheters/importance of permanent access access develop outside of the dialysis center
Basic infection control practices during Basic infection control practices during
6 6
catheter accessing process (as a means to engage patients) cannulation process (as a means to engage patients)
Content source: Centers for Disease Control and Prevention (CDC), National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Di-
vision of Healthcare Quality Promotion (DHQP) [70].

OALibJ | DOI:10.4236/oalib.1102953 10 August 2016 | Volume 3 | e2953

 A. Karkar

11. Conclusion
Contaminated hands of healthcare workers are among the most common modes of transmission of health-
care-associated infections. Hand hygiene is singled out as the most important infection prevention intervention.
Compliance can be improved by continuous education, supervision and monitoring of hand hygiene behaviors,
providing, in convenient locations, a sufficient number of sinks with soap dispensers, paper towels, hand lotions,
and alcohol-based hand rub placed at each patient station. Equally important is the adherence to other Standard
Precautions including glove and other PPE use, equipment and environmental cleaning, and safe injection prac-
tices, as well as other recommended practices of screening for HBV, HCV, HIV, tuberculosis infections, and
immunizations. Regular feedback of surveillance results and steps taken to control spread of infection to every-
one involved in the healthcare delivery would help to stimulate and encourage active engagement and improve
compliance with infection prevention efforts. Education and training and full awareness of infection control
policies and procedures should be provided to all HCWs and to be repeated regularly. The patient and/or care-
giver should also be educated on hand hygiene and the care of new vascular access. Finally, implementation of
evidence-based international guidelines is of great value and instrumental in helping reduce healthcare-asso-
ciated infections, where patient’s safety and well-being remain a top priority.

Conflict of Interest
No conflict of interest.

References
[1] Rayner, H.C., Pisoni, R.L., Bommer, J., Canaud, B., Hecking, E., Locatelli, F., Piera, L., Bragg-Gresham, J.L., Feld-
man, H.I., Goodkin, D.A., Gillespie, B., Wolfe, R.A., Held, P.J. and Port, F.K. (2004) Mortality and Hospitalization in
Haemodialysis Patients in Five European Countries: Results from the Dialysis Outcomes and Practice Patterns Study
(DOPPS). Nephrology Dialysis Transplantation, 19, 108-120. http://dx.doi.org/10.1093/ndt/gfg483
[2] Dalrymple, L.S., Johansen, K.L., Chertow, G.M., Cheng, S.C., Grimes, B., Gold, E.B. and Kaysen, G.A. (2010) Infec-
tion-Related Hospitalizations in Older Patients with ESRD. American Journal of Kidney Diseases, 56, 522-530.
http://dx.doi.org/10.1053/j.ajkd.2010.04.016
[3] Lafrance, J., Rahme, E., Iqbal, S., Leblanc, M., Pichette, V., Elftouh, N. and Vallee, M. (2013) Magnitude of Discor-
dance between Registry Data and Death Certificate When Evaluating Leading Causes of Death in Dialysis Patients.
BMC Medical Research Methodology, 13, 51. http://dx.doi.org/10.1186/1471-2288-13-51
[4] Fridkin, S.K., Pear, S.M., Williamson, T.H., Galgiani, J.N. and Jarvis, W.R. (1996) The Role of Understaffing in Cen-
tral Venous Catheter-Associated Bloodstream Infections. Infection Control and Hospital Epidemiology, 17, 150-158.
http://dx.doi.org/10.2307/30142373
[5] Vicca, A.F. (1999) Nursing Staff Workload as a Determinant of Methicillin-Resistant Staphylococcus aureus Spread in
an Adult Intensive Therapy Unit. Journal of Hospital Infection, 43, 109-113. http://dx.doi.org/10.1053/jhin.1999.0246
[6] Harbarth, S., Sudre, P., Dharan, S., Cadenas, M. and Pittet, D. (1999) Outbreak of Enterobacter cloacae Related to
Understaffing, Overcrowding, and Poor Hygiene Practices. Infection Control and Hospital Epidemiology, 20, 598-603.
http://dx.doi.org/10.1086/501677
[7] Arenas, M.D., Sanchez-Paya, J., Barril, G., Garcia-Valdecasas, J., Gorriz, J.L., Soriano, A., et al. (2005) A Multicen-
tric Survey of the Practice of Hand Hygiene in Haemodialsis Units: Factors Affecting Compliance. Nephrology Dialy-
sis Transplantation, 20, 1164-1171. http://dx.doi.org/10.1093/ndt/gfh759
[8] Cimiotti, J.P., Aiken, L.H., Sloane, D.M. and Wu, E.S. (2012) Nurse Staffing, Burnout, and Healthcare-Associated In-
fection. American Journal of Infection Control, 40, 486-490. http://dx.doi.org/10.1016/j.ajic.2012.02.029
[9] Efstathiou, G., Papastavrou, E., Raftopoulos, V. and Merkouris, A. (2011) Factors Influencing Nurses’ Compliance
with Standard Precautions in Order to Avoid Occupational Exposure to Microorganisms: A Focus Group Study. BMC
Nursing, 10, 1. http://dx.doi.org/10.1186/1472-6955-10-1
[10] Sax, H., Perneger, T., Hugonnet, S., Herrault, P., Chraiti, M.N. and Pittet, D. (2005) Knowledge of Standard and Isola-
tion Precautions in a Large Teaching Hospital. Infection Control and Hospital Epidemiology, 26, 298-304.
http://dx.doi.org/10.1086/502543
[11] Oliveira, A.C., Cardoso, C.S. and Mascarenhas, D. (2010) Contact Precautions in Intensive Care Units: Facilitating and
Inhibiting Factors for Professionals’ Adherence. Revista da Escola de Enfermagem da USP, 44, 161-165.
http://dx.doi.org/10.1590/S0080-62342010000100023
[12] Madan, A., Raafat, A., Hunt, J., Rentz, D., Wahle, M. and Flint, L. (2002) Barrier Precautions in Trauma: Is Know-

OALibJ | DOI:10.4236/oalib.1102953 11 August 2016 | Volume 3 | e2953

 A. Karkar

ledge Enough? The Journal of Trauma Injury, Infection and Critical Care, 52, 540-543.
http://dx.doi.org/10.1097/00005373-200203000-00020
[13] Kelen, G.D., DiGiovanna, T.A., Celentano, D.D., Kalainov, D., Bisson, L., Junkins, E., Stein, A., Lofy, L., Scott, C.R.
and Silvertson, K.J. (1990) Adherence to Universal (Barrier) Precautions during Interventions on Critically Ill and In-
jured Emergency Department Patients. Journal of Acquired Immune Deficiency Syndromes, 3, 987-994.
[14] Pittet, D., Dharan, S., Touveneau, S., Sauvan, V. and Perneger, T.V. (1999) Bacterial Contamination of the Hands of
Hospital Staff during Routine Patient Care. Archives of Internal Medicine, 159, 821-826.
http://dx.doi.org/10.1001/archinte.159.8.821
[15] CDC (2011) Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.
http://www.cdc.gov/HAI/pdfs/guidelines/standards-of-ambulatory-care-7-2011
[16] CDC (2001) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients.
Morbidity and Mortality Weekly Report, 50, 1-43.
[17] O’Grady, N.P., et al. and the Healthcare Infection Control Practices Advisory Committee (HICPAC) (2011) Guidelines
for the Prevention of Intravascular Catheter-Related Infections, 2011. Centers for Disease Control and Prevention
(CDC), Atlanta, 83 p.
[18] CDC (2013) CDC Approach to BSI Prevention in Dialysis Facilities I.E., the Core Interventions for Dialysis Blood-
stream Infection (BSI) Prevention. https://www.cdc.gov/dialysis/PDFs/Dialysis-Core-Interventions-5_10_13.pdf
[19] Karkar, A., Mandin Bouhaha, B. and Dammang, M.L. (2014) Infection Control in Hemodialysis Units: A Quick
Access to Essential Elements. Saudi Journal of Kidney Diseases and Transplantation, 25, 496-519.
http://dx.doi.org/10.4103/1319-2442.132150
[20] Pittet, D., Allegranzi, B., Sax, H., Dharan, S., Lúcia Pessoa-Silva, C., Donaldson, L. and Boyce, J.M. (2006) Evi-
dence-Based Model for Hand Transmission during Patient Care and Role of Improved Practices. On Behalf of the
WHO Global Patient Safety Challenge and World Alliance for Patient Safety. The Lancet Infectious Diseases, 6, 641-
652. http://dx.doi.org/10.1016/S1473-3099(06)70600-4
[21] Bauer, T.M., Ofner, E., Just, H.M., Just, H. and Daschner, F. (1990) An Epidemiological Study Assessing the Relative
Importance of Airborne and Direct Contact Transmission of Microorganisms in a Medical Intensive Care Unit. Journal
of Hospital Infection, 15, 301-309. http://dx.doi.org/10.1016/0195-6701(90)90087-5
[22] Pittet, D. (2001) Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach. Emerging Infectious
Diseases, 7, 234-240. http://dx.doi.org/10.3201/eid0702.010217
[23] Bhalla, A., Pultz, N.J., Gries, D.M., et al. (2004) Acquisition of Nosocomial Pathogens on Hands after Contact with
Environmental Surfaces near Hospitalized Patients. Infection Control and Hospital Epidemiology, 25, 164-167.
http://dx.doi.org/10.1086/502369
[24] Larson, E.A. (1988) Causal Link between Hand Washing and Risk of Infection? Examination of the Evidence. Infec-
tion Control and Hospital Epidemiology, 9, 28-29. http://dx.doi.org/10.2307/30144131
[25] Farrington, M., Ling, J., Ling, T. and French, G.L. (1990) Outbreaks of Infection with Methicillin-Resistant Staphylo-
coccus aureus on Neonatal and Burn Units of a New Hospital. Epidemiology and Infection, 105, 215-228.
http://dx.doi.org/10.1017/S0950268800047828
[26] Gould, D. (1991) Nurses’ Hands as Vectors of Hospital-Acquired Infection: A Review. Journal of Advanced Nursing,
16, 1216-1225. http://dx.doi.org/10.1111/j.1365-2648.1991.tb01531.x
[27] Duckro, A.N., Blom, D.W., Lyle, E.A., Weinstein, R.A. and Hayden, M.K. (2005) Transfer of Vancomycin-Resistant
Enterococci via Healthcare Worker Hands. Archives of Internal Medicine, 165, 302-307.
http://dx.doi.org/10.1001/archinte.165.3.302
[28] Shimokura, G., Weber, D.J., Miller, W.C., Wurtzel, H. and Alter, M.J. (2006) Factors Associated with Personal Pro-
tection Equipment Use and Hand Hygiene among Hemodialysis Staff. American Journal of Infection Control, 34, 100-
107. http://dx.doi.org/10.1016/j.ajic.2005.08.012
[29] Kampf, G. and Kramer, A. (2004) Epidemiologic Background of Hand Hygiene and Evaluation of the Most Important
Agents for Scrubs and Rubs. Clinical Microbiology Reviews, 17, 863-893.
http://dx.doi.org/10.1128/CMR.17.4.863-893.2004
[30] Boyce, J.M. and Pittet, D. (2002) Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the
Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task
Force. Morbidity and Mortality Weekly Report, 51, 1-44.
[31] Arenas, D., Sanchez-Paya, J., Barril, G., García-Valdecasas, J., Gorriz, J.L., Soriano, A., Antolin, A., Lacueva, J.,
Garcıa, S., Sirvent, A., Espinosa, A. and Angoso, M. (2005) A Multicentric Survey of the Practice of Hand Hygiene in
Haemodialysis Units: Factors Affecting Compliance. Nephrology Dialysis Transplantation, 20, 1164-1171.
http://dx.doi.org/10.1093/ndt/gfh759

OALibJ | DOI:10.4236/oalib.1102953 12 August 2016 | Volume 3 | e2953

 A. Karkar

[32] APIC (2010) Guide to the Elimination of Infections in Hemodialysis.

http://www.infectioncontroltoday.com/news/2010/06/apic-introduces-guide-to-elimination-of-infection.aspx
[33] WHO (2016) Save Lives: Clean Your Hands. Hand Hygiene in Outpatient and Home-Based Care and Long-Term Care
Facilities. A Guide to the Application of the WHO Multimodal Hand Hygiene Improvement and the “My Five Mo-
ments of Hand Hygiene” Approach. WHO Library Catologuing-in-Publication Data.
http://www.who.int/gpsc/5may/EN_PSP_GPSC1_5May_2016/en/
[34] Allegranzi, B., Gayet-Ageron, A., Damani, N., Bengaly, L., McLaws, M.L., Moro, M.L., Memish, Z., Urroz, O., Ri-
chet, H., Storr, J., Donaldson, L. and Pittet, D. (2013) Global Implementation of WHO’s Multimodal Strategy for Im-
provement of Hand Hygiene: A Quasi-Experimental Study. The Lancet Infectious Diseases, 13, 843-851.
http://dx.doi.org/10.1016/S1473-3099(13)70163-4
[35] Hedderwick, S.A., McNeil, S.A., Lyons, M.J. and Kauffman, C.A. (2000) Pathogenic Organisms Associated with Ar-
tificial Fingernails Worn by Healthcare Workers. Infection Control and Hospital Epidemiology, 21, 505-509.
http://dx.doi.org/10.1086/501794
[36] Siegel, J.D., Rhinehart, E., Jackson, M., Chiarello, L. and the Healthcare Infection Control Practices Advisory Com-
mittee (2007) Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Set-
tings. http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
[37] Infection Control Today (ICT) (2013) Challenges and Solutions for Measuring Hand Hygiene Compliance. On-De-
mand Webinar.
[38] Lin, C.M., Wu, F.M., Kim, H.K., Doyle, M.P., Michael, B.S. and Williams, L.K. (2003) A Comparison of Hand
Washing Techniques to Remove Escherichia Coli and Caliciviruses under Natural or Artificial Fingernails. Journal of
Food Protection, 66, 2296-2301.
[39] Edel, E., Houston, S., Kennedy, V. and LaRocco, M. (1998) Impact of a 5-Minute Scrub on the Microbial Flora Found
on Artificial, Polished, or Natural Fingernails of Operating Room Personnel. Nursing Research, 47, 54-59.
http://dx.doi.org/10.1097/00006199-199801000-00010
[40] Pottinger, J., Burns, S. and Manske, C. (1989) Bacterial Carriage by Artificial versus Natural Nails. American Journal
of Infection Control, 17, 340-344. http://dx.doi.org/10.1016/0196-6553(89)90003-5
[41] Vanholder, R., Canaud, B., Fluck, R., Jadoul, M., Labriola, L., Mart-Monros, A., Tordoir, J. and Van Biesen, W. (2010)
Diagnosis, Prevention and Treatment of Haemodialysis Catheter-Related Bloodstream Infections (CRBSI): A Position
Statement of European Renal Best Practice (ERBP). NDT Plus, 3, 234-246. http://dx.doi.org/10.1093/ndtplus/sfq041
[42] Tordoir, J., Canaud, B., Haage, P., Konner, K., Basci, A., Fouque, D., Kooman, J., Martin-Malo, A., Pedrini, L., Piz-
zarelli, F., Tattersall, J., Vennegoor, M., Wanner, C., Wee, P. and Vanholder, R. (2007) EBPG on Vascular Access.
Nephrology Dialysis Transplantation, 22, ii88-ii117. http://dx.doi.org/10.1093/ndt/gfm021
[43] ERA/EDTA Guidelines (2002) European Best Practice Guidelines for Haemodialysis (Part 1). Section VI: Haemodi-
alysis-Associated Infection. Nephrology Dialysis Transplantation, 17, 73-87.
[44] National Kidney Foundation (2006) KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations:
2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. American Journal of
Kidney Diseases, 48, S1-S322.
[45] National Kidney Foundation (2001) KDOQI Clinical Practice Guidelines for Vascular Access: Updates 2000. Ameri-
can Journal of Kidney Diseases, 37, S137-S181. http://dx.doi.org/10.1016/S0272-6386(01)70007-8
[46] Wiener-Well, Y., Galuty, M., Rudensky, B., Schlesinger, Y., Attias, D. and Yinnon, A.M. (2011) Nursing and Physi-
cian Attire as Possible Source Of Nosocomial Infections. American Journal of Infection Control, 39, 555-559.
http://dx.doi.org/10.1016/j.ajic.2010.12.016
[47] Perry, C., Marshall, R. and Jones, E. (2001) Bacterial Contamination of Uniforms. Journal of Hospital Infection, 48,
238-241. http://dx.doi.org/10.1053/jhin.2001.0962
[48] Babb, J.R., Davies, J.G. and Ayliffe, G.A. (1983) Contamination of Protective Clothing and Nurses’ Uniforms in an
Isolation Ward. Journal of Hospital Infection, 4, 149-157. http://dx.doi.org/10.1016/0195-6701(83)90044-0
[49] Fijan, S. and Turk, S.S. (2012) Hospital Textiles, Are They a Possible Vehicle for Hospital-Associated Infection? In-
ternational Journal of Environmental Research and Public Health, 9, 3330-3343.
http://dx.doi.org/10.3390/ijerph9093330
[50] Wilson, J.A., Loveday, H.P., Hoffman, P.N. and Pratt, R.J. (2007) Uniform: An Evidence Review of the Microbiolog-
ical Significance of Uniforms and Uniform Policy in the Prevention and Control of Healthcare-Associated Infections.
Report to the Department of Health (England). Journal of Hospital Infection, 66, 301-307.
http://dx.doi.org/10.1016/j.jhin.2007.03.026
[51] Jackson, R. and Cole, M. (2010) Healthcare Workers’ Uniforms: Roles, Types and Determining Policy. British Journal
of Nursing, 19, 438-441. http://dx.doi.org/10.12968/bjon.2010.19.7.47445

OALibJ | DOI:10.4236/oalib.1102953 13 August 2016 | Volume 3 | e2953

 A. Karkar

[52] Kramer, A., Schwebke, I. and Kampf, G. (2006) How Long Do Nosocomial Pathogens Persist on Inanimate Surfaces?
A Systematic Review. BMC Infectious Diseases, 6, 130. http://www.biomedcentral.com/1471-2334/6/130
http://dx.doi.org/10.1186/1471-2334-6-130
[53] Dietze, B., Rath, A., Wendt, C. and Martiny, H. (2001) Survival of MRSA on Sterile Goods Packaging. Journal of
Hospital Infection, 49, 255-261. http://dx.doi.org/10.1053/jhin.2001.1094
[54] Bond, W.W., Favero, M.S., Peterson, N.J., Gravell, C.R., Ebert, J.W. and Maynhard, J.E. (1981) Survival of Hepatitis
B Virus after Drying and Storage for One Week. The Lancet, 1, 550-551.
http://dx.doi.org/10.1016/S0140-6736(81)92877-4
[55] CDC (2016) Hepatitis C FAQs for the Public. www.cdc.gov/hepatitis/C/cFAQ.htm
[56] Ciesek, S., Friesland, M., Steinmann, J., Becker, B., Wedemeyer, H., Manns, M.P., Steinmann, J., Pietschmann, T. and
Steinmann, E. (2010) How Stable Is the Hepatitis C Virus (HCV)? Environmental Stability of HCV and Its Suscepti-
bility to Chemical Biocides. Journal of Infectious Diseases, 201, 1859-1866. http://dx.doi.org/10.1086/652803
[57] Barré-Sinoussi, F., Nugeyre, M.T. and Chermann, J.C. (1985) Resistance of AIDS Virus at Room Temperature. The
Lancet, 11, 721-722. http://dx.doi.org/10.1016/S0140-6736(85)92955-1
[58] Tjotta, E., Hungnes, O. and Grinde, B. (1991) Survival of HIV-I: Activity after Disinfection, Temperature and pH
Changes, or Drying. Journal of Medical Virology, 35, 223-227. http://dx.doi.org/10.1002/jmv.1890350402
[59] Cataňo, J.C., Echeverri, L.M. and Szela, C. (2012) Bacterial Contamination of Clothes and Environmental Items in a
Third-Level Hospital in Colombia. Interdisciplinary Perspectives on Infectious Diseases, 2012, Article ID: 507640.
[60] Dancer, S.J. (2009) The Role of Environmental Cleaning in the Control of Hospital-Acquired Infection. Journal of
Hospital Infection, 73, 378-385. http://dx.doi.org/10.1016/j.jhin.2009.03.030
[61] CDC (2008) Infection Control Requirements for Dialysis Facilities and Clarification Regarding Guidance on Parenteral
Medication Vials. Morbidity and Mortality Weekly Report, 57, 875-876.
[62] Hoen, B., Paul-Dauphin, A., Hestin, D. and Kessler, M. (1998) EPIBACDIAL: A Multicenter Prospective Study of
Risk Factors for Bacteremia in Chronic Haemodialysis Patients. Journal of the American Society of Nephrology, 9,
869-876.
[63] CDC/National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion.
Haemodialysis Central Venous Catheter Scrub-the-Hub-Protocol.
www.cdc.gov/dialysis/PDFs/collaborative/hemodialysis-central-venous-catheter-sth-protocol.pdf
[64] Salzman, M.B., Isenberg, H.D. and Rubin, J.G. (1993) Use of Disinfectants to Reduce Microbial Contamination of
Hubs of Vascular Catheters. Journal of Clinical Microbiology, 31, 475-479.
[65] Hess, S. and Bren, V. (2013) Essential Components of an Infection Prevention Program for Outpatient Hemodialysis
Centers. Seminars in Dialysis, 26, 384-398. http://dx.doi.org/10.1111/sdi.12102
[66] Garrick, R. and Morey, R. (2015) Dialysis Facility Safety: Processes and Opportunities. Seminars in Dialysis, 28, 514-
524. http://dx.doi.org/10.1111/sdi.12395
[67] Kapoian, T., Meyer, K.B. and Johnson, D.S. (2015) Infection Prevention and the Medical Director: Uncharted Territo-
ry. Clinical Journal of the American Society of Nephrology, 10, 863-874.
http://dx.doi.org/10.2215/CJN.06050614
[68] CDC (2012) NHSN Dialysis Event Protocol. http://www.cdc.gov/nhsn/PDFs/pscManual/8pscDialysisEventcurrent.pdf
[69] De Ambrogi, M. (2016) The Simple Story of Clean Hands. The Lancet Infectious Diseases, 16, 903.
http://dx.doi.org/10.1016/S1473-3099(16)30203-1
[70] CDC/National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion. Key
Areas for Patient Education—Collaborative—Dialysis.
www.cdc.gov/dialysis/prevention-tools/Key-areas-patient-education.html
[71] Miller, H.M., Tong, A., Tunnicliffe, D.J., Campbell, D., Pinter, J., Commons, R.J., Athane, E., Craig, J.C., Gilroy, N.,
Green, J., Henderson, B., Howell, M., Stuart, R.L., Van Eps, C., Wong, M.G., De Zoysa, J. and Jardine, M.J. (2016)
Identifying and Integrating Patient and Caregiver Perspectives for Clinical Practice Guidelines on the Screening and
Management of Infectious Microorganisms in Hemodialysis Units. Hemodialysis International, Online.
[72] Kidney International (2008) Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for
the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis C in Chronic Kidney Disease. Kidney International,
73, S1-S99.

OALibJ | DOI:10.4236/oalib.1102953 14 August 2016 | Volume 3 | e2953

 A. Karkar

Abbreviation Note List

ABHR Alcohol-Based Hand Rub
ARB Access-Related Bloodstream Infection
AVF Arteriovenous Fistula
AVG Arteriovenous Graft
APIC Association for Professionals in Infection Control and Epidemiology
BSI Bloodstream Infection
CDC Centers for Disease Control and Prevention
C. difficile Clostridium Difficile
DHQP Division of Healthcare Quality Promotion
EBPG/ERBP European Best Practice Guidelines/European Renal Best Practice
HAIs Healthcare-Associated Infections
HICPAC Healthcare Infection Control Practices Advisory Committee
HCW Healthcare Workers
HD Hemodialysis
HBsAg Hepatitis B Surface Antigen
HBV Hepatitis B Virus
HCV Hepatitis C Virus
HIV Human Immunodeficiency Virus
KDOQI Kidney Disease Outcomes Quality Initiative
LASI Local Access Site Infection
MRSA Methicillin-Resistant Staphylococcus Aureus
NAT Nucleic Acid Amplification
NCEZID National Center for Emerging and Zoonotic Infectious Diseases
NHSN National Healthcare Safety Network
PPE Personal Protective Equipment
VA Vascular Access
VAI Vascular Access Infection
VRE Vancomycin-Resistant Enterococci
WHO World Health Organization

Submit or recommend next manuscript to OALib Journal and we will provide best service for you:
 Publication frequency: Monthly
 9 subject areas of science, technology and medicine
 Fair and rigorous peer-review system
 Fast publication process
 Article promotion in various social networking sites (LinkedIn, Facebook, Twitter, etc.)
 Maximum dissemination of your research work
Submit Your Paper Online: Click Here to Submit
Contact Us: service@oalib.com

OALibJ | DOI:10.4236/oalib.1102953 15 August 2016 | Volume 3 | e2953

View publication stats