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From the Centers for Disease Control and Prevention
November 5, 2008

Infection Control Requirements for Dialysis Facilities and Clarification Regarding Guidance on Parenteral Medication Vials

JAMA. 2008;300(17):1993. doi:10.1001/jama.300.17.1993

MMWR. 2008;57:875-876

In April 2008, the Centers for Medicare and Medicaid Services (CMS) published in the Federal Register its final rule on Conditions for Coverage for End-Stage Renal Disease (ESRD) Facilities.1 The rule establishes new conditions dialysis facilities must meet to be certified under the Medicare program and is intended to update CMS standards for delivery of quality care to dialysis patients. CDC's 2001 Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients2 have been incorporated by reference into the new CMS conditions for coverage. Thus, effective October 14, 2008, all ESRD facilities are expected to follow the CDC recommendations as a condition for receiving Medicare payment for outpatient dialysis services.

In recent years, outbreak investigations in dialysis and other health-care settings have demonstrated that mishandling of parenteral medication vials can contribute to the risk for hepatitis C virus (HCV) infection and bacterial and other infections.37 In 2002, a CDC communication to CMS suggested that reentry into single-use parenteral medication vials (i.e., to administer medication to more than one patient), when performed on a limited basis and under strict conditions in hemodialysis settings, likely would result in low risk for bacterial infection.8 However, the 2002 communication did not address risks for bloodborne viral infections (e.g., HCV and hepatitis B virus infection). This report is intended to clarify and restate CDC's recommendation on parenteral medication to include bloodborne viral infections. The recommendations in this report supersede the 2002 CDC communication to CMS.

To prevent transmission of both bacteria and bloodborne viruses in hemodialysis settings, CDC recommends that all single-use injectable medications and solutions be dedicated for use on a single patient and be entered one time only. Medications packaged as multidose should be assigned to a single patient whenever possible. All parenteral medications should be prepared in a clean area separate from potentially contaminated items and surfaces. In hemodialysis settings where environmental surfaces and medical supplies are subjected to frequent blood contamination, medication preparation should occur in a clean area removed from the patient treatment area. Proper infection control practices must be followed during the preparation and administration of injected medications.9 This is consistent with official CDC recommendations for infection control precautions in hemodialysis2 and other health-care settings.9

Health departments and other public health partners should be aware of the new CMS conditions for ESRD facilities. All dialysis providers are advised to follow official CDC recommendations regarding Standard Precautions and infection control in dialysis settings.2,9 Specifically, CDC has recommended the following: “Intravenous medication vials labeled for single use, including erythropoietin, should not be punctured more than once. Once a needle has entered a vial labeled for single use, the sterility of the product can no longer be guaranteed.”2 Additional guidance on safe injection practices can be found in the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007.9

Dialysis providers also should be aware of their responsibility to report clusters of infections or other adverse events to the appropriate local or state public health authority. Failure to report illness clusters to public health authorities can result in delays in recognition of disease outbreaks10 and implementation of control measures. Additional information regarding the new CMS Conditions for Coverage for End-Stage Renal Disease Facilities is available at http://www.cms.hhs.gov/cfcsandcops/13_esrd.asp.

References
1.
US Department of Health and Human Services. Centers for Medicare and Medicaid Services.  Medicare and Medicaid programs; conditions for coverage for end-stage renal disease facilities. 42 CFR Parts 405, 410, 413, 414, 488, and 494. Available at http://www.cms.hhs.gov/cfcsandcops/downloads/esrdfinalrule0415.pdf
2.
CDC.  Recommendations for preventing transmission of infections among chronic hemodialysis patients.  MMWR. 2001;50:(No. RR-5)  1-43
3.
Thompson N, Bialek S. Hepatitis C virus transmission in the hemodialysis setting: importance of infection control practices and aseptic technique [Abstract]. In: programs and abstracts of the National Kidney Foundation Spring Meeting; April 3, 2008; Grapevine, TX
4.
CDC.  Acute hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic—Nevada, 2007.  MMWR Morb Mortal Wkly Rep. 2008;57(19):513-517PubMed
5.
Williams IT, Perz JF, Bell BP. Viral hepatitis transmission in ambulatory health care settings.  Clin Infect Dis. 2004;38(11):1592-1598PubMedArticle
6.
Alter MJ. Healthcare should not be a vehicle for transmission of hepatitis C virus.  J Hepatol. 2008;48(1):2-4PubMedArticle
7.
Grohskopf LA, Roth VR, Feikin DR,  et al.  Serratia liquefaciens bloodstream infections from contamination of epoetin alfa at a hemodialysis center.  N Engl J Med. 2001;344(20):1491-1497PubMedArticle
8.
Department of Health and Human Services. Centers for Medicare and Medicaid Services.  CDC revised recommendations for single-use intravenous medication vials in end-stage renal disease (ESRD) facilities, 2002. Available at http://www.cms.hhs.gov/surveycertificationgeninfo/downloads/scletter02-43.pdf
9.
Siegel JD, Rhinehart E, Jackson M, Chiarello L.Healthcare Infection Control Practices Advisory Committee.  Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at http://www.cdc.gov/ncidod/dhqp/gl_isolation.html
10.
CDC.  Acute allergic-type reactions among patients undergoing hemodialysis—multiple states, 2007-2008.  MMWR Morb Mortal Wkly Rep. 2008;57(5):124-125PubMed
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