Infection Control in Dialysis
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Direct answer
Dialysis units have been the setting for some of the largest hospital-acquired hepatitis B and C outbreaks on record, because one contaminated machine, one shared vial or one pair of unchanged gloves can carry virus between patients within a single shift — so infection control here is engineering plus behaviour: isolation of hepatitis B surface antigen (HBsAg)-positive patients with dedicated machines and preferably dedicated staff, screening and vaccination of every patient, hand hygiene and fresh gloves between every patient contact, and systematic cleaning, disinfection and microbiological surveillance of water, machines and environment. India's Pradhan Mantri National Dialysis Programme (launched 2016 under the National Health Mission) made these practices the benchmark for district-level dialysis services.
What you must remember
- Screen every patient at first dialysis for HBsAg, anti-HCV and HIV, with results in the unit register; Indian guidelines commonly recommend repeat HBsAg monthly and anti-HCV every six months, or as per unit policy.
- Vaccinate every HBsAg-negative patient with the higher-strength 40 microgram dose intramuscularly (deltoid) at 0, 1, 2 and 6 months — dialysis patients need double-dose schedules; check anti-HBs titre one to two months after the last dose (target above 10 mIU/mL), then annually, with a booster when it falls.
- HBsAg-positive patients dialyse in a separate area with dedicated machines and instruments, and preferably dedicated staff; anti-HCV-positive patients are also assigned dedicated machines and separate scheduling.
- Staff must not simultaneously care for HBsAg-positive and negative patients in one shift; cohort to one group.
- Hand hygiene before and after every patient or machine contact, and a fresh pair of gloves for every patient — gloves replace nothing: hands are washed between patients even when gloves were worn.
- Between patients at a station: clean and disinfect the chair, table, machine surfaces, blood pressure cuff and shared items; discard single-use items; never share multi-dose vials.
- Microbiological surveillance: water cultures and endotoxin testing at least monthly (bacteria below 200 CFU/mL, action level 50; endotoxin below 2 EU/mL, action level 1), with machine disinfection cycles performed and logged.
- Bio-medical waste is segregated in colour-coded bags under the Bio-Medical Waste Management Rules 2016 — blood-soaked dressings to the yellow bag, sharps to the puncture-proof container.
One shift, done correctly
Follow a morning shift, because the measures only make sense in sequence. Before the first patient, the technologist confirms the machine completed its overnight disinfection cycle from the log; the daily chlorine test is done at the plant; the first station is laid out with its own consumables — no shared trolleys travelling bed to bed.
At every cannulation the sequence is identical: hand hygiene, gloves and mask, skin preparation, connection, then gloves off with hand hygiene before touching the next chart, machine or patient. Between patients the station is wiped down, including the machine keyboard, chair arms and cuff; a blood spill brings out the chlorine-releasing agent and the spill protocol, not a tissue. HBsAg-positive patients dialyse in their own room on their own machines with their own stethoscope and cuff, tended by staff who will not cross to the negative cohort that shift. After the last patient, machines run their disinfection cycles, waste is segregated into the correct colour-coded containers, and the month's culture samples are drawn and sent.
Where students slip
The classic error is treating gloves as a substitute for hand hygiene: the same gloved hands that cannulated patient one will transmit hepatitis B to patient two, and gloves alone protect the wearer, not the ward. The second slip is the vaccination record — knowing the double-dose 40 microgram schedule (0, 1, 2, 6 months) with annual anti-HBs titres separates a prepared candidate from one reciting the normal adult schedule. Third, candidates forget that screening continues even after vaccination: a falling titre needs a booster, and monthly HBsAg testing is how a unit catches an outbreak in week one rather than month six.
Frequently asked questions
What hepatitis B vaccination schedule is used in dialysis patients?
The higher 40 microgram dose intramuscularly in the deltoid at 0, 1, 2 and 6 months, because standard schedules give poor responses in uraemia. Anti-HBs is checked after the last dose and annually, with a booster when the titre falls below 10 mIU/mL.
Which infections require dedicated machines or isolation?
HBsAg-positive patients need a separate area, dedicated machines and instruments and preferably dedicated staff; anti-HCV-positive patients are given dedicated machines with separate scheduling, per Indian guidelines.
How often is dialysis water tested microbiologically?
At least monthly and after any repair or modification of the water loop — bacteria below 200 CFU/mL (action level 50) and endotoxin below 2 EU/mL (action level 1), with stricter ultrapure targets for high-flux dialysis.
Which colour bag is used for blood-soaked dressings and dialysis tubing?
The yellow bag, under the Bio-Medical Waste Management Rules 2016; sharps such as needles go into the puncture-proof sharps container at the point of use.