Outbreak of Pyrogenic Reactions and Gram-Negative Bacteremia in a Hemodialysis Center

Abstract

Six episodes of gram-negative bacteremia and seven pyrogenic reactions occurred in 11 patients in one hemodialysis center. Gram-negative bacter-emias and/or pyrogenic reactions were not related to reuse and were more likely to occur if dialysis was performed in one unit of the center (8/13 unit 5 vs. 221/1,151 in other units, p < 0.001) and with one type of dialysis machine (10/13 vs. 581/1,151 with other machines, p = 0.05), which was preferentially used in unit 5 (p < O.Ol). Bacterial and endotoxin concentrations of water used to prepare dialysate and reprocess hemodialyzers, and of dialysate, exceeded allowable concentrations recommended by the Association for the Advancement of Medical Instrumentation (AAMI). The implicated dialysis machines were disinfected with chemicals daily, but not heat-disinfected daily as suggested by the manufacturer. Results suggest that the outbreak was caused by the use of water that did not meet AAMI standards and inadequate disinfection of one type of dialysis machine.

A Cluster of Bloodstream Infections and Pyrogenic Reactions among Hemodialysis Patients Traced to Dialysis Machine Waste-Handling Option Units

“…Most BSI outbreaks in hemodialysis units have resulted from inadequate disinfection of water treatment and distribution systems, reprocessed dialyzers, or other dialysis equipment [3][4][5][6][7][8][9][10]. During this outbreak, 12 patients were identified with E. cloacae BSI or PR.…”

“…The procedure remains potentially hazardous to patients, and numerous clusters of gram-negative bacteremia and pyrogenic reactions (PR) have been reported. Most such clusters have been traced to bacterial contamination of water and/or dialysate [3,4], errors in dialyzer reprocessing [5][6][7], and improper setup procedures [8][9][10]. In this paper, we describe an outbreak of Enterobacter cloacae bloodstream infections and PR at Hôpital Charles-LeMoyne, a 590-bed university-affiliated teaching hospital in the Montreal area, that was first detected in August 1995 when five episodes of bacteremia occurred among the dialysis unit's 60 chronic hemodialysis patients.…”

Prevent infection linked to the dialysis water in a hemodialysis center in Fez city (Morocco)

“…This causes significant long-term morbidity in HD patients and forms part of the larger syndrome of malnutrition, inflammation and atherosclerosis, the so-called MIA syndrome [4, 5]. The inadequate disinfection of the water distribution systems or pipes inside the dialyzers has been incriminated in several outbreaks of Gram-negative bactereamia and pyrogenia in HD units [6, 7]. So, Disinfection protocol must be preventative and frequent to assure a control quality of dialysis unit [8].…”

Microbiologic Purity of Dialysate:Rationale and Te chnical Aspects

“…First, hemodialysis operational conditions have changed over the last decade, increasing the risks related to dialysate contamination [12,13]. The general use of sodium bicarbonate as buffer in the dialysate, favoring bacteria proliferation, has been associated with pyrogenic reactions and water-borne bacteremia [14][15][16][17]. The combined use of highly permeable membrane with a dialysis machine equipped with an ultrafiltration controller system has enhanced the backtransport phenomenon [18] (backfiltration and/or diffusion) from dialysate to blood, enhancing the risks related to contaminant of the dialysis fluid [19,20].…”