Document Detail


An outbreak of gram-negative bacteremia in hemodialysis patients traced to hemodialysis machine waste drain ports.
MedLine Citation:
PMID:  10580625     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
OBJECTIVE: To investigate an outbreak of gram-negative bacteremias at a hemodialysis center (December 1, 1996-January 31, 1997). DESIGN: Retrospective cohort study. Reviewed infection control practices and maintenance and disinfection procedures for the water system and dialysis machines. Performed cultures of the water and dialysis machines, including the waste-handling option (WHO), a drain port designed to dispose of saline used to flush the dialyzer before patient use. Compared isolates by pulsed-field gel electrophoresis. SETTING: A hemodialysis center in Maryland. RESULTS: 94 patients received dialysis on 27 machines; 10 (11%) of the patients had gram-negative bacteremias. Pathogens causing these infections were Enterobacter cloacae (n = 6), Pseudomonas aeruginosa (n = 4), and Escherichia coli (n = 2); two patients had polymicrobial bacteremia. Factors associated with development of gram-negative bacteremias were receiving dialysis via a central venous catheter (CVC) rather than via an arterio-venous shunt (all 10 infected patients had CVCs compared to 31 of 84 uninfected patients, relative risk [RR] undefined; P<.001) or dialysis on any of three particular dialysis machines (7 of 10 infected patients were exposed to the three machines compared to 20 of 84 uninfected patients, RR = 5.8; P = .005). E cloacae, P aeruginosa, or both organisms were grown from cultures obtained from several dialysis machines. WHO valves, which prevent backflow from the drain to dialysis bloodlines, were faulty in 8 (31%) of 26 machines, including 2 of 3 machines epidemiologically linked to case-patients. Pulsed-field gel electrophoresis patterns of available dialysis machine and patient E cloacae isolates were identical. CONCLUSIONS: Our study suggests that WHO ports with incompetent valves and resultant backflow were a source of cross-contamination of dialysis bloodlines and patients' CVCs. Replacement of faulty WHO valves and enhanced disinfection of dialysis machines terminated the outbreak.
Authors:
S A Wang; R B Levine; L A Carson; M J Arduino; T Killar; F G Grillo; M L Pearson; W R Jarvis
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America     Volume:  20     ISSN:  0899-823X     ISO Abbreviation:  Infect Control Hosp Epidemiol     Publication Date:  1999 Nov 
Date Detail:
Created Date:  1999-12-14     Completed Date:  1999-12-14     Revised Date:  2004-11-17    
Medline Journal Info:
Nlm Unique ID:  8804099     Medline TA:  Infect Control Hosp Epidemiol     Country:  UNITED STATES    
Other Details:
Languages:  eng     Pagination:  746-51     Citation Subset:  IM; N    
Affiliation:
Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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MeSH Terms
Descriptor/Qualifier:
Ambulatory Care Facilities
Cohort Studies
Cross Infection / epidemiology,  etiology*
Disease Outbreaks*
Equipment Failure
Gram-Negative Bacterial Infections / epidemiology,  etiology*
Humans
Maryland / epidemiology
Renal Dialysis / adverse effects*,  instrumentation
Retrospective Studies
Risk Factors

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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