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

Jochimsen, Elise M.; Frenette, Charles; Delorme, Monique; Arduino, Matthew J.; Aguero, Sonia M.; Carson, Loretta A.; Ismaïl, Johanne; Lapierre, Stephen; Czyziw, Elizabeth; Tokars, Jerome I.; Jarvis, William R.

doi:10.1159/000013392

Cited by 30 publications

(15 citation statements)

References 9 publications

(12 reference statements)

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“…This finding was supported by increasing reports of Gram-negative rods causing frequent infections in hemodialysis and is the main cause of morbidity among patients undergoing this treatment 19,33 .…”

Section: Discussionsupporting

confidence: 64%

Microbiological contamination of a hemodialysis center water distribution system

Montanari

Sartori

Cardoso

et al. 2009

Rev. Inst. Med. trop. S. Paulo

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SUMMARYThe microbiological monitoring of the water used for hemodialysis is extremely important, especially because of the debilitated immune system of patients suffering from chronic renal insufficiency. To investigate the occurrence and species diversity of bacteria in waters, water samples were collected monthly from a hemodialysis center in upstate São Paulo and tap water samples at the terminal sites of the distribution system was sampled repeatedly (22 times) at each of five points in the distribution system; a further 36 samples were taken from cannulae in 19 hemodialysis machines that were ready for the next patient, four samples from the reuse system and 13 from the water storage system. To identify bacteria, samples were filtered through 0.22 µm-pore membranes; for mycobacteria, 0.45 µm pores were used. Conventional microbiological and molecular methods were used in the analysis. Bacteria were isolated from the distribution system (128 isolates), kidney machine water (43) and reuse system (3). Among these isolates, 32 were Gram-positive rods, 120 Gram-negative rods, 20 Gram-positive cocci and 11 mycobacteria. We propose the continual monitoring of the water supplies in hemodialysis centers and the adoption of effective prophylactic measures that minimize the exposure of these immunodeficient patients to contaminated sources of water.

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Section: Discussionsupporting

confidence: 64%

Microbiological contamination of a hemodialysis center water distribution system

Montanari

Sartori

Cardoso

et al. 2009

Rev. Inst. Med. trop. S. Paulo

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“…Water quality, membrane reuse, and infection control are key areas of safety risk, and adverse events have been reported in each area (7)(8)(9)(10)(11)(12)(13)(14)(15). Infection control risks, such as design flaws (9), inadequate hand hygiene, and faulty machine and equipment disinfection (7,8,15,16), have been associated with outbreaks of unusual biopathogens (8,9,13), as well as transmission of vancomycin-resistant enterococcus and hepatitis B and C viruses. The regulations and safety guidelines for water quality, reuse, and infection control are established and readily available (14,17).…”

Section: Dialysis Safety Prioritiesmentioning

confidence: 99%

“…It is possible (although not definite from the survey questions) that the error was caught before initiation of therapy; however, patients also could have been unaware of the errors (6,19). In addition to clinical safety, failure to follow protocol has also contributed to technical mistakes and lapses in infection control (1,2,(4)(5)(6)(7)(8)(9). Among other risks, protocol departures can result in critical errors in dialysis reuse, dialysate composition, and water purification, with catastrophic effects on an entire facility (7)(8)(9)(10)(11)(12)(13).…”

Section: Failure To Follow Policies and Protocolsmentioning

confidence: 99%

Patient and Facility Safety in Hemodialysis

Garrick

Kliger

Stefanchik

2012

Clinical Journal of the American Society of Nephrology

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SummaryPatient safety is the foundation of high-quality health care. More than 350,000 patients receive dialysis in the United States, and the safety of their care is ultimately the responsibility of the facility medical director. The medical director must establish a culture of safety in the dialysis unit and lead the quality assessment and performance improvement process. Several lines of investigation, including surveys of patients and dialysis professionals, have helped to identify important areas of safety risk in dialysis facilities. Among these are lapses in communication, medication errors, patient falls, errors in machine and membrane preparation, failure to follow established policies, and lapses in infection control. The quality assessment and performance improvement process should include a dedicated safety team to focus on specifically identified areas of risk and to establish outcome goals guided by best practices and agreed-upon measures of success. A safety questionnaire can be given to patients and staff and the responses evaluated to improve understanding of the prevailing attitudes and concerns about safety. By sharing these results, openly acknowledging the challenges, and using a blame-free root cause process to identify action plans, the facility can begin to establish a culture of safety.

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“…While Enterobacter species have been linked to disease outbreaks, the victims of such disease have been in a weakened or immunocompromised state. Outbreaks have been linked to contaminated IV fluid (15), infant formula (17), hemodialysis (13), and vaporizers and whirlpools (2).…”

Section: Preparation Of Culturesmentioning

confidence: 99%

Inoculum Size Influences Bacterial CrossContamination betweenSurfaces

Montville

Schaffner

2003

Appl Environ Microbiol

121

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Many factors have been shown to influence bacterial transfer between surfaces, including surface type, bacterial species, moisture level, pressure, and friction, but the effect of inoculum size on bacterial transfer has not yet been established. Bacterial cross contamination rates during performance of common food service tasks were previously determined in our laboratory using nalidixic acid-resistant Enterobacter aerogenes. Eight different transfer rates were determined, each involving a minimum of 30 volunteers. The influence of source inoculum level on the percentage of bacteria transferred (percent transfer rates) and log 10 CFU per recipient surface was determined using statistical analysis. The effect of inoculum size on transfer rate was highly statistically significant (P < 0.0001) for all transfer rate data combined (352 observations) and for each individual cross contamination rate, except for data on contamination via transfer from chicken to hand through a glove barrier (P ‫؍‬ 0.1643). Where inoculum size on the source was greater, transfer rates were lower, and where inoculum size on the source was less, transfer rates were higher. The negative linear trend was more obvious for activities that had a larger range of inoculum sizes on the source surface. This phenomenon has serious implications for research seeking to determine bacterial cross contamination rates, since the different transfer efficiencies that were previously shown to be associated with certain activities may actually be the result of differing initial inoculum levels. The initial inoculum size on the source and the amount of bacteria transferred must both be considered to accurately determine bacterial transfer rates.Microbial concentration plays an essential role in many microbial systems. It plays an essential role in regulating bioluminescence (8), antibiotic biosynthesis (1), virulence determination (20), catalase activity (6), and initiation of chromosomal replication (29). Bacillus megaterium spores germinate faster when present at higher concentrations (4). The inoculum size of Clostridium botulinum affects time to detection and the fraction of samples that show growth (30). A threshold inoculum size for Listeria monocytogenes to initiate growth at suboptimal conditions has been established (19,23). Whether due to interaction between cells, statistical effects, or sensitivity of microbiological methods, initial inoculum levels can drastically affect experimental results.Many factors that influence the transfer of bacteria from surface to surface have been identified. Type of bacteria (14, 24), source and destination surfaces (5, 10, 24), time postinoculation (26), and moisture level (10, 25) have all been shown to affect cross contamination rates. However, the effect of the initial inoculum level on transfer efficiency has not been established.Research conducted in our laboratory to determine the effectiveness of gloves as a barrier to cross contamination identified inoculum size as a possible factor influencing the percent t...

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

Cited by 30 publications

References 9 publications

Microbiological contamination of a hemodialysis center water distribution system

Microbiological contamination of a hemodialysis center water distribution system

Patient and Facility Safety in Hemodialysis

Inoculum Size Influences Bacterial CrossContamination betweenSurfaces

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