An Outbreak of Bloodstream Infections Arising from Hemodialysis Equipment

Arnow, Paul M.; Garcia-Houchins, Sylvia; Neagle, Mark B.; Bova, Judith L.; Dillon, John; Chou, Teresa

doi:10.1086/515363

Cited by 23 publications

(9 citation statements)

References 25 publications

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“…This is supported by the positive hand culture mentioned. WHOPs have been implicated in several dialysis units as responsible for disease outbreaks and/or environmental contamination with other, usually water-associated, Gram-negative bacteria, 1,5,10,16,22 including, previously, our own unit. 7 Several reasons have been shown to explain this association: there can be backflow from the drainage tubes, failure to consider the port as nonsterile, contamination of the ports by health care worker hands, and/or failure of a washing arm designed to continuously wash the external side of the port.…”

Section: Discussionmentioning

confidence: 99%

“…7 Several reasons have been shown to explain this association: there can be backflow from the drainage tubes, failure to consider the port as nonsterile, contamination of the ports by health care worker hands, and/or failure of a washing arm designed to continuously wash the external side of the port. 1,5,7,10,16,22 As the port is in contact briefly, during the flushing connection, with the line that will then be connected directly to patients_ vascular access sites, there is the possibility of contamination accessing patients_ blood streams. With respect to our index cases, both had vascular access via indwelling catheter devices, not arteriovenous anatomic shunts.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Halomonas, a Newly Recognized Human Pathogen Causing Infections and Contamination in a Dialysis Center

Stevens¹,

Hamilton²,

Johnson³

et al. 2009

Medicine

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Our Renal Care Center (RCC) is a separate building, performing almost 2500 outpatient dialysis runs per month. In May 2007, 2 patients developed, days apart, bacteremia with an apparently identical nonfermentative Gram-negative rod. Because of difficulty identifying the organism, testing in the Biolog system identified them as a Halomonas species. Sequencing of approximately 1500 bases of the 16S rRNA gene in both organisms in 3 reference laboratories confirmed, searching against 3 databases, that the organisms were identical and were Halomonas species. There were 54 recognized species of this genus, associated with marine or saline sites. Initial attempts at environmental isolation as primary cultures, including a 4% salt agar plate, or initial incubation in 6.5% salt broth enrichment culture with subculture to agar, to exploit the halophilicity of Halomonas, were successful in demonstrating the colonies seen in the blood cultures, only from sites not contaminated with other organisms, because of competing growth. A more selective method was developed for use on samples suspected to be heavily contaminated with other organisms, using the strategy of increased salt concentration in a broth enrichment culture to further exploit Halomonas halotolerance, and thereby inhibit other organisms. A 16.5% salt concentration in brain-heart infusion broth, incubated at 35 degrees C for 48-72 hours, then subcultured to agar plates incubated in room air at 35 degrees C, proved optimal for selection and secondary isolation. With a combination of these techniques, 14/15 cultures of dialysates and 10/38 from the outflow pathways of the machines were Halomonas positive, compared to 0/31 cultures from the inflow side of the machines (including water supplies and storing, mixing, and preparation tanks). The exception was sites associated with or downstream of bicarbonate influx, 12/54 of which were positive. Two other local hospitals' dialysis centers, and our own inpatient dialysis facility, were cultured at sites that yielded Halomonas from our RCC, and Halomonas was not isolated. Further study by 16S rRNA gene sequencing and DNA-DNA hybridization revealed the cultures represented 3 novel species: 1 (H. stevensii sp. nov.) in the patients and environment and 2 (H. hamiltonii sp. nov., H. johnsoniae sp. nov.) in the environment, most closely related to H. magadiensis. Of 35 speciated isolates, 22 were H. stevensii, 10 H. johnsoniae, and 3 H. hamiltonii. We hypothesize that the RCC became contaminated with these halophilic organisms from bicarbonate used to prepare dialysis fluid, and they persist despite cleaning and flushing procedures because of biofilm in machines and bicarbonate fluid inflow sites. Our experience, together with the review of the literature presented here, indicates the genus Halomonas has pathogenic potential.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Halomonas, a Newly Recognized Human Pathogen Causing Infections and Contamination in a Dialysis Center

Stevens¹,

Hamilton²,

Johnson³

et al. 2009

Medicine

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“…Many of these studies examined outbreaks 15e22 and evaluations of intervention strategies, 23e25 while others attempted to identify factors associated with potential nosocomial transmission (i.e. healthcare worker carriage, 26,27 direct contact with cases, 28,29 inadequate cleaning of medical equipment 30,31 and the physical layout of hospital utilities 32,33 ). Only four studies described the spatial distribution of cases to show the impact of hospital renovations 34 or the layout of cases across specialities, 16,27,34,35 with the majority of studies describing temporal trends in cases.…”

Section: Descriptive Studiesmentioning

confidence: 99%

Spatial and temporal analyses to investigate infectious disease transmission within healthcare settings

Davis

Sevdalis

Drumright

2014

Journal of Hospital Infection

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The incorporation of spatiotemporal analysis has been limited in healthcare settings, with only 15% of studies including any such analysis. Analytical studies provided greater data on transmission dynamics and effective control interventions than studies without spatiotemporal analyses. This indicates the need for greater integration of spatiotemporal techniques into HCAI investigations, as even simple analyses provide significant improvements in the understanding of prevention over simple descriptive summaries.

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“…Enterococci have been cultured from dialysate, treated HD water, and components of HD machines (88–91). The reported prevalence of VRE (generally based on rectal swab cultures) in dialysis outpatients has varied from 0 to 12% and was as high as 28% among hospitalized HD patients (92–97).…”

Section: Vre In Dialysis Patientsmentioning

confidence: 99%

Infection with Antimicrobial‐resistant Microorganisms in Dialysis Patients

Berns

2003

Seminars in Dialysis

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The prevalence of antimicrobial-resistant microorganisms in various health care settings, including outpatient dialysis facilities, has increased dramatically in the last decade. Antimicrobial use and patient-to-patient transmission of resistant strains are the two main factors that have contributed to this rapid increase. Methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci are commonly isolated as a cause of hemodialysis (HD) catheter-related bacteremia and peritoneal dialysis (PD)-related catheter infection and peritonitis. The widespread use of vancomycin in dialysis patients is of concern because of an increase in the prevalence of vancomycin-resistant enterococci (VRE) in dialysis patients. Staphylococci with reduced sensitivity to vancomycin have also appeared in dialysis patients. A more recent problem is the appearance of S. aureus isolates with a high degree of resistance to the topical antimicrobial agent mupirocin. This has been seen in PD patients who have received prophylactic application of mupirocin at the peritoneal catheter exit site. Appropriate antimicrobial use will help protect the efficacy of currently used antibiotics, such as vancomycin. Published guidelines for use of vancomycin should be followed. New antimicrobials such as linezolid and quinupristin/dalfopristin have activity against VRE and MRSA, but resistance to these agents has already occurred. Preventing transmission of antimicrobial-resistant microorganisms in health care settings, including outpatient dialysis facilities, is important in limiting the spread of these resistant organisms.

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An Outbreak of Bloodstream Infections Arising from Hemodialysis Equipment

Cited by 23 publications

References 25 publications

Halomonas, a Newly Recognized Human Pathogen Causing Infections and Contamination in a Dialysis Center

Halomonas, a Newly Recognized Human Pathogen Causing Infections and Contamination in a Dialysis Center

Spatial and temporal analyses to investigate infectious disease transmission within healthcare settings

Infection with Antimicrobial‐resistant Microorganisms in Dialysis Patients

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