An Outbreak of Pyrogenic Reactions in Chronic Hemodialysis Patients Associated with Hemodialyzer Reuse

Abstract

In February 1992, 22 patients undergoing chronic hemodialysis at an outpatient dialysis center experienced pyrogenic reactions (PR). The PR rate was significantly greater (p < 0.001) during the epidemic (February 3-5) than the pre-epidemic period (November 1, 1992-February 1, 1992). All patients with PR used dialyzers that had been manually reprocessed either on February 1 or 3. These dialyzers contained up to 120.8 EU/ml of endotoxin in the blood compartment. The only dialyzer reprocessed before February 1 that was available for analysis was found to contain no detectable endotoxin, while dialyzers reprocessed during the epidemic period contained a median endotoxin concentration of 52.8 EU/ml. The bioburden of water used to prepare dialysate was in excess of the Association for the Advancement of Medical Instrumentation (AAMI) standard for water, < or = 200 colony forming units (CFU)/ml. Samples of treated water collected in the reuse area were within AAMI standards at the time of the investigation (February 11 and February 26), but before the investigation, water samples were assayed with a culture method that could not detect microbial concentrations below 10(3) CFU/ml. In addition, the treated water feed line to the disinfectant container may never have been disinfected. However, no samples were collected from this line during the investigation. This outbreak emphasizes the need to use water that meets the AAMI bacteriologic and endotoxin standards of < or = to 200 CFU/ml and/or 5 EU/ml, respectively, for reprocessing hemodialyzers nad to ensure that appropriate culture techniques are used for treated water dialysate.

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

“…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.…”

Current Situation of Endotoxin Retentive Filter

“…Periodical and long activation of blood cells by HD is now recognized as the major cause of chronic microinflammation that is implied in the development of long-term dialysis-related complications. So it has been generally recognized that contaminated dialysis fluid was one of the most important factors which induced dialysis-related complications such as dialysisrelated amyloidosis (DRA) [4] , anemia [5] , cardiovascular complications [6] , intradialytic complications [7] , neurologic disorders [8] , nutrition [9] , residual renal function [10] and poor prognosis of dialysis patients ( table 1 ). From the point of view for preventing inflammation in most dialysis-related pathologies, the standard recommends that UPD should be used for all dialysis modalities at all dialysis facilities.…”

Nosocomial Infections in Hemodialysis Units

“…cultured using calibrated loop and blood agar plates-results were always recorded as no growth Phialemonium curvatum access infections Observations at the facility noted some irregularities Review infection control practices; clean and disinfect in 4 hemodialysis patients; 2 of these in site prep for needle insertion. All 156 of headers with gauze; staff not routinely header; change gloves frequently; process dialyzers changing gloves; dialyzers not processed for immediately after rinsing and cleaning several hours after disassembly and cleaning Pyrogenic reactions in 3 high-flux dialysis patients 157 Dialyzer reprocessed with two disinfectants; water Do not disinfect dialyzers with multiple germicides; more used for reuse did not meet AAMI standards frequent disinfection of water system Pyrogenic reactions in 14 high-flux dialysis Dialyzers rinsed with city water; water for reuse Do not rinse or clean dialyzers with city water; disinfect patients; 1 death 158 did not meet AAMI standards water treatment system more frequently Pyrogenic reactions in 18 patients 51 Dialyzers rinsed with city water containing high Do not rinse or clean dialyzers with city water; disinfect levels of endotoxin; water used for reuse did not water treatment system more frequently meet AAMI standards Pyrogenic reactions in 22 patients 159 Water for reuse did not meet AAMI standards; Use correct microbial assay procedure; disinfect water improper microbial assay technique distribution system…”