Elimination of an outbreak of gram-negative bacteremia in a hemodialysis unit

Outbreak of Burkholderia cepacia Bacteremia Caused by Contaminated Chlorhexidine in a Hemodialysis Unit

“…1,2 This organism colonizes water supplies, filter membranes, and antiseptic solutions. 3 " 5 Inadequate catheter care, defects in membrane integrity, and the reprocessing of dialyzers have all been implicated in outbreaks in hemodialysis units.…”

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.…”

An Outbreak of Gram-Negative Bacteremia in Hemodialysis Patients Traced to Hemodialysis Machine Waste Drain Ports

“…Outbreaks of gram-negative bacterial BSIs in hemodialysis units have commonly been due to inadequate disinfection of water treatment or distribution systems, reprocessed dialyzers, or other dialysis equipment. [3][4][5][6][7][8][9][10][11] During this outbreak, evidence suggests that gram-negative bacterial BSIs were caused by cross-contamination of hemodialysis CVCs from the WHO port, a waste drain port unique to a particular model of hemodialysis machine.…”