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

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          From June 17 through November 15, 1995, ten episodes of Enterobacter cloacae bloodstream infection and three pyrogenic reactions occurred in patients at a hospital-based hemodialysis center. In a case-control study limited to events occurring during October 1–31, 1995, seven dialysis sessions resulting in E. cloacae bacteremia or pyrogenic reaction without bacteremia were compared with 241 randomly selected control sessions. Dialysis machines were examined, dialysis fluid and equipment were cultured, and E. cloacae isolates were genotyped by pulsed-field gel electrophoresis. Each dialysis machine had a waste-handling option (WHO) through which dialyzer-priming fluid was discarded before each dialysis session; in 7 of 11 machines, one-way check valves designed to prevent backflow from the WHO into patient bloodlines were dysfunctional. In the case-control study, case sessions were more frequent when machines with ≥1 dysfunctional check valves were used. E. cloacae with identical pulsed-field gel electrophoresis patterns were isolated from case patients, dialysis fluid, station drains, and WHO units. Our investigation shows that bloodstream infections and pyrogenic reactions were caused by backflow from contaminated dialysis machine WHO units into patient bloodlines. The outbreak was terminated when WHO use was discontinued, check valves were replaced, and dialysis machine disinfection was enhanced.

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          Most cited references 2

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          Pseudomonas stutzeri bacteremia associated with hemodialysis.

           Angella Goetz (1983)
          Pseudomonas stutzeri bacteremia developed in six patients undergoing hemodialysis. Fever, shaking chills, nausea, and vomiting were observed. All patients recovered, although only two received specific antibiotic therapy. The infections occurred sporadically over a period of nine months. Pseudomonas stutzeri was subsequently isolated from the dialysate that circulates within the hemodialysis machine. The ultimate source was the deionized water that is combined with the liquid concentrate to form the dialysate. Pseudomonas stutzeri could be localized to the top cannister of the dialysis machine but was also isolated throughout the machine, including the bottom reservoir and the recirculating pump. The emphasis on handwashing, strict compliance with disinfection procedures, and elimination of prolonged sitting times for the filled machine after disinfection resulted in no further cases of P stutzeri infection.
            • Record: found
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            Pyrogenic reactions associated with the reuse of disposable hollow-fiber hemodialyzers

             S. Dov Gordon (1988)

              Author and article information

              Am J Nephrol
              American Journal of Nephrology
              S. Karger AG
              December 1998
              09 December 1998
              : 18
              : 6
              : 485-489
              a Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Ga., USA; b Hôpital Charles-LeMoyne, Greenfield Park, Québec, Qué., c Laboratoire de Santé Publique du Québec, Montréal, Qué., and d Field Epidemiology Training Program, Bureau of Communicable Disease Epidemiology, Ottawa, Ont., Canada
              13392 Am J Nephrol 1998;18:485–489
              © 1998 S. Karger AG, Basel

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              Page count
              Figures: 2, References: 16, Pages: 5
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