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Outbreak of gram-negative bacteremia and pyrogenic reactions in a hemodialysis center
C M Beck-Sague1, W R Jarvis, L A Bland
1Centers for Disease Control, Public Health Service, US Department of Health and Human Services, Atlanta, GA.
Abstract:
During the period from April 4, 1988, to April 20, 1988, nine pyrogenic reactions and five gram-negative bacteremias occurred in 11 patients undergoing dialysis. All pyrogenic reactions and gram-negative bacteremias occurred among patients in whom a reprocessed dialyzer was used. The rate of pyrogenic reactions or bacteremias per 100 sessions using a reprocessed dialyzer was higher than in sessions during which a new dialyzer was used (4.5 vs. 0; p = 0.03). Dialyzers were manually reprocessed with 2.5% Renalin germicide. The Renalin concentrations varied widely in 12 dialyzers stored after manual reprocessing during the epidemic period (0.9-4.2%); the median endotoxin concentrations varied from 0 to 246 ng/ml and were higher in dialyzers with Renalin concentrations less than or equal to 1.0% than in dialyzers with higher concentrations (p = 0.01). Experiments using a dilution technique described by a technician resulted in Renalin concentrations ranging from 1.4% at the surface to 3.5% at the bottom of the preparation container. These findings suggest that failure to adequately admix Renalin during dilution may be associated with low levels of disinfectant, high levels of bacteria and endotoxins in dialyzers, and outbreaks of pyrogenic reactions and gram-negative bacteremias in dialysis patients.
Insights
Improper reprocessing of dialysis equipment with Renalin disinfectant led to patient infections. Inadequate mixing caused low disinfectant levels, allowing bacteria and endotoxins to contaminate dialyzers, resulting in pyrogenic reactions and bacteremia.
Area of Science:
- Nephrology
- Infectious Disease Epidemiology
- Healthcare-Associated Infections
Background:
- Reprocessing of dialyzers is a common practice to reduce costs in hemodialysis.
- Inadequate disinfection of medical equipment can lead to patient infections and outbreaks.
Purpose of the Study:
- To investigate an outbreak of pyrogenic reactions and gram-negative bacteremias among hemodialysis patients.
- To identify the cause of infections linked to reprocessed dialyzers.
Main Methods:
- Retrospective analysis of patient data during an outbreak period.
- Measurement of Renalin disinfectant concentrations and endotoxin levels in reprocessed dialyzers.
- Laboratory experiments to assess Renalin dilution accuracy.
Main Results:
- Nine pyrogenic reactions and five gram-negative bacteremias occurred in 11 patients using reprocessed dialyzers.
- Significantly higher rates of infection were observed with reprocessed dialyzers compared to new ones (4.5 vs. 0 per 100 sessions, p=0.03).
- Variable Renalin concentrations (0.9-4.2%) and elevated endotoxin levels (0-246 ng/ml) were found in reprocessed dialyzers, particularly those with low Renalin concentrations (≤1.0%).
Conclusions:
- Failure to adequately mix Renalin during manual reprocessing can lead to insufficient disinfectant levels.
- Low disinfectant levels in dialyzers are associated with increased bacterial and endotoxin contamination.
- Inadequate dialyzer reprocessing is a likely cause of the observed outbreak of pyrogenic reactions and gram-negative bacteremias.