Hemodialyzer Reuse and Gram-Negative Bloodstream Infections

Abstract

Background: Clusters of bloodstream infections caused by Burkholderia cepacia and Stenotrophomonas maltophilia are uncommon, but have been previously identified in hemodialysis centers that reprocessed dialyzers for reuse on patients. We investigated an outbreak of bloodstream infections caused by B cepacia and S maltophilia among hemodialysis patients in clinics of a dialysis organization.

Study design: Outbreak investigation, including matched case-control study.

Setting & participants: Hemodialysis patients treated in multiple outpatient clinics owned by a dialysis organization.

Predictors: Main predictors were dialyzer reuse, dialyzer model, and dialyzer reprocessing practice.

Outcomes: Case patients had a bloodstream infection caused by B cepacia or S maltophilia; controls were patients without infection dialyzed at the same clinic on the same day as a case; results of environmental cultures and organism typing.

Results: 17 cases (9 B cepacia and 8 S maltophilia bloodstream infections) occurred in 5 clinics owned by the same dialysis organization. Case patients were more likely to have received hemodialysis with a dialyzer that had been used more than 6 times (matched OR, 7.03; 95% CI, 1.38-69.76) and to have been dialyzed with a specific reusable dialyzer (Model R) with sealed ends (OR, 22.87; 95% CI, 4.49-∞). No major lapses during dialyzer reprocessing were identified that could explain the outbreak. B cepacia was isolated from samples collected from a dialyzer header-cleaning machine from a clinic with cases and was indistinguishable from a patient isolate collected from the same clinic, by pulsed-field gel electrophoresis. Gram-negative bacteria were isolated from 2 reused Model R dialyzers that had undergone the facility's reprocessing procedure.

Limitations: Limited statistical power and overmatching; few patient isolates and dialyzers available for testing.

Conclusions: This outbreak was likely caused by contamination during reprocessing of reused dialyzers. Results of this and previous investigations demonstrate that exposing patients to reused dialyzers increases the risk for bloodstream infections. To reduce infection risk, providers should consider implementing single dialyzer use whenever possible.

Keywords: Burkholderia cepacia; Gram-negative bacteria; Hemodialysis; Stenotrophomonas maltophilia; bloodstream infection (BSI); case-control; contamination; decontamination; dialysis organization; dialyzer reprocessing; dialyzer reuse; end-stage renal disease (ESRD); human error; infection prevention; outbreak; patient safety.

Figure 1

Epidemic curve of bloodstream infections caused by select organisms at dialysis organization clinics, April 2012 to September 2014. *Pseudomonas aeruginosa, Proteus species, Morganella morganii, Serratia maracescens, Xanthomonas, Ralstonia pickettii, or Candida parapsilosis.