Waterborne Pseudomonas septicemia.
A small cluster of waterborne septicemias with Pseudomonas species occurred in a dialysis unit despite regular control of bacterial contents of tap water and dialysate conforming to preset standards. Pseudomonas aeruginosa, P. maltophilia, and/or P. vesicularis were found in the blood cultures of three patients in whom four pyrogenic reactions developed. The cluster occurred only in patients treated with formaldehyde-reused dialyzers. Pseudomonads were also cultured from the effluent of two dialyzers reprocessed with formaldehyde and not yet used; these two dialyzers had extremely low formaldehyde concentrations. The tap water used for dialyzer rinsing in the reuse procedure contained only 220 colony forming units/ml pseudomonads. The problem appeared to be related to the inadequate mixing of the sterilant with the tap water used in the automated reprocessing device--in the absence of an alarm for this failure. After immediate discontinuation of the reuse procedure with this device (that had been in use for 6 years) no further septicemic episodes were registered. It is concluded that septicemias may occur despite a bacteriologic contamination level of water conforming to preset standards. Such episodes can be avoided only by total water decontamination.
Vanholder
R
R
Nephrology Department, University Hospital, Ghent, Belgium.
Vanhaecke
E
E
Ringoir
S
S
D000368:Aged; D015169:Colony Count, Microbial; D003428:Cross Infection / Q000635:transmission*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011552:Pseudomonas Infections / Q000635:transmission*; D011550:Pseudomonas aeruginosa / Q000302:isolation & purification; D006435:Renal Dialysis / Q000009:adverse effects*; D018805:Sepsis / Q000635:transmission*; D014871:Water Microbiology