Epidemic parenteral exposure to volatile sulfur-containing compounds at a hemodialysis center.
OBJECTIVE
To determine the cause of acute illness on August 30, 2000, among patients at an outpatient dialysis center (center A).


METHODS
We performed a cohort study of all patients receiving dialysis on August 30, 2000; reviewed dialysis procedures; and analyzed dialysis water samples using microbiologic and chemical assays.


METHODS
Dialysis center (center A).


METHODS
A case-patient was defined as a patient who developed chills within 5 hours after starting hemodialysis at center A on August 30, 2000.


RESULTS
Sixteen (36%) of 44 patients at center A met the case definition. All case-patients were hospitalized; 2 died. Besides chills, 15 (94%) of the case-patients experienced nausea; 12 (75%), vomiting; and 4 (25%), fever. Illness was more frequent on the second than the first dialysis shift (16 of 20 vs 0 of 24, P < .001); no other risk factors were identified. The center's water treatment system had received inadequate maintenance and disinfection and a sulfurous odor was noted during sampling of the water from the reverse osmosis (RO) unit. The water had elevated bacterial counts. Volatile sulfur-containing compounds (ie, methanethiol, carbon disulfide, dimethyldisulfide, and sulfur dioxide) were detected by gas chromatography and mass spectrometry in 8 of 12 water samples from the RO unit and in 0 of 28 samples from other areas (P < .001). Results of tests for heavy metals and chloramines were within normal limits.


CONCLUSIONS
Parenteral exposure to volatile sulfur-containing compounds, produced under anaerobic conditions in the RO unit, could have caused the outbreak. This investigation demonstrates the importance of appropriate disinfection and maintenance of water treatment systems in hemodialysis centers.
Selenic
Dejana
D
Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
Alvarado-Ramy
Francisco
F
Arduino
Mathew
M
Holt
Stacey
S
Cardinali
Fred
F
Blount
Benjamin
B
Jarrett
Jeff
J
Smith
Forrest
F
Altman
Neil
N
Stahl
Charlotte
C
Panlilio
Adelisa
A
Pearson
Michele
M
Tokars
Jerome
J
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000554:Ambulatory Care Facilities; D002954:Citrobacter / Q000302:isolation & purification; D015331:Cohort Studies; D015169:Colony Count, Microbial; D003428:Cross Infection / Q000453:epidemiology / Q000209:etiology / Q000382:microbiology; D004196:Disease Outbreaks; D004220:Disulfides / Q000633:toxicity*; D004866:Equipment Contamination; D005260:Female; D017583:Hemodiafiltration / Q000009:adverse effects* / Q000295:instrumentation*; D015312:Hemodialysis Solutions / Q000633:toxicity; D006801:Humans; D008297:Male; D008875:Middle Aged; D009995:Osmosis; D006435:Renal Dialysis / Q000009:adverse effects* / Q000295:instrumentation; D013212:Staphylococcus epidermidis / Q000302:isolation & purification; D014877:Water Pollution, Chemical / Q000009:adverse effects* / Q000032:analysis
D004220:Disulfides; D015312:Hemodialysis Solutions