[From the Mailing List SIN: expected and unexpected professional risks for the nephrologists--reflections from an outbreak of Burkholderia cepacia bacteremia in a hemodialysis unit].
An outbreak of bacteremia in 20 hemodialysed patients who developed central venous catheter (CVC) infection related to Burkholderia cepacia is reported, introducing medical and professional responsibilities in nephrology units. The cepacia was documented in the blood stream, in the CVC biofilm, in the water supply and in the distribution. This and other confounding factors delayed the identification of the contamination source. Finally, it was isolated, clonally identical to that found in the blood stream, from ammonium chloride solution used to disinfect the skin and distributed in a sterile disposable kit. Burkholderia cepacia was clonally different in blood with respect to water. The possible differing responsibilities in the organizational steps of nephrology activity are discussed.
Bellazzi
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Unita' Operativa di Nefrologia e Dialisi, P.O. della Lomellina, Azienda Ospedaliera della Provincia di Pavia, Vigevano (PV). roberto_bellazzi@ospedali.pavia.it
Ciniselli
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F
D000643:Ammonium Chloride; D016470:Bacteremia / Q000453:epidemiology* / Q000382:microbiology; D019121:Burkholderia Infections / Q000453:epidemiology* / Q000382:microbiology; D016956:Burkholderia cepacia / Q000302:isolation & purification*; D003428:Cross Infection / Q000453:epidemiology; D004196:Disease Outbreaks; D004340:Drug Contamination; D034742:Electronic Mail; D004866:Equipment Contamination; D006436:Hemodialysis Units, Hospital / Q000706:statistics & numerical data; D006801:Humans; D017758:Infectious Disease Transmission, Patient-to-Professional / Q000706:statistics & numerical data*; D007558:Italy / Q000453:epidemiology; D009398:Nephrology / Q000331:legislation & jurisprudence
D000643:Ammonium Chloride