title: 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.
  
  
  METHODS
  Outbreak investigation, including matched case-control study.
  
  
  METHODS
  Hemodialysis patients treated in multiple outpatient clinics owned by a dialysis organization.
  
  
  METHODS
  Main predictors were dialyzer reuse, dialyzer model, and dialyzer reprocessing practice.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA; Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA. Electronic address: wedens@cdc.gov.
authors.forename: Chris
authors.initials: C
authors.lastname: Edens
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA; California Department of Public Health, Richmond, CA.
authors.forename: Jacklyn
authors.initials: J
authors.lastname: Wong
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA; Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Meghan
authors.initials: M
authors.lastname: Lyman
authors.affiliation: California Department of Public Health, Richmond, CA.
authors.forename: Kyle
authors.initials: K
authors.lastname: Rizzo
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Duc
authors.initials: D
authors.lastname: Nguyen
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Michela
authors.initials: M
authors.lastname: Blain
authors.affiliation: California Department of Public Health, Richmond, CA.
authors.forename: Sam
authors.initials: S
authors.lastname: Horwich-Scholefield
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Heather
authors.initials: H
authors.lastname: Moulton-Meissner
authors.affiliation: California Department of Public Health, Richmond, CA.
authors.forename: Erin
authors.initials: E
authors.lastname: Epson
authors.affiliation: California Department of Public Health, Richmond, CA.
authors.forename: Jon
authors.initials: J
authors.lastname: Rosenberg
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: Priti R
authors.initials: PR
authors.lastname: Patel
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016470:Bacteremia / Q000453:epidemiology*; D019121:Burkholderia Infections / Q000453:epidemiology*; D016956:Burkholderia cepacia; D016022:Case-Control Studies; D003666:Decontamination; D004196:Disease Outbreaks; D004203:Disinfection / Q000706:statistics & numerical data*; D004866:Equipment Contamination; D005260:Female; D016905:Gram-Negative Bacterial Infections / Q000453:epidemiology*; D006801:Humans; D017053:Infection Control; D007676:Kidney Failure, Chronic / Q000628:therapy*; D007688:Kidneys, Artificial / Q000382:microbiology / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D006435:Renal Dialysis; D020615:Stenotrophomonas maltophilia / Q000276:immunology*; D014481:United States / Q000453:epidemiology
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