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Clustered Bacteremias in a Hemodialysis Unit Cross-Contaminationof Blood Tubing From Ultrafiltrate Waste

Published online by Cambridge University Press:  21 June 2016

Robert N. Longfield ,
William G. Wortham ,
Linda L. Fletcher  and
William F. Nauscheutz
Robert N. Longfield*
Affiliation:
Infectious Disease Service, Brooke Army Medical Center, Fort Sam Houston, Texas
William G. Wortham
Affiliation:
Nephrology Service, Brooke Army Medical Center, Fort Sam Houston, Texas
Linda L. Fletcher
Affiliation:
Infection Control Service, Brooke Army Medical Center, Fort Sam Houston, Texas
William F. Nauscheutz
Affiliation:
Clinical Microbiology Service, Brooke Army Medical Center, Fort Sam Houston, Texas
*
Infectious Disease Service, HSHE-MDI, Brooke Army Medical Center, Fort Sam Houston, TX 78234-6200
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Abstract

Objectve:

To determine the cause of clustered bacteremias occurring among chronic hemodialysis patients.

Design:

A retrospective investigation of clinical and laboratory records with direct observation of dialysis facilities and technique. Bacterial blood isolates were identified and compared with environmental isolates.

Setting:

The 1 1-station chronic hemodialysis unit that serves approximately 50 patients in a 450-bed military hospital.

Patients:

Hemodialysis unit patients with aerobic gram-negative bacillus orEnterococcus casseliflavus blood isolates between April 1988 and February 1990.

Results:

The recovery and species identification of the unique isolate, Ecasseliflavus, from 2 index cases of bacteremia in February 1990 helped identify the cluster and demonstrated its protracted course. Dialysis blood tubing was contaminated with ultrafiltrate waste during dialyzer setup.

Intervention:

Bacteremias were controlled by halting the practice of attaching the venous tubing directly to a waste container while priming the membrane, by emphasizing glove changes and handwashing after contact with ultrafiltrate waste and by daily decontamination of ultrafiltrate waste bags.

Conclusions:

We recommend that other hemodialysis units institute these interventions.

Type
Brief Report
Information
Infection Control & Hospital Epidemiology , Volume 13 , Issue 3 , March 1992 , pp. 160 - 164
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1992 

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