Clinical Study

Outbreak of Pyrogenic Reactions and Gram-Negative Bacteremia in a Hemodialysis Center
Benita M. Jacksona, Consuelo M. Beck-Sagueb, Lee A. Blandb, Matthew J. Arduinob, Lisa Meyera, William R. Jarvisb

^aDivision of Field Epidemiology, Epidemiology Program Office, and
^bHospital Infectious Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Public Health Service, US Department of Health and Human Services, Atlanta, Ga., USA

Address of Corresponding Author

Am J Nephrol 1994;14:85-89 (DOI: 10.1159/000168694)

  Key Words

• Hemodialysis
• Gram-negative bacteremia
• Pyrogenic reactions

  Abstract

Six episodes of gram-negative bacteremia and seven pyrogenic reactions occurred in 11 patients in one hemodialysis center. Gram-negative bacter-emias and/or pyrogenic reactions were not related to reuse and were more likely to occur if dialysis was performed in one unit of the center (8/13 unit 5 vs. 221/1,151 in other units, p < 0.001) and with one type of dialysis machine (10/13 vs. 581/1,151 with other machines, p = 0.05), which was preferentially used in unit 5 (p < O.Ol). Bacterial and endotoxin concentrations of water used to prepare dialysate and reprocess hemodialyzers, and of dialysate, exceeded allowable concentrations recommended by the Association for the Advancement of Medical Instrumentation (AAMI). The implicated dialysis machines were disinfected with chemicals daily, but not heat-disinfected daily as suggested by the manufacturer. Results suggest that the outbreak was caused by the use of water that did not meet AAMI standards and inadequate disinfection of one type of dialysis machine.

Copyright © 1994 S. Karger AG, Basel

  Author Contacts

Benita M. Jackson, MD, University Hospital Clinic, Room 4510, Ohio State University, Columbus, OH 43210 (USA)

  Article Information

Received: October 19, 1993
Accepted: November 20, 1993
Published online: October 28, 2008
Number of Print Pages : 5