of a bacterial infection in the blood (sepsis) by three patients with
chronic kidney failure treated at a dialysis center in Los Angeles
County. Sepsis is caused by improper cleaning and disinfection of a
reusable medical device called a dialyzer - an artificial kidney.
Described in a poster presented at the 39th Annual Educational
Conference and International Meeting of the Association for
Professionals in Infection Control and Epidemiology (APIC), the County
of Los Angeles Department of Public Health, conducted an investigation
led by public health nurse L'Tanya English, RN, MPH, who found that the
bacteria infecting the three patients were genetically linked. These
patients were infected with Stenotrophomonas
), a rare type
of gram-negative bacteria.
Two of these patients were also positive for Candida
), a fungus
that can cause sepsis in immune-compromised patients. One of these
patients was positive for C. parapsilosis
dialyzer only, and one patient was positive for
in the blood and in the dialyzer, which was
genetically traced back to the same fungus in a faucet in the
reprocessing room, where the dialyzers are disinfected and sanitized.
The infections were reported to the health department in August 2011.
Two patients developed fevers and were hospitalized. One patient was
assessed and treated as an outpatient; all patients later recovered.
The County of Los Angeles Department of Public Health became aware of
the situation when a hospital in southern California reported an
outbreak of sepsis tied to one dialysis center. During the course of
their investigation, they discovered that all of the cases used the same
type of dialyzer with a removable component - an O-ring header. These
three patients were the only ones in the facility to use this type of
dialyzer. In response to this outbreak, the facility decided to
discontinue use of multi-use dialyzers with O-ring headers.
"Hemodialysis technology is life-saving, but carries a high risk of
infection, regardless of the type of dialyzer used," said English.
"Dialysis centers must work to reduce the risk of infection for their
patients by ensuring proper cleaning and disinfection procedures are
being followed throughout the facility. If multi-use dialyzers with
removable headers and O-rings are used, processes to ensure proper
disinfection must be in place."
The County of Los Angeles Department of Public Health is working with
state and federal partners to conduct outreach to dialysis centers to
decrease dialysis-associated infections and will discuss lessons learned
from the investigation at the APIC Annual Conference.
"Contaminated O-rings have been previously implicated in
dialysis-associated infection outbreaks. This report underscores the
need for adequate infection prevention training in dialysis settings, as
well as the critical partnership between public health departments and
infection preventionists in hospitals and outpatient settings," said
Michelle Farber, RN, CIC, APIC 2012 president. "Collaboration with
public health is essential to pinpoint the cause of infection outbreaks
and improve infection prevention practices across all healthcare
Hemodialysis is a life-saving procedure that uses an artificial kidney,
or dialyzer, to remove waste from the blood when the kidneys no longer
work. It is most often the treatment for end-stage renal disease.
Following cardiovascular disease, infection is the second highest cause
of death for hemodialysis patients.
The most recent draft of the U.S. Department of Health and Human
Services' National Action Plan to Prevent Healthcare-associated
Infections: Roadmap to Elimination includes a revised chapter on efforts
to prevent and reduce healthcare-associated infections in end-stage
renal disease patients.
In an effort to establish best practices for protecting patients
undergoing hemodialysis, APIC published a Guide to the Elimination of
Infections in Hemodialysis and has an archived webinar on dialysis event
surveillance and reporting.