Improper cleaning and disinfection of artificial kidneys
led to three patients with chronic kidney failure to contract sepsis, according
to data from a poster presented at the 39th Annual Educational Conference and
International Meeting of the Association for Professionals in Infection
Control.
Researchers from the County of Los Angeles Department of
Public Health conducted an epidemiologic and environmental investigation of the
dialysis center in August 2011, when they were notified that five patients from
the center were diagnosed with bacteremia. Cases were defined as dialysis
patients in the center who tested positive for Stenotrophomonas
maltophilia.
There were four cases, and in three of the patients, the
bacteria were genetically linked. Two of these patients were also positive for
Candida parapsilosis. One patient was positive for C.
parapsilosis in the artificial kidney only. One patient was positive in the
blood and in the artificial kidney. These were genetically traced to the same
fungus in a faucet in the reprocessing room, where the artificial kidneys are
disinfected and sanitized.
L’Tanya English
During the investigation, the researchers found that all
cases used an artificial kidney with a removable component — an O-ring
header — and they were the only patients to use this type of artificial
kidney. The facility, therefore, discontinued multi-use artificial kidneys with
O-ring headers.
“Hemodialysis technology is life-saving, but
carries a high risk for infection, regardless of the type of [artificial
kidney] used,” L’Tanya English, RN, MPH, of the County of Los Angeles
Department of Public Health, said in a press release. “Dialysis centers
must work to reduce the risk for infection among their patients by ensuring
proper cleaning and disinfection procedures are being followed throughout the
facility. If multi-use [artificial kidneys] with removable headers and O-rings
are used, processes to ensure proper disinfection must be in place.”
References:
English L. #9-136. Presented at: 39th Annual Educational
Conference and International Meeting of the Association for Professionals in
Infection Control; Jun 4-6, 2012; San Antonio.
Disclosures:
Ms. English reports no relevant financial
disclosures.