Multicenter Outbreak of Gram-Negative Bloodstream Infections in Hemodialysis Patients

Details

• Alternative Title:
  Am J Kidney Dis
• Personal Author:
  Novosad, Shannon A. ; Lake, Jason ; Nguyen, Duc ; Soda, Elizabeth ; Moulton-Meissner, Heather ; Pho, Mai T. ; Gualandi, Nicole ; Bepo, Lurit ; Stanton, Richard A. ; Daniels, Jonathan B. ; Turabelidze, George ; Van Allen, Kristen ; Arduino, Matthew ; Halpin, Alison Laufer ; Layden, Jennifer ; Patel, Priti R.
• Description:
  Rationale & Objective
  
  Contaminated water and other fluids are increasingly recognized to be associated with health care–associated infections. We investigated an outbreak of Gram-negative bloodstream infections at 3 outpatient hemodialysis facilities.
  
  Study Design
  
  Matched case-control investigations.
  
  Setting & Participants
  
  Patients who received hemodialysis at Facility A, B, or C from July 2015 to November 2016.
  
  Exposures
  
  Infection control practices, sources of water, dialyzer reuse, injection medication handling, dialysis circuit priming, water and dialysate test findings, environmental reservoirs such as wall boxes, vascular access care practices, pulsed-field gel electrophoresis, and whole-genome sequencing of bacterial isolates.
  
  Outcomes
  
  Cases were defined by a positive blood culture for any Gram-negative bacteria drawn July 1, 2015 to November 30, 2016 from a patient who had received hemodialysis at Facility A, B, or C.
  
  Analytical Approach
  
  Exposures in cases and controls were compared using matched univariate conditional logistic regression.
  
  Results
  
  58 cases of Gram-negative bloodstream infection occurred; 48 (83%) required hospitalization. The predominant organisms were Serratia marcescens (n = 21) and Pseudomonas aeruginosa (n = 12). Compared with controls, cases had higher odds of using a central venous catheter for dialysis (matched odds ratio, 54.32; lower bound of the 95% CI, 12.19). Facility staff reported pooling and regurgitation of waste fluid at recessed wall boxes that house connections for dialysate components and the effluent drain within dialysis treatment stations. Environmental samples yielded S marcescens and P aeruginosa from wall boxes. S marcescens isolated from wall boxes and case-patients from the same facilities were closely related by pulsed-field gel electrophoresis and whole-genome sequencing. We identified opportunities for health care workers’ hands to contaminate central venous catheters with contaminated fluid from the wall boxes.
  
  Limitations
  
  Limited patient isolates for testing, on-site investigation occurred after peak of infections.
  
  Conclusions
  
  This large outbreak was linked to wall boxes, a previously undescribed source of contaminated fluid and biofilms in the immediate patient care environment.
  
  
• Subjects:
  Aged Bacteremia Cross Infection Disease Outbreaks Female Follow-Up Studies Gram-Negative Bacteria Gram-Negative Bacterial Infections Humans Male Middle Aged Outpatients Renal Dialysis Retrospective Studies United States

  More +
• Source:
  Am J Kidney Dis. 74(5):610-619
• Pubmed ID:
  31375298
• Pubmed Central ID:
  PMC10826890
• Document Type:
  Journal Article
• Funding:
  CC999999/ImCDC/Intramural CDC HHSUnited States/
• Volume:
  74
• Issue:
  5
• Collection(s):
  CDC Public Access
• Main Document Checksum:
  urn:sha-512:15c2db5caf739ce880588d3484c7f2615ea08dadf146bf4ddd0c12cd4c817ae8de9ea654abb1d82c7c5c75e8a6cb0799383264467918511271ec454cfef1e122
• Download URL:
  https://stacks.cdc.gov/view/cdc/147666/cdc_147666_DS1.pdf
• File Type:
  [PDF - 710.04 KB ]