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.
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• 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.
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• Subjects:
  • Aged
  • Bacteremia
  • Cross Infection
  • Disease Outbreaks
  • Female
  • Follow-Up Studies
  • Gram-Negative Bacteria
  • Gram-Negative Bacterial Infections
  • Humans
  • Male
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• 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
• Download URL:
  https://stacks.cdc.gov/view/cdc/147666/cdc_147666_DS1.pdf
• File Type:
  [PDF - 710.04 KB]
• Collection(s):
  CDC Public Access
• Main Document Checksum:
  urn:sha-512:15c2db5caf739ce880588d3484c7f2615ea08dadf146bf4ddd0c12cd4c817ae8de9ea654abb1d82c7c5c75e8a6cb0799383264467918511271ec454cfef1e122