APIC: LA outbreak symptomatic of more widespread IC problems in dialysis settings

January 12th, 2015

San Antonio: Improper disinfection of reusable “O-ring” devices used in dialysis equipment led to bacterial infections in three patients, two of which required hospitalization, a public health investigator reports at the annual conference of the Association for Professionals in Infection Control and Epidemiology. 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, which are an emerging issue nationwide. In this case, investigators discovered that there were no quality measures in place to verify that the O-rings were removed and properly disinfected during dialysis reprocessing. Use of this type of equipment was discontinued at the outbreak site. “Contaminated O-rings have been previously implicated in dialysis-associated infection outbreaks,” says 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. 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,” Reporting the outbreak at APIC was L’Tanya English, RN, MPH, an LA public health investigator who found that infecting bacteria were genetically linked. The patients were infected with Stenotrophomonas maltophilia, a rare type of gram-negative bacteria. Two of these patients were also positive for Candida parapsilosis, a fungus that can cause sepsis in immune-compromised patients. One of the patients was positive for C. parapsilosis in the dialyzer only, and one patient was positive for Candida 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. Public health investigators became aware of the situation when a hospital in southern California reported an outbreak of sepsis tied to one dialysis center. Following cardiovascular disease, infection is the second highest cause of death for hemodialysis patients.

The Centers for Medicare and Medicaid Services (CMS) is partnering with the Centers for Disease Control and Prevention to prevent healthcare associated infections in dialysis facilities. The initiative includes a new CMS requirement for dialysis facilities to submit three months of 2012 infection and antibiotic use data to CDC's National Healthcare Safety Network (NHSN) in order to receive full Medicare payment. This is the first CMS/CDC data collaboration related to dialysis settings. However, the two agencies have been aligning patient safety efforts on multiple hospital quality measures.

In 2008 data, hemodialysis patients acquired some 37,000 central-line associated bloodstream infections (CLABSIs), the CDC reports. In addition, within the last decade there have been more than 30 outbreaks of hepatitis B and hepatitis C in non-hospital healthcare settings that include dialysis centers.