ELIMINATION OF AN OUTBREAK OF GRAM-NEGATIVE BACTEREMIA IN A HEMODIALYSIS UNIT

Background: The purpose of this study was to identify the cause of an unusual outbreak of gram-negative bacteremia in patients undergoing lo ng-term hemodialysis. Methods: We performed direct observation and inv estigation of current dialysis techniques and facilities including mic robiologic sampling in a long-term hemodialysis unit in a tertiary car e center. We also performed a retrospective review of medical charts a nd laboratory data of 10 patients undergoing long-term hemodialysis wh o experienced 11 episodes of gram-negative bacteremia between March 4 and June 28, 1993. ResuIts: All of these patients underwent dialysis b y jugular venous access. Containers used to collect flush solution aft er priming of dialysis tubing remained unemptied for extended periods of time, and quantitative culture revealed more than 200 colony-formin g units/ml gram-negative bacilli, including species isolated in blood cultures. Dialysis tubing and connector were left submerged in flush s olution collection containers during priming, and the process of disin fecting tubing before patient connection had recently been discontinue d. Control measures included emptying of Rush containers after each us e and daily decontamination. All dialysis tubing was to be disinfected before patient connection. Conclusion: Outbreak was due to contaminat ion during dialysis setup. After institution of appropriate control me asures, no new cases have occurred.