Three patients with chronic kidney failure treated at a dialysis center in Los Angeles contracted sepsis caused by improper cleaning and disinfection of a reusable medical device called a dialyzer, an artificial kidney, according to research findings presented at the 39th Annual Educational Conference and International Meeting of the Association for Professionals in Infection Control and Epidemiology.
The infections were reported to the County of Los Angeles Department of Public Health in August 2011. A hospital in southern California reported an outbreak of sepsis tied to one dialysis center. During the course of their investigation, they discovered that all of the cases used the same type of dialyzer with a removable component — an O-ring header.
Researchers found the three 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 these 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.
In response to this outbreak, the dialysis center decided to discontinue use of multi-use dialyzers with O-ring headers.
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The infections were reported to the County of Los Angeles Department of Public Health in August 2011. A hospital in southern California reported an outbreak of sepsis tied to one dialysis center. During the course of their investigation, they discovered that all of the cases used the same type of dialyzer with a removable component — an O-ring header.
Researchers found the three 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 these 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.
In response to this outbreak, the dialysis center decided to discontinue use of multi-use dialyzers with O-ring headers.
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