BACKGROUND: Approximately 24% of the >6,000 hemodialysis centers nationwide reuse dialyzers, reprocessing (cleaning and disinfecting) them between treatments. During August 2014, CDC became aware of gram-negative bloodstream infections (BSIs) among outpatients at multiple Company A hemodialysis facilities. Affected patients had been assigned to dialyzer reuse. We investigated to identify additional BSIs, assess risk factors, and recommend control measures.
METHODS: A case was a blood culture positive for Burkholderia cepacia or Stenotrophomonas maltophilia in a patient ≤1 week after hemodialysis at any Company A facility, during September 2013–September 2014. We used Company A’s microbiology database and local hospital records to identify cases. We performed a 1:3 case-control study, matching on facility and dialysis date. Data were analyzed by using conditional logistic regression. We visited 6 Company A facilities to observe practices and collect environmental samples, which were compared with patient isolates by using pulsed-field gel electrophoresis.
RESULTS: We identified 17 cases among 16 patients at 5 facilities. More case-patients participated in dialyzer reuse compared with control subjects (94% versus 76%), but the difference was not significant (matched odds ratio [mOR]: 4.4; 95% confidence interval [CI]: 0.6–35.4). Compared with control subjects, case-patients more often had a high (>6) number of reuses (mOR: 7.0; 95% CI: 1.5–33.8). We observed nonstandardized cleaning of dialyzer headers and caps, presenting opportunity for contamination during reprocessing. We isolated B. cepacia and S. maltophilia from reprocessing equipment or purified water at 3 facilities. Within 1 facility, a B. cepacia environmental isolate was indistinguishable from a patient isolate. Company A voluntarily stopped reuse in 1 facility.
CONCLUSIONS: BSIs were associated with frequent dialyzer reuse. Less frequent reuse or nonreuse might improve patient safety. Facilities practicing reuse should standardize reprocessing procedures to avoid contamination.