Clinical and microbiological effects of dialyzers reuse in hemodialysis patients / Efeitos clínicos e microbiológicos do reúso de dialisadores em pacientes em hemodiálise

Abstract Introduction: Chronic kidney disease (CKD) has a high prevalence and is a worldwide public health problem. Reuse of dialyzers is a cost reduction strategy used in many countries. There is controversy over its effects on clinical parameters and microbiological safety. Methods: In this clinical crossover study, 10 patients performed consecutive hemodialysis (HD) sessions divided in two phases: "single use" sessions (N = 10 HD sessions) followed by "dialyzer reuse" sessions (N = 30 HD sessions). Clinical, laboratory, and microbiological parameters were collected in the following time points: "single use", 1st, 6th, and 12th sessions with reuse of dialyzers, including bacterial cultures, endotoxins quantification in serum and dialyzer blood chamber, and detection of hemoglobin and protein residues in dialyzers. Results: Mean age of the sample was 37 ± 16 years, 6 (60%) were men, and 5 (50%) were white. CKD and HD vintage were 169 ± 108 and 47 (23-111) months, respectively. Serum C-reactive protein (CRP) [4.9 (2.1) mg/mL], ferritin (454 ± 223 ng/mL), and endotoxin levels [0.76 (0.61-0.91) EU/mL] were high at baseline. Comparison of pre- and post-HD variations of serum levels of CRP and endotoxins in the "single use" versus "reuse" phases did not result in differences (p = 0.8 and 0.4, respectively). Samples of liquid in the dialyzer inner chamber were negative for the growth of bacteria or endotoxins. There was no significant clinical manifestation within and between the phases. Conclusion: Dialyzers reuse was safe from a clinical, microbiological, and inflammatory point of view. The dialyzer performance remained adequate until the 12th reuse.

Resumo Introdução: A doença renal crônica (DRC) é um problema de saúde pública mundial de alta prevalência. O reúso de dialisadores é uma estratégia de redução de custos empregada em muitos países. Seus efeitos sobre parâmetros clínicos e de segurança microbiológica são alvo de controvérsia. Métodos: No presente estudo clínico cruzado, 10 pacientes realizaram sessões consecutivas de hemodiálise (HD) divididas em duas fases: a primeira com sessões de "uso único" (N = 10 sessões de HD) e a segunda com sessões com "reúso de dialisadores" (N = 30 sessões de HD). Parâmetros clínicos, laboratoriais e microbiológicos foram registrados nos seguintes momentos: "uso único", 1a, 6a e 12a sessões com reúso de dialisadores, incluindo culturas bacterianas, quantificação de endotoxinas no soro e na câmara interna do dialisador e detecção de hemoglobina e resíduos de proteína nos dialisadores. Resultados: A idade média da amostra foi de 37 ± 16 anos seis (60%) eram homens e cinco (50%) eram brancos. Os tempos com DRC e em HD foram de 169 ± 108 e 47 (23-111) meses, respectivamente. Os níveis séricos de proteína C-reativa (PCR) [4,9 (2,1) mg/mL], ferritina (454 ± 223 ng/mL) e endotoxinas [0,76 (0,61-0,91) UE/mL] estavam elevados no início do estudo. A diferença dos níveis séricos de PCR e endotoxinas pré e pós-HD nas fases de "uso único" e "reúso" não foi significativa (p = 0,8 e 0,4, respectivamente). As amostras de líquido retiradas da câmara interna do dialisador foram negativas para crescimento de bactérias e endotoxinas. Não houve registro de manifestações clínicas significativas nas fases do estudo. Conclusão: O reúso de dialisadores foi seguro dos pontos de vista clínico, microbiológico e inflamatório. O desempenho do dialisador permaneceu adequado até o 12º reuso.

Clinical and microbiological effects of dialyzers reuse in hemodialysis patients.

INTRODUCTION: Chronic kidney disease (CKD) has a high prevalence and is a worldwide public health problem. Reuse of dialyzers is a cost reduction strategy used in many countries. There is controversy over its effects on clinical parameters and microbiological safety. METHODS: In this clinical crossover study, 10 patients performed consecutive hemodialysis (HD) sessions divided in two phases: "single use" sessions (N = 10 HD sessions) followed by "dialyzer reuse" sessions (N = 30 HD sessions). Clinical, laboratory, and microbiological parameters were collected in the following time points: "single use", 1st, 6th, and 12th sessions with reuse of dialyzers, including bacterial cultures, endotoxins quantification in serum and dialyzer blood chamber, and detection of hemoglobin and protein residues in dialyzers. RESULTS: Mean age of the sample was 37 ± 16 years, 6 (60%) were men, and 5 (50%) were white. CKD and HD vintage were 169 ± 108 and 47 (23-111) months, respectively. Serum C-reactive protein (CRP) [4.9 (2.1) mg/mL], ferritin (454 ± 223 ng/mL), and endotoxin levels [0.76 (0.61-0.91) EU/mL] were high at baseline. Comparison of pre- and post-HD variations of serum levels of CRP and endotoxins in the "single use" versus "reuse" phases did not result in differences (p = 0.8 and 0.4, respectively). Samples of liquid in the dialyzer inner chamber were negative for the growth of bacteria or endotoxins. There was no significant clinical manifestation within and between the phases. CONCLUSION: Dialyzers reuse was safe from a clinical, microbiological, and inflammatory point of view. The dialyzer performance remained adequate until the 12th reuse.

Fate of Escherichia coli in dialysis device exposed into sewage influent and activated sludge.

Tracing the fate of pathogens in environmental water, particularly in wastewater, with a suitable methodology is a demanding task. We investigated the fate of Escherichia coli K12 in sewage influent and activated sludge using a novel approach that involves the application of a biologically stable dialysis device. The ion concentrations inside the device could reach that of surrounding solution when it was incubated in phosphate buffered saline for 2 h. E. coli K12 above 107 CFU mL-1 (inoculated in distilled water, influent, activated sludge) were introduced into the device and incubated in influent and activated sludge for 10 days. Without indigenous microorganisms, E. coli K12 could survive even with the limited ions and nutrients concentrations in influent and activated sludge. E. coli K12 abundance in influent and activated sludge were reduced by 60 and 85%, respectively, after just 1 day. The establishment of microbial community in wastewater played an important role in reducing E. coli K12. Bacteriophage propagated in filtered influent or activated sludge when E. coli K12 was introduced, but not in raw influent or activated sludge. The methodology developed in this study can be applied in the actual environmental water to trace the fate of pathogens.

Hemodialyzer Reuse and Gram-Negative Bloodstream Infections.

BACKGROUND: Clusters of bloodstream infections caused by Burkholderia cepacia and Stenotrophomonas maltophilia are uncommon, but have been previously identified in hemodialysis centers that reprocessed dialyzers for reuse on patients. We investigated an outbreak of bloodstream infections caused by B cepacia and S maltophilia among hemodialysis patients in clinics of a dialysis organization. STUDY DESIGN: Outbreak investigation, including matched case-control study. SETTING & PARTICIPANTS: Hemodialysis patients treated in multiple outpatient clinics owned by a dialysis organization. PREDICTORS: Main predictors were dialyzer reuse, dialyzer model, and dialyzer reprocessing practice. OUTCOMES: Case patients had a bloodstream infection caused by B cepacia or S maltophilia; controls were patients without infection dialyzed at the same clinic on the same day as a case; results of environmental cultures and organism typing. RESULTS: 17 cases (9 B cepacia and 8 S maltophilia bloodstream infections) occurred in 5 clinics owned by the same dialysis organization. Case patients were more likely to have received hemodialysis with a dialyzer that had been used more than 6 times (matched OR, 7.03; 95% CI, 1.38-69.76) and to have been dialyzed with a specific reusable dialyzer (Model R) with sealed ends (OR, 22.87; 95% CI, 4.49-∞). No major lapses during dialyzer reprocessing were identified that could explain the outbreak. B cepacia was isolated from samples collected from a dialyzer header-cleaning machine from a clinic with cases and was indistinguishable from a patient isolate collected from the same clinic, by pulsed-field gel electrophoresis. Gram-negative bacteria were isolated from 2 reused Model R dialyzers that had undergone the facility's reprocessing procedure. LIMITATIONS: Limited statistical power and overmatching; few patient isolates and dialyzers available for testing. CONCLUSIONS: This outbreak was likely caused by contamination during reprocessing of reused dialyzers. Results of this and previous investigations demonstrate that exposing patients to reused dialyzers increases the risk for bloodstream infections. To reduce infection risk, providers should consider implementing single dialyzer use whenever possible.

Evaluating Approaches for the Diagnosis of Hemodialysis Catheter-Related Bloodstream Infections.

BACKGROUND AND OBJECTIVES: Guideline-recommended diagnostic criteria for hemodialysis (HD) catheter-related bloodstream infections (CRBSIs) are based on data from indwelling central catheters in patients not on HD and non-HD situations, and upon which peripheral vein cultures are the gold standard. We aimed to examine the validity of these criteria in patients on HD. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS: Adult patients on in-center HD using catheters were prospectively followed from 2011 to 2014 at a large academic-based HD facility (Toronto, Canada). When a CRBSI was suspected, blood culture sets were obtained from four sites (peripheral vein, both catheter hubs, and HD circuit) to determine the guideline-recommended differential time to positivity (DTTP). DTTP criteria were met when catheter hub cultures turned positive ≥120 minutes before peripheral vein cultures. The sensitivity, specificity, and accuracy were first calculated using peripheral vein cultures as the gold standard and then these same calculations were repeated with additional information, including exit site/catheter tip and HD circuit cultures, as the true gold standard. The feasibility of obtaining peripheral vein cultures was determined. RESULTS: Of 178 suspected CRBSIs, 100 had peripheral vein blood cultures. Using the true gold standard, sensitivity, specificity, and accuracy of blood culture results were highest in samples from the HD circuit (93.5%, 100%, and 95%, respectively). The guideline recommended combination of peripheral vein and arterial hub blood cultures was the least sensitive, specific, and accurate (91.7%, 93.1%, and 92.7%, respectively). The diagnostic criteria using measured DTTP were met in less than one third of events. CONCLUSIONS: In patients on HD, blood culture results are the most sensitive, specific, and accurate for diagnosing CRBSIs when taken from the HD circuit and the venous catheter hub, and blood culture results are the least sensitive, specific, and accurate in any combination with peripheral vein cultures. The DTTP does not increase diagnostic accuracy, reducing the necessity for venipuncture and its potential vein damage. Future guidelines should consider the applicability of criterion on specific patient populations and tailor them accordingly.

Evaluation of the effectiveness of manual and automated dialyzers reprocessing after multiple reuses.

A cross-sectional study was conducted to evaluate the effectiveness of manual and automated dialyzer reprocessing. Dialyzers were filled with fluid thioglycollate medium from blood and dialysate chambers after being reprocessed and chemically sterilized with 0.2% peracetic acid. They were incubated for 14 days at 35°C ± 2°C, and microbiologic analysis was performed. Microorganisms were identified in 3 of the 11 samples (27.3%) from the blood chambers: Sphingomonas paucimobilis (2/3) and Penicillium spp (1/3) and in 11 of the 11 samples (100%) from the dialysate chambers: S paucimobilis (7/11), Stenotrophomonas maltophilia (4/11), Pseudomonas aeruginosa (3/11), Candida spp (1/11), and Acinetobacter baumannii (1/11). Of the 4 manually reprocessed dialyzers, gram-positive bacillus were identified in 1 sample (25%) from the blood chamber, and Bacillus spp and Burkholderia spp were identified in 1 sample (25%) from the dialysate chamber. The dialyzers reprocessing can pose risks safety because of exposure patient to microorganisms.

Outbreak of bloodstream infections associated with multiuse dialyzers containing O-rings.

This report details an outbreak investigation conducted by the Los Angeles County Department of Public Health of 3 cases of bacterial infection among patients receiving hemodialysis who were treated at the same dialysis center in 2011. Improper disinfection of reusable dialyzers was hypothesized as the source of transmission.

Novel approach for bacteremia detection in patients with end-stage renal failure undergoing hemodialysis.

Severe systemic infections are one of the leading causes of death in patients with end-stage renal disease and are often associated with hospitalization. Since bacteria can be identified in used hemofilters in an ICU setting, it was investigated whether this method might be useful in patients undergoing regular intermittent hemodialysis. By analyzing used hemodialyzers in (n = 13) patients, we identified systemic bacteremia in two patients (15.4%) while corresponding blood cultures were negative. In two further patients, positive microbiological findings from hemodialyzers appeared to be of unclear clinical relevance. Cultures from hemodialyzers might be an add-on approach for the identification of bacteria in the blood stream of patients undergoing regular intermittent hemodialysis.

Effectiveness of disinfectants used in hemodialysis against both Candida orthopsilosis and C. parapsilosis sensu stricto biofilms.

Biofilms have been observed in the fluid pathways of hemodialysis machines. The impacts of four biocides used for the disinfection of hemodialysis systems were tested against Candida parapsilosis sensu stricto and Candida orthopsilosis biofilms generated by isolates obtained from a hydraulic circuit that were collected in a hemodialysis unit. Acetic acid was shown to be the most effective agent against Candida biofilms. Strategies for effective disinfection procedures used for hemodialysis systems should also seek to kill and inhibit biofilms.

Cat induced Pasteurella multocida peritonitis in peritoneal dialysis: a case report and review of the literature.

A 7-year-old girl treated with peritoneal dialysis developed a peritonitis due to Pasteurella multocida after physical contact of the domestic cat with the dialysis machine. Only 25 of such cases have been reported, mostly concerning adults. We report the third case involving a child, together with a literature review.

Biofilm removal from silicone tubing: an assessment of the efficacy of dialysis machine decontamination procedures using an in vitro model.

The aim of this study was to assess the efficacy of 21 decontamination procedures, for the removal of a multispecies biofilm. Experiments were performed on five-day-old biofilms grown inside silicone tubing, using a reactor system that mimics a dialysis machine. The treatments were tested on 5 cm tubing samples. Effects of treatment were measured using direct microscopy following staining. Bacterial viability and endotoxin removal were determined using conventional microbiological methods following biofilm detachment by scraping. The 21 procedures were classified into four groups based on the amount of biofilm removed. The most effective treatment was an acid pre-treatment, followed by use of a concentrated bleach solution. Acid pre-treatment removes calcium and magnesium carbonate crystals that are always found in dialysis biofilms. Treatments performed at high temperature did not increase the efficacy of biofilm removal. Most treatments caused at least a 10(5)-fold reduction in bacterial viability with a few resulting in complete kill. Autoclaved and bleach-treated samples gave the best results for viability reduction, with both treatments providing an equally effective and complete kill. In addition, autoclaving led to a significant decrease in endotoxin level (removal of 99.99%).

[Sensitivity to disinfectants of Candid albicans strains isolated from the hospital environment]. / Wrazliwosc na srodki dezynfekujace szczepów Candida albicans izolowanych ze srodowiska szpitalnego.

In recent years an increase of the incidence of Candida infections caused mainly by C. albicans strains especially in high risk inpatients with neoplasms, decreased immunity, burns and after treatment with multiple antibiotics has been observed. Candida organisms are particularly dangerous for newborns being responsible for about 30% of septicaemia cases in newborns in intensive care units. Fungal infections can be endogenous in origin but exogenous infection sources occur in hospitals. The cause of the latter are errors in aseptic management and insufficiently disinfected medical instruments and equipment. The purpose of the study was a comparison of the sensitivity to disinfectants of C. albicans belonging to two laboratory strains C. albicans PZH and C. albicans ATCC 10231 used for the determination of concentrations of two disinfectants used. Besides that, this sensitivity was determined in 14 strains isolated from the patients and one from the circuit of dialysis solution supply to artificial kidney. The study was carried out by the qualitative suspension method, in which the cells in the fluid were subjected to the action of disinfectants, and by the carrier method in which the cells of the microorganisms were present on the surface of metal cylinders. By the suspension method the sensitivity was determined to chloramine T in concentrations from 5.0% to 0.001%, formalin from 10.0% to 0.25%, glutaraldehyde from 2.0% to 0.1%, Septyl from 3.5% to 0.25%. The exposure time was 5, 10, 15, 30 and 60 minutes. The tested strains differed in their sensitivity to the disinfectants used. The greatest interstrain differences were observed in the sensitivity to the disinfectants used. The greatest interstrain differences were observed in the sensitivity to chloramine T. The highest concentrations were tolerated by the strains isolated from the patients and from the artificial kidney circuit as well as by the standard strain ATCC 10231. In the 10-minute exposure time accepted by us as comparison standard these strains were 200-time less susceptible to chloramine than the standard C. albicans PZH strain. Two strain isolated from the patients were tenfold as sensitivive. The sensitivity to the remaining tested disinfectants showed less evident differences. The sensitivity of the strains from the patients to formalin was similar to that of the standard PZH strain. A similar sensitivity was found to Septyl, with the exception of the strain from the artificial kidney circuit which was sevenfold less sensitive than the PZH strain. In the case of glutaraldehyde 9 strains from the patients and the ATCC 10231 strain were two or four times less sensitive than the PZH strain. No cross-sensitivity or tolerance to the disinfectants were noted in the study. Both standard strains were similarly sensitive to formalin, but the ATCC 10231 strain was less sensitive to Septyl, glutaraldehyde and chloramine T. In the experiment by the carrier method the effect was evidenced of the surface on the action of disinfectants. This was particularly evident in the case of chloramine T. Even in sensitive strains the disinfection parameters (concentration and exposure time) were significantly higher than in the suspension method. The least sensitive strains survived the effect of 5% chloramine during 2 hours of exposure. Septyl in the working concentration 2.5% at 10-minute exposure time disinfected all carriers with the exception of that carrying the strain isolated from the artificial kidney circuit, which survived 15% Septyl exposure during 10 minutes. The disinfectant Aldesan (2% glutaraldehyde) and formalin 8% killed all fungi during 10 minutes. The study shows that the sensitivity of C. albicans strains to disinfectants varies. For the assessment of the fungicidal action of disinfectants the standard test ATCC 10231 should be used since its sensitivity was similar to that of most strains from the patients and medical equipment. (ABSTRACT TRUNCATED)