Table 3.
An overview of all the hemodialysis related outbreaks in hospitals with the number of cases with the respective strains
| Study | Country | Strain | N of cultures, (%) | N of cases, (%) | Mortality, N (%) | Cause of the outbreak |
|---|---|---|---|---|---|---|
| CDC [21] | Canada | Enterobacter cloacae | NA | 9 | Unknown | Waste handling option (WHO) porta: Incompetent one-way valve of the drain line waste of the dialysis machine → backflow |
| CDC and Wang et al. [21, 22] | United States |
1. Enterobacter cloacae 2. Pseudomonas aeruginosa 3. Escherichia coli |
1. 14 out of 26 machines (53.8) 2. 7 out of 26 machines (26.9) 3. Unknown |
N = 10 1. 6 (60.0) 2. 4 (40.0) 3. 2 (20.0) Two were polymicrobial |
Unknown |
WHO porta: Incompetent valves on waste drain lines. Cross-contamination of hemodialysis central venous catheters from the WHO port: Reflux from the waste drain line into the WHOa port Bacterial growth in the nutrient-rich environment of the WHOa port |
| Rao et al. [23] | United States | Phialemonium curvatum | 2 out of 19 treatment stations (10.5) | 2 | Unknown | Malfunction and improper maintenance of WHOa port |
| CDC [21] | Israel |
1. Enterobacter cloacae 2. Pseudomonas aeruginosa 3. Escherichia coli 4. Stenotrophomonas maltophilia |
6 out of 13 dialysis machines (46.1) |
N = 8 1. 2 (25.0) 2. 3 (37.5) 3. 4 (50.0) 4. 1 (12.5) |
Unknown | Backflow of the WHOa port |
| Yan et al. [24] | China | Burkholderia cepacia | NA | 9 | Unknown | Reverse osmosis water |
| Souva et al. [14] | Brazil | Burkholderia cepacia | 33 | 28 | Unknown | Inadequate cleaning procedures → leaking connections of the reverse osmosis tubing |
| Magalhaes et al. [16] | Brazil |
1. Burkholderia cepacia 2. Staphylococcus aureus 3. Streptococcus agalactiae 4. Enterobacter aerogenes 5. Pseudomonas aeruginosa 6. Acinetobacter baumanii |
37 |
N = 14 1. 6 (42.9) 2. 4 (28.6) 3. 1 (7.1) 4. 1 (7.1) 5. 1 (7.1) 6. 1 (7.1) |
Unknown | Probable colonization in the reverse osmosis membrane |
| Nazemi et al. [25] | Iran |
1. Legionella pneumophila 2. Pseudomonas aeruginosa 3. Staphylococcus aureus 4. Escherichia coli 5. Burkholderia cepacia 6. Gram-positive cocci |
24 out of 50 samples (48.0) 1. 4 (16.7) 2. 6 (25.0) 3. 3 (12.6) 4. 3 (12.5) 5. 2 (8.3) 6. 6 (25.0) |
NA | NA | Most commonly during reverse osmosis, in the storage tank and dialysate effluent |
| Kaitwatcharachai et al. [15] | Thailand | Burkholderia cepacian | NA | 9 | 1 (11.1) | Deionized water used to dilute the dialysate concentrate and the in-use dialysis fluid |
| Oie et al. [26] | Japan |
1. Moraxella spp 2. Pseudomonas aeruginosa 3. Gram-negative bacteria 4. Sphingomonas paucimobilis 5. Ralstonia pickettii 6. Pseudomonas stutzeri 7. Pasteurella multocida |
17 out of 40 (42.5) dialysate samples showed bacterial count exceeding the AAMI standard |
1. 10 (25.0) 2. 8 (20.0) 3. 6 (15.0) 4. 5 (12.5) 5. 2 (5.0) 6. 2 (5.0) 7. 2 (5.0) |
NA | Tubing within the dialysis machine may be the site of biofilm development |
| Arnow et al. [20] | United States |
1. Enterobacter cloacae 2. Stenotrophomonas maltophilia 3. Enterococcus faecalis 4. Acinetobacter baumannii 5. Candida parapsilosis 6. Candida tropicalis 7. Pseudomonas aeruginosa 8. Alcaligenes xylosoxidans 9. Serratia marcescens 10. Acinetobacter Iwoffi 11. Enterococcus faecium 12. Klebsiella pneumoniae 13. Flavobacterium species 14. Lactobacillus species 15. Burkholderia pickettii 16. Pseudomonas stutzeri |
Unknown |
N = 29 1. 7 (24.1) 2. 7 (24.1) 3. 6 (20.7) 4. 5 (17.2) 5. 4 (13.8) 6. 3 (10.3) 7. 3 (10.3) 8. 3 (10.3) 9. 2 (6.9) 10. 1 (3.4) 11. 1 (3.4) 12. 1 (3.4) 12. 1 (3.4) 13. 1 (3.4) 14. 1 (3.4) 15. 1 (3.4) |
1b (3.4) | Microbial growth in the outer portion of the WHOa port despite circulation of a disinfectant through the fluid pathway deeper in the lumen |
| Olver et al. [27] | United Kingdom | Enterococcus faecali | NA | 2 | NA | WHOa port cannot be cleaned adequately |
aWHO port: Waste handling option port: a drain port to dispose of saline used to flush the dialyser before patient use
bUnrelated to the bloodstream infection