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Contaminated Product Water as the Source of Phialemonium curvatum Bloodstream Infection among Patients Undergoing Hemodialysis

Published online by Cambridge University Press:  02 January 2015

Carol Y. Rao ,
Constance Pachucki ,
Salvatore Cali ,
Mangai Santhiraj ,
Kathi L. K. Krankoski ,
Judith A. Noble-Wang ,
David Leehey ,
Subhash Popli ,
Mary E. Brandt  and
Mark D. Lindsley
...Show all authors
Carol Y. Rao*
Affiliation:
Divisions of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Constance Pachucki
Affiliation:
Edward Hines Jr., Veterans Affairs Hospital, Hines, Illinois
Salvatore Cali
Affiliation:
University of Illinois at Chicago School of Public Health, Chicago, Illinois
Mangai Santhiraj
Affiliation:
Edward Hines Jr., Veterans Affairs Hospital, Hines, Illinois
Kathi L. K. Krankoski
Affiliation:
Edward Hines Jr., Veterans Affairs Hospital, Hines, Illinois
Judith A. Noble-Wang
Affiliation:
Divisions of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
David Leehey
Affiliation:
Edward Hines Jr., Veterans Affairs Hospital, Hines, Illinois
Subhash Popli
Affiliation:
Edward Hines Jr., Veterans Affairs Hospital, Hines, Illinois
Mary E. Brandt
Affiliation:
Foodborne, Bacterial, and Mycotic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Mark D. Lindsley
Affiliation:
Foodborne, Bacterial, and Mycotic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Scott K. Fridkin
Affiliation:
Divisions of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Matthew J. Arduino
Affiliation:
Divisions of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
*
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop A-35, Atlanta, GA, 30333 ([email protected])
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Abstract

Objective.

We investigated a cluster of cases of bloodstream infection (BSI) due to the mold Phialemonium at a hemodialysis center in Illinois and conducted a cohort study to identify risk factors.

Design.

Environmental assessment and cohort study.

Setting.

A hemodialysis center in a tertiary care hospital.

Methods.

A case patient was defined as a person who underwent dialysis at the center and had a blood sample that tested positive for Phialemonium curvatum on culture. We reviewed microbiology and medical records and tested water, surface, and dialysate samples by culture. Molds isolated from environmental and clinical specimens were identified by their morphological features and confirmed by sequencing DNA.

Results.

We identified 2 case patients with BSI due to P. curvatum. Both became febrile and hypotensive while undergoing dialysis on the same machine at the same treatment station, although on different days. Dialysis machines were equipped with waste handling option ports that are used to discard dialyzer priming fluid. We isolated P. curvatum from the product water (ie, water used for dialysis purposes) at 2 of 19 treatment stations, one of which was the implicated station.

Conclusion.

The source of P. curvatum was likely the water distribution system. To our knowledge, this is the first report of patients acquiring a mold BSI from contaminated product water. The route of exposure in these cases of BSI due to P. curvatum may be related to the malfunction and improper maintenance of the waste handling option ports. Waste handling option ports have been previously implicated as the source of bacterial BSI due to the backflow of waste fluid into a patient's blood line. No additional cases of infection were noted after remediation of the water distribution system and after discontinuing use of waste handling option ports at the facility.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 30 , Issue 9 , September 2009 , pp. 840 - 847
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2009

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References

1. US Renal Data System (USRDS) 2007 annual data report: atlas of chronic kidney disease and end-stage renal disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2007.Google Scholar
2.Taylor, G, Gravel, D, Johnston, L, Embil, J, Holton, D, Paton, S.; Canadian Nosocomial Infection Surveillance Program; Canadian Hospital Epidemiology Committee. Incidence of bloodstream infection in multicenter inception cohorts of hemodialysis patients. Am J Infect Control 2004;32:155–160.CrossRefGoogle ScholarPubMed
3.Hoen, B, Paul-Dauphin, A, Hestin, D, Kessler, M. EPIBACDIAL: A multicenter prospective study of risk factors for bacteremia in chronic hemodialysis patients. J Am Soc Nephrol 1998;9:869–876.Google Scholar
4.Oie, S, Kamiya, A, Yoneda, I, et al.Microbial contamination of dialysate and its prevention in haemodialysis units. J Hosp Infect 2003;54:115–119.Google Scholar
5.Tokars, JI, Arduino, MJ, Alter, MJ. Infection control in hemodialysis units. Infect Dis Clin North Am 2001;15:797–812.Google Scholar
6.Grohskopf, LA, Roth, VR, Feikin, DR, et al.Serratia liquefaciens bloodstream infections from contamination of epoetin alfa at a hemodialysis center. N Engl J Med 2001;344:1491–1497.Google Scholar
7.Jackson, BM, Becksague, CM, Bland, LA, Arduino, MJ, Meyer, L, Jarvis, WR. Outbreak of pyrogenic reactions and gram-negative bacteremia in a hemodialysis center. Am J Nephrol 1994;14:85–89.CrossRefGoogle Scholar
8.Tokars, JI, Miller, ER, Stein, G. New national surveillance system for he-modialysis-associated infections: initial results. Am J Infect Control 2002;30:288–295.Google Scholar
9.Gams, W, McGinnis, MR. Phialemonium, a new anamorph genus intermediate between Phialophora and Acremonium. Mycologia 1983;75:977–987.Google Scholar
10.Gavin, PJ, Sutton, DA, Katz, BZ. Fatal endocarditis in a neonate caused by the dematiaceous fungus Phialemonium obovatum: case report and review of the literature. J Clin Microbiol 2002;40:2207–2212.CrossRefGoogle Scholar
11.Guarro, J, Nucci, M, Akiti, T, et al.Phialemonium fungemia: two documented nosocomial cases. J Clin Microbiol 1999;37:2493–2497.CrossRefGoogle ScholarPubMed
12.Heins-Vaccari, EM, Machado, CM, Saboya, RS, et al.Phialemonium curvatum infection after bone marrow transplantation. Rev Inst Med Trop Sao Paulo 2001;43:163–166.Google Scholar
13.King, D, Pasarell, L, Dixon, DM, McGinnis, MR, Merz, WG. A pheohyphomy-cotic cyst and peritonitis caused by Phialemonium species and a réévaluation of its taxonomy. J Clin Microbiol 1993;31:1804–1810.Google Scholar
14.McGinnis, MR, Gams, W, Goodwin, MN. Phialemonium obovatum infection in a burned child. J Med Vet Mycol 1986;24:51–55.Google Scholar
15.Proia, LA, Hayden, MK, Kammeyer, PL, et al.Phialemonium: an emerging mold pathogen that caused 4 cases of hemodialysis-associated endovas-cular infection. Clin Infect Dis 2004;39:373–379.CrossRefGoogle ScholarPubMed
16.Schanheyder, HC, Jensen, HE, Gams, W, et al.Late bioprosthetic valve endocarditis caused by Phialemonium aff. curvatum and Streptococcus sanguis: a case report. J Med Vet Mycol 1996;34:209–214.Google Scholar
17.Scott, RS, Sutton, DA, Jagirdar, J. Lung infection due to opportunistic fungus, Phialemonium obovatum, in a bone marrow transplant recipient: an emerging infection with fungemia and Crohn disease-like involvement of the gastrointestinal tract. Ann Diagn Pathol 2005;9:227–230.Google Scholar
18.Strahilevitz, J, Rahav, G, Schroers, HJ, et al.An outbreak of Phialemonium infective endocarditis linked to intracavernous penile injections for the treatment of impotence. Clin Infect Dis 2005;40:781–786.Google Scholar
19.Zayit-Soudry, S, Neudorfer, M, Barak, A, Loewenstein, A, Bash, E, Siegman-Igra, Y. Endogenous Phialemonium curvatum endophthalmitis. Am J Ophthalmol 2005;140:755–757.Google Scholar
20.Dan, M, Yossepowitch, O, Hendel, D, Shwartz, O, Sutton, DA. Phialemonium curvatum arthritis of the knee following intra-articular injection of a corticosteroid. Med Mycol 2006;44:571–574.Google Scholar
21.Clark, T, Huhn, GD, Conover, C, et al.Outbreak of bloodstream infection with the mold Phialemonium among patients receiving dialysis at a hemodialysis unit. Infect Control Hosp Epidemiol 2006;27:1164–1170.CrossRefGoogle Scholar
22.Centers for Disease Control and Prevention. Guidelines for environmental infection control in health-care facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 2003;52(RR-10):1–44.Google Scholar
23.Association for the Advancement of Medical Instrumentation. ANSI/AAMI RD52:2004: dialysate for hemodialysis. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2004.Google Scholar
24.GAMBRO Renal Care Products. COBE Waste Handling Option (WHO): instructions for use with the COBE Centrysystem 3 family of dialysis delivery systems. Lakewood, CO: GAMBRO Renal Care Products, Inc.; 1999.Google Scholar
25.Jornet, AR, Garcia, AG, Mariscal, D, et al.An outbreak of gram-negative bacteremia (GNB), especially Enterobacter cloacae, in patients with long-term tunnelled haemodialysis catheters. Nefrologia 2003;23:333–343.Google Scholar
26.Azadian, BS, Beck, A, Curtis, JR, et al.Disseminated infection with Mycobacterium chelonei in a haemodialysis patient. Tubercle 1981;62:281–284.Google Scholar
27.Block, C, Backenroth, R, Gershon, E, et al.Outbreak of bloodstream infectious associated with dialysis machine waste ports in a hemodialysis facility. Eur J Clin Microbiol Infect Dis 1999;18:723–725.Google Scholar
28.Wang, SA, Levine, RB, Carson, LA, et al.An outbreak of gram-negative bacteremia in hemodialysis patients traced to hemodialysis machine waste drain ports. Infect Control Hosp Epidemiol 1999;20:746–751.Google Scholar
29.Olver, WJ, Webster, C, Clements, H, Weston, V, Boswell, T. Two cases of Enterococcus faecalis bacteremia associated with a hemodialysis machine. J Infect Dis 1999;179:1312–1312.Google Scholar
30.Jochimsen, EM, Frenette, C, Delorme, M, et al.A cluster of bloodstream infections and pyrogenic reactions among hemodialysis patients traced to dialysis machine waste-handling option units. Am J Nephrol 1998;18:485–489.Google Scholar
31.Arnow, PM, Garcia-Houchins, S, Neagle, MB, Bova, JL, Dillon, JJ, Chou, T. An outbreak of bloodstream infections arising from hemodialysis equipment. J Infect Dis 1998;178:783–791.Google Scholar
32.Centers for Disease Control and Prevention. Outbreaks of gram-negative bacterial bloodstream infections traced to probable contamination of hemodialysis machines—Canada, 1995;United States, 1997;and Israel, 1997. MMWR Morb Mortal Wkly Rep 1998;47:55–59.Google Scholar
33.Arvanitidou, M, Spaia, S, Velegraki, A, et al.High level of recovery of fungi from water and dialysate in haemodialysis units. J Hosp Infect 2000;45:225–230.CrossRefGoogle ScholarPubMed
34.Klein, E, Pass, T, Harding, GB, Wright, R, Million, C. Microbial and endotoxin contamination in water and dialysate in the central United States. Artif Organs 1990;14:85–94.CrossRefGoogle ScholarPubMed
35.Bambauer, R, Schauer, M, Jung, WK, Daum, V, Vienken, J. Contamination of dialysis water and dialysate. A survey of 30 centers. ASAIO J 1994;40:1012–1016.Google Scholar
36.Centers for Disease Control and Prevention. Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR Recomm Rep 2001;50(RR-5):1–43.Google Scholar
37.Finelli, L, Miller, JT, Tokars, JI, Alter, MJ, Arduino, MJ. National surveillance of dialysis-associated diseases in the United States, 2002. Semin Dial 2005;18:52–61.Google Scholar