Confronting and eradicating an epidemic of bacteraemia.

Obtaining vascular access by catheterisation is a good option, especially in patients with vascular system fragility. In the authors' department, there was an increase in Gram Negative Bacillus (GNB) infection in patients with long term catheters (LTC). An objective was set to design an action plan and a new working methodology in order to eradicate the infection and the cause. Three periods were established in the prospective follow-up of LTC patients: the pre-epidemic period (01/94 to 03/99), with a bacteraemia every 144 days per patient, the epidemic period (04/99 to 12/00) with a bacteraemia every ten days per patient, and the post-epidemic period (01/01 to 04/02). A multidisciplinary working group was established, which produced action plans for nursing and technical staff. The working methodology of the service was studied and analysed by means of a review. The deionised water cultures at the entrance to the haemodialysis ward were negative. The dialysis and connector cultures were positive for GNB, confirming that they were of the same genetic origin. An evaluation of the periods was carried out, studying the working methodology, to which no changes were made between the pre-epidemic and epidemic period. In the post-epidemic period, a number of changes were made to the care dynamic, with no other bacteraemia arising to date. Adapting and improving protocols is a good indicator of quality. The role of nursing staff is vital in prevention of GNB.

[An outbreak of gram-negative bacteremia (GNB), especially enterobacter cloacae, in patients with long-term tunnelled haemodialysis catheters]. / Brote epidémico de bacteriemias por bacilos gram-negativos (BGN), especialmente enterobacter cloacae, en una unidad de hemodiálisis, en pacientes portadores de catéteres permanentes tunelizados.

Vascular access through a venous catheter for haemodialysis is associated with increased risk of thrombosis, central venous stenosis, short access survival and inadequate dialysis. The most important catheter-related complications, which determine method survival, are infection and dysfunction. In particular, infectious episodes are in some studies the leading cause for untimely catheter removal and for catheter-related morbidity but also for morbidity in dialysis patients. Double-lumen central venous catheters used for haemodialysis, are common causes of septicaemia. Most cases are caused by staphylococci. Episodes of gram-negative bacteriemia have been traced to bacterial contamination of water and/or dialysate, errors in dialyzer reprocessing, and improper setup procedures. In this paper, we describe and outbreak of gram-negative bacteremia, firstly E. cloacae, in an outpatients haemodialysis unit, in the patients with long-term tunnelled haemodialysis catheters. We describe the epidemic investigation that we achieved to identify the source of contaminating bacteria and the route by which bacteria gained access to the bloodstream. We prove the contamination by gram-negative bacterium of the water-distribution lines and haemodialysis machines. Moreover, E. cloacae strains isolated from the lines and machines are genotypically identical to the isolated from the patients. Also, we prove that the hands of health care personnel are unintentional carriers. The outbreak was finished when decontamination of dialysis machines was enhanced and dialyzer-priming fluid was modified.

Brote epidémico de bacteriemias por bacilos gram-negativos (BGN), especialmente enterobacter cloacae, en una unidad de hemodiálisis, en pacientes portadores de catéteres permanentes tunelizados / An outbreak of Gram-Negative Bacteremia (GNB), especially Enterobacter Cloacae, in patients with long-term tunnelled haemodialysis catheters

Se considera a los catéteres permanentes tunelizados un acceso vascular para hemodiálisis de segundo orden por la morbilidad más elevada que comportan respecto a otros accesos. Las complicaciones son más numerosas, y se relacionan especialmente con la trombosis parcial que origina disfunción en la diálisis, y con las infecciones. Estas últimas pueden originar bacteriemias, mayoritariamente debidas a cocos gram-positivos, estafilococos sobre todo. Las infecciones por bacilos gram-negativos (BGN) son más excepcionales y su origen, aún hoy en día, no está explicado. En las Unidades de Hemodiálisis, se han descrito brotes epidémicos relacionados con la contaminación accidental del agua tratada, del líquido de diálisis o del material accesorio de las máquinas. Describimos un brote epidémico de bacteriemias por BGN, especialmente Enterobacter cloacae, en la Unidad de Hemodiálisis de pacientes crónicos, en enfermos portadores de catéteres permanentes tunelizados. Detallamos minuciosamente los pasos seguidos para intentar descubrir el origen de las bacteriemias, consiguiendo finalmente demostrar la contaminación por BGN de los accesorios de los monitores de hemodiálisis, y el papel humano como vector transmisor involuntario. Establecemos la relación genética entre las cepas de E. cloacae aisladas en los hemocultivos de los pacientes y en los accesorios contaminados de los monitores de hemodiálisis. Tras el aumento de la desinfección de los accesorios de los monitores de diálisis y el cambio en el modo de cebado de los dializadores, se ha conseguido erradicar las bacteriemias por BGN en nuestra Unidad

Vascular access through a venous catheter for haemodialysis is associated with increased rik of thrombosis, central venous stenosis, short access survival and inadequate dialysis. The most important catheter-related complications, which determine method survival, are infection and dysfunction. In particular, infectious episodes are in some studies the leading cause for untimely catheter removal and for catheter-related morbidity but also for morbidity in dialysis patients. Double-lumen central venous catheters used for haemodialysis, are common causes of septicaemia. Most cases are caused by staphylococci. Episodes of gram-negative bacteriemia have been traced to bacterial contamination of water and/or dialysate, errors in dialyzer reprocessing, and improper setup procedures. In this paper, we describe and outbreak of gram-negative bacteremia, firstly E. cloacae, in an outpatients haemodialysis unit, in the patients with long-term tunnelled haemodialysis catheters. We describe the epidemic investigation that we achieved to identify the source of cantaminating bacteria and the route by which bacteria gained access to the bloodstream. We prove the contamination by gramnegative bacterium of the water-distribution lines and haemodialysis machines. Moreover, E. cloacae strains isolated from the lines and machines are genotypically identical to the isolated from the patients. Also, we prove that the hands of health care personnel are unintentional carriers. The outbreak was finished when decontamination of dialysis machines was enhanced and dialyser-priming fluid was modified