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Dialysis Patient Safety

Dialysis-Related Outbreaks

Bacterial and Fungal Infections

• Rao CY, Pachucki C, Cali S, Santhiraj M, Krankoski KL, Noble-Wang JA, Leehey D, Popli S, Brandt ME, Lindsley MD, Fridkin SK, Arduino MJ. Contaminated product water as the source of Phialemonium curvatum bloodstream infection among patients undergoing hemodialysis. Infect Control Hosp Epidemiol. 2009 Jul 17. [Epub ahead of print].
• Clark T, Huhn GD, Connover C, Cali S, Arduino MJ, Hajjeh R, Brandt ME, Fridkin SK. Outbreak of bloodstream infection with the mold Phialemonium among patients receiving dialysis at a hemodialysis unit. PDF (180 KB / 7 pages) Infect Control Hospital Epidemiol 2006;27(11):1164-70.
• McDonald LC, Hageman JC. Vancomycin intermediate and resistant Staphylococcus aureus. What the nephrologist needs to know. Nephrol News Issues. 2004 Oct;18(11):63-4, 66-7, 71-2
• CDC. Tuberculosis Transmission in a Renal Dialysis Center --- Nevada, 2003. MMWR 2004; 53(37);873-875.
• CDC. Staphylococcus aureus Resistant to Vancomycin --- United States, 2002. MMWR 2002; 51(26);565-567.
• Tokars JI, Gehr T, Jarvis WR, Anderson J, Armistead N, Miller ER, Parrish J, Qaiyumi S, Arduino M, Holt SC, Tenover FC, Westbrook G, Light P. Related Articles Vancomycin-resistant enterococci colonization in patients at seven hemodialysis centers. Kidney Int. 2001 Oct;60(4):1511-6.
• Grohskopf LA, Roth VR, Feikin DR, Arduino MJ, Carson LA, Tokars JI, Holt SC, Jensen BJ, Hoffman RE, Jarvis WR. Serratia liquefaciens bloodstream infections from contamination of epoetin alfa at a hemodialysis center. PDF (192 KB/ 7 pages) N Engl J Med 2001; 344(20):1491-1497
• CDC. Staphylococcus aureus with Reduced Susceptibility to Vancomycin -- Illinois, 1999. MMWR 2000; 48(51);1165-1167.
• Wang SA, Levine RB, Carson LA, Arduino MJ, Killar T, Grillow FG, Pearson ML, Jarvis WR. An outbreak of gram-negative bacteremia in hemodialysis patients traced to a hemodialysis machine waste drain ports. PDF (79 KB / 6 pages) Infect Control Hospital Epidemiol 1999; 20 (11): 746-751
• Jochimsen EM, Frenette C, Delorme M, Arduino M, Aguero S, Carson L, Ismail J, Lapierre S, Czyziw E, Tokars JI, Jarvis WR. A cluster of bloodstream infections and pyrogenic reactions among hemodialysis patients traced to dialysis machine waste-handling option units. Am J Nephrol 1998; 18(6): 485-489
• Welbel SF, Schoendorf K, Bland LA, Arduino MJ, Groves CG, Schable B, O'Hara CM, Tenover FC, Jarvis WR. An outbreak of gram-negative bloodstream infections in chronic hemodialysis patients. Am J Nephrol 1995; 15(1):1-4
• Jackson BM, Becke-Sague MC, Bland LA, Arduino MJ, Meyers L, Jarvis WR. Pyrogenic reactions and gram-negative bacteremia in a hemodialysis center. Am J Nephrol 1994; 14:85-89
• Lowry PW, Beck-Sague CM, Bland LA, Aguero SM, Arduino MJ, Minuth AN, Murray RA, Swenson JM, Jarvis WR. Mycobacterium chelonae infections among patients receiving high flux dialysis in a hemodialysis clinic, California. J Infect Dis 1990;161:85-90
• Beck-Sague C, Jarvis WR, Bland LA, Arduino MJ, Aguero SM, Verosec G. Outbreak of Gram-negative bacteremia and pyrogenic reactions in a hemodialysis center. Am J Nephrol 1990; 10:397-403
• CDC. Contaminated Povidone-Iodine Solution -- Texas. MMWR 1988; 38(8);133-134.
• Bolan G, Reingold AL, Carson LA, Silcox VA, Woodley CL, Hayes PS, Hightower AW, McFarland L, Brown JW 3rd, Petersen NJ, et al. Infections with Mycobacterium chelonei in patients receiving dialysis and using processed hemodialyzers. J Infect Dis. 1985;152(5):1013-9.
• Kantor RJ, Carson LA, Graham DR, Petersen NJ, Favero MS. Outbreak of pyrogenic reactions at a dialysis center. Association with infusion of heparinized saline solution. Am J Med. 1983;74(3):449-56.
• CDC. Epidemiologic Notes and Reports Nontuberculous Mycobacterial Infections in Hemodialysis Patients -- Louisiana, 1982. MMWR 1983; 32(18);244-6
• Band JD, Ward JI, Fraser DW, Peterson NJ, Silcox VA, Good RC, Ostroy PR, Kennedy J. Peritonitis due to a mycobacterium chelonei-like organism associated with intermittent chronic peritoneal dialysis. J Infect Dis. 1982;145(1):9-17.
• CDC. Epidemiologic Notes and Reports Pseudomonas aeruginosa Peritonitis Attributed to a Contaminated Iodophor Solution -- Georgia. MMWR 1982;31(15)197-8
• Berkelman RL, Godley J, Weber JA, Anderson RL, Lerner AM, Petersen NJ, Allen JR. Pseudomonas cepacia peritonitis associated with contamination of automatic peritoneal dialysis machines. Ann Intern Med. 1982;96(4):456-8.

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Viral Infections

• Thompson ND, Novak RT, Datta D, Cotter S, Arduino MJ, Patel PR, Williams IT, Bialek SR. Hepatitis C virus transmission in hemodialysis units: importance of infection control practices and aseptic technique. Infect Control Hosp Epidemiol. 2009 Sep;30(9):900-3.
• CDC. Hepatitis C Virus Transmission at an Outpatient Hemodialysis Unit --- New York, 2001--2008. MMWR 2009; 58(08);189-194
• Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med. 2009;150(1):33-9.
• El Sayed NM, Gomatos PJ, Beck-Sagué CM, Dietrich U, von Briesen H, Osmanov S, Esparza J, Arthur RR, Wahdan MH, Jarvis WR. Epidemic transmission of human immunodeficiency virus in renal dialysis centers in Egypt. PDF (290 KB / 7 pages) J Infect Dis. 2000;181(1):91-7.
• Hutin YJ, Goldstein ST, Varma JK, O'Dair JB, Mast EE, Shapiro CN, Alter MJ. An outbreak of hospital-acquired hepatitis B virus infection among patients receiving chronic hemodialysis. PDF (77 KB / 5 pages) Infect Control Hosp Epidemiol. 1999;20(11):731-5.
• CDC. Outbreaks of Hepatitis B Virus Infection Among Hemodialysis Patients -- California, Nebraska, and Texas, 1994. MMWR 1996; 45(14);285-9.
• Velandia M, Fridkin SK, Cárdenas V, Boshell J, Ramirez G, Bland L, Iglesias A, Jarvis W. Transmission of HIV in dialysis centre. Lancet. 1995;345(8962):1417-22.
• Outbreaks of hepatitis B virus infection among hemodialysis patients-1994. MMWR April 12, 1996;45(14);285-9
• Niu MT, Alter MJ, Kristensen C, Margolis HS. Outbreak of hemodialysis-associated non-A, non-B hepatitis and correlation with antibody to hepatitis C virus. Am J Kidney Dis. 1992;19(4):345-52.
• Lettau LA, Alfred HJ, Glew RH, Fields HA, Alter MJ, Meyer R, Hadler SC, Maynard JE. Nosocomial transmission of delta hepatitis. Ann Intern Med. 1986;104(5):631-5.
• Alter MJ, Ahtone J, Maynard JE. Hepatitis B virus transmission associated with a multiple-dose vial in a hemodialysis unit. Ann Intern Med. 1983;99(3):330-3.

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Microbial toxins

• Jochimsen EM, Carmichael WW, An JS, Cardo DM, Cookson ST, Holmes CE, Antunes MB, de Melo Filho DA, Lyra TM, Barreto VS, Azevedo SM, Jarvis WR. Liver failure and death after exposure to microcystins at a hemodialysis center in Brazil. N Engl J Med. 1998 Mar 26;338(13):873-8. Erratum in: N Engl J Med 1998 Jul 9;339(2):139.
• Mangram AJ, Archibald LK, Hupert M, Tokars JI, Silver LC, Brennan P, Arduino M, Peterson S, Parks S, Raymond A, McCullough M, Jones M, Wasserstein A, Kobrin S, Jarvis WR. Outbreak of sterile peritonitis among cycling continuos peritoneal dialysis patients. Kidney Int 1998; 54(4): 1367-1371
• Rudnick JR, Arduino MJ, Bland LA, Cusick L, McAllister SK, Aguero SM, Jarvis WR. An outbreak of pyrogenic reactions in a chronic hemodialysis center associated with hemodialyzer reuse. Artif Organs 1995; 19: 289-294
• Gordon SM, Tipple M, Bland LA, Jarvis WR. Pyrogenic reactions associated with the reuse of disposable hollow-fiber hemodialyzers. JAMA. 1988;260(14):2077-81.
• Gutman RA, Shelburne JD, Peterson NJ, Carson LA, Favero MS. Aseptic peritonitis with home peritoneal dialysis. N Engl J Med. 1977;297(14):788.
• Hindman SH, Favero MS, Carson LA, Petersen NJ, Schonberger LB, Solano JT. Pyrogenic reactions during haemodialysis caused by extramural endotoxin. Lancet. 1975;2(7938):732-4.

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Chemical Intoxication

• CDC. Elevated Serum Aluminum Levels in Hemodialysis Patients Associated with Use of Electric Pumps --- Wyoming, 2007. MMWR 2008; 57(25):689-691.
• Selenic D, Alvarado-Ramy F, Arduino M, Holt S, Cardinali F, Blount B, Jarrett J, Smith F, Altman N Stahl C, Panlilio A,1 Pearson M, Tokars J. Epidemic parenteral exposure to volatile sulfur-containing compounds at a hemodialysis center. Infect Control Hospital Epidemiol 2004; 25(3):256-261.
• Hutter JC, Kuehnert MJ, Wallis RR, Lucas AD, Sen S, Jarvis WR. Acute onset of decreased vision and hearing traced to hemodialysis treatment with aged dialyzers. JAMA. 2000;283(16):2128-34.
• FDA/CDC. Important Information Relating to Cellulose Acetate Dialyzers. FDA, CDRH, Public health Notification 1996.
• Burwen DR, Olsen SM, Bland LA, Arduino MJ, Reid MH, Jarvis WR. Epidemic aluminum intoxication in hemodialysis patients traced to use of an aluminum pump. Kidney Int 1995; 48:469-474
• Arnow PM, Bland LA, Garcia-Houchins S, Fridkin S, Fellner SK. An outbreak of fatal fluoride intoxication in a long-term hemodialysis unit. Ann Intern Med. 1994 1;121(5):339-44.
• Tipple MA, Shusterman N, Bland LA, McCarthy MA, Favero MS, Reid MH, Arduino MJ, Jarvis WR. Illness in hemodialysis patients following exposure to chloramine-contaminated dialysate. ASAIO Trans 1991; 37:588-591
• Gordon SM, Drachman J, Bland LA, Reid MH, Favero M, Jarvis WR. Epidemic hypotension in a dialysis center caused by sodium azide. PDF (596 KB / 6 pages) Kidney Int. 1990;37(1):110-5.
• Gordon SM, Bland LA, Alexander SR, Newman HF, Arduino MJ, Jarvis WR. Hemolysis associated with hydrogen peroxide at a pediatric facility. Am J Nephrol 1990; 10 (2):123-127
• Arduino MJ, Bland LA, Favero MS. Adverse patient reactions due to chemical contamination of hemodialysis fluids. Dialysis Transplant 1989;18:655-658
• Tipple MA, Bland LA, Favero MS, Jarvis WR. Investigation of hemolytic anemia after chloramine exposure in a dialysis center. ASAIO Trans. 1988;34(4):1060 [letter to editor]
• CDC. Epidemiologic Notes and Reports Occupational Exposures to Formaldehyde in Dialysis Units. MMWR 1986;35(24);399-401
• Schreeder MT, Favero MS, Hughes JR, Petersen NJ, Bennett PH, Maynard JE. Dialysis encephalopathy and aluminum exposure: an epidemiologic analysis. J Chronic Dis. 1983;36(8):581-93.
• Hughes JR, Schreeder MT. EEG in dialysis encephalopathy. Neurology 1980;30(11):1148-54.

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Adverse Drug & Device Events

• Blossom DB, Kallen AJ, Patel PR, Elward A, Robinson L, Gao G, Langer R, Perkins KM, Jaeger JL, Kurkjian KM, Jones M, Schillie SF, Shehab N, Ketterer D, Venkataraman G, Kishimoto TK, Shriver Z, McMahon AW, Austen KF, Kozlowski S, Srinivasan A, Turabelidze G, Gould CV, Arduino MJ, Sasisekharan R. Outbreak of adverse reactions associated with contaminated heparin. N Engl J Med. 2008;359:2674-2684
• Kallen AJ, Jhung MA, Cheng S, Hess T, Turabelidze G, Abramova L, Arduino M, Guarner J, Pollack B, Saab G, Patel PR. Gadolinium-containing magnetic resonance imaging contrast and nephrogenic systemic fibrosis: a case-control study. Am J Kidney Dis 2008; 51(6):976-986
• CDC. Nephrogenic Fibrosing Dermopathy Associated with Exposure to Gadolinium-Containing Contrast Agents --- St. Louis, Missouri, 2002--2006. MMWR 2007;56(07);137-141.
• Arduino MJ. CDC investigations of noninfectious outbreaks of adverse events in hemodialysis facilities, 1979-1999. Semin Dial. 2000 Mar-Apr;13(2):86-91.
• Multistate Outbreak of Hemolysis in Hemodialysis Patients -- Nebraska and Maryland, 1998 MMWR June 19, 1998;47(23);483-484
• Pegues DA, Beck-Sague C, Woollen SW, Greenspan B, Burns SM, Bland LA, Arduino MJ, Mackow RC, Favero MS. Anaphylactic reactions associated with reuse of hollow-fiber hemodialyzers and angiotensin-converting enzyme inhibitors. Kidney Int 1992; 42:1232-1237
• CDC. Epidemiologic Notes and Reports Acute Allergic Reactions Associated with Reprocessed Hemodialyzers -- Virginia, 1989. MMWR 1989;38(50);873-874
• Duffy R, Tomashek K, Spangenberg M, Spry L, Dwyer D, Safranek TJ, Ying C, Portesi D, Kobrenski J, Arduino M, Tokars J, Jarvis W. Multistate outbreak of hemolysis in hemodialysis patients traced to faulty blood tubing sets. Kidney Int 2000; 57:1668-1674.
• Outbreaks of Gram-Negative Bacterial Bloodstream Infections Traced to Probable Contamination of Hemodialysis Machines -- Canada, 1995 United States, 1997; and Israel, 1997 MMWR January 30, 1998;47(03);55-58

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