Dialysis-Related Outbreaks: Archives

Adverse Drug and Device Events

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.external icon 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
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. pdf icon[PDF – 265 KB]external icon 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

Bacterial and Fungal Infections

Vancomycin intermediate and resistant external iconStaphylococcus aureusexternal icon. What the nephrologist needs to knowexternal icon. Nephrol News Issues. 2004 Oct;18(11):63-4, 66-7, 71-2.
Tuberculosis Transmission in a Renal Dialysis Center — Nevada, 2003. MMWR 2004; 53(37);873-875.
Staphylococcus aureus Resistant to Vancomycin — United States, 2002. MMWR 2002; 51(26);565-567.
Serratia liquefaciens bloodstream infections from contamination of epoetin alfa at a hemodialysis center. pdf icon[PDF – 192 KB]external icon N Engl J Med 2001; 344(20):1491-1497
Related Articles Vancomycin-resistant enterococci colonization in patients at seven hemodialysis centers. Kidney Int. 2001 Oct;60(4):1511-6.
Staphylococcus aureus with Reduced Susceptibility to Vancomycin – Illinois, 1999. MMWR 2000; 48(51);1165-1167.
An outbreak of Gram-negative bacteremia in hemodialysis patients traced to a hemodialysis machine waste drain ports.external icon Infect Control Hospital Epidemiol 1999; 20 (11): 746-751
A cluster of bloodstream infections and pyrogenic reactions among hemodialysis patients traced to dialysis machine waste-handling option units.external icon Am J Nephrol 1998; 18(6): 485-489
An outbreak of Gram-negative bloodstream infections in chronic hemodialysis patients.external icon Am J Nephrol 1995; 15(1):1-4
Pyrogenic reactions and Gram-negative bacteremia in a hemodialysis center.external icon Am J Nephrol 1994; 14:85-89
Mycobacterium chelonae infections among patients receiving high flux dialysis in a hemodialysis clinic, California.external icon J Infect Dis 1990;161:85-90
Outbreak of Gram-negative bacteremia and pyrogenic reactions in a hemodialysis center.external icon 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.external icon 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.
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.external icon J Infect Dis. 1982;145(1):9-17.
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.external icon Ann Intern Med. 1982;96(4):456-8.

Chemical Intoxication

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.external icon JAMA. 2000;283(16):2128-34.
FDA/CDC. Important Information Relating to Cellulose Acetate Dialyzers.external icon 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.external icon 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.external icon 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.external icon 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 icon[PDF – 596 KB]external icon 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.external icon 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. external iconJ Chronic Dis. 1983;36(8):581-93.
Hughes JR, Schreeder MT. EEG in dialysis encephalopathy.external icon Neurology 1980;30(11):1148-54.

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.external icon 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.external icon 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.external icon Artif Organs 1995; 19: 289-294
Gordon SM, Tipple M, Bland LA, Jarvis WR. Pyrogenic reactions associated with the reuse of disposable hollow-fiber hemodialyzersexternal icon. JAMA. 1988;260(14):2077-81.
Gutman RA, Shelburne JD, Peterson NJ, Carson LA, Favero MS. Aseptic peritonitis with home peritoneal dialysisexternal icon. 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.

Viral Infections

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.external icon 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.external icon 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 centreexternal icon. 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.external icon 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.external icon 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.external icon Ann Intern Med. 1983;99(3):330-3.

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Page last reviewed: June 9, 2016

Content source: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP)