American Journal of Kidney Diseases

Hemodialyzer Reuse and Gram-Negative Bloodstream Infections

Published:December 07, 2016DOI:


      Clusters of bloodstream infections caused by Burkholderia cepacia and Stenotrophomonas maltophilia are uncommon, but have been previously identified in hemodialysis centers that reprocessed dialyzers for reuse on patients. We investigated an outbreak of bloodstream infections caused by B cepacia and S maltophilia among hemodialysis patients in clinics of a dialysis organization.

      Study Design

      Outbreak investigation, including matched case-control study.

      Setting & Participants

      Hemodialysis patients treated in multiple outpatient clinics owned by a dialysis organization.


      Main predictors were dialyzer reuse, dialyzer model, and dialyzer reprocessing practice.


      Case patients had a bloodstream infection caused by B cepacia or S maltophilia; controls were patients without infection dialyzed at the same clinic on the same day as a case; results of environmental cultures and organism typing.


      17 cases (9 B cepacia and 8 S maltophilia bloodstream infections) occurred in 5 clinics owned by the same dialysis organization. Case patients were more likely to have received hemodialysis with a dialyzer that had been used more than 6 times (matched OR, 7.03; 95% CI, 1.38-69.76) and to have been dialyzed with a specific reusable dialyzer (Model R) with sealed ends (OR, 22.87; 95% CI, 4.49-∞). No major lapses during dialyzer reprocessing were identified that could explain the outbreak. B cepacia was isolated from samples collected from a dialyzer header-cleaning machine from a clinic with cases and was indistinguishable from a patient isolate collected from the same clinic, by pulsed-field gel electrophoresis. Gram-negative bacteria were isolated from 2 reused Model R dialyzers that had undergone the facility’s reprocessing procedure.


      Limited statistical power and overmatching; few patient isolates and dialyzers available for testing.


      This outbreak was likely caused by contamination during reprocessing of reused dialyzers. Results of this and previous investigations demonstrate that exposing patients to reused dialyzers increases the risk for bloodstream infections. To reduce infection risk, providers should consider implementing single dialyzer use whenever possible.

      Index Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Kidney Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Saran R.
        • Li Y.
        • Robinson B.
        • et al.
        US Renal Data System 2015 Annual Data Report: epidemiology of kidney disease in the United States.
        Am J Kidney Dis. 2016; 67: S1-S434
        • Daugirdas J.T.
        • Blake P.G.
        • Ing T.S.
        Handbook of Dialysis.
        Lippincott Williams & Wilkins, Philadelphia, PA2012
        • Lacson Jr., E.
        • Lazarus J.M.
        Dialyzer best practice: single use or reuse?.
        Semin Dial. 2006; 19: 120-128
        • Pegues D.A.
        • Beck-Sague C.M.
        • Woollen S.W.
        • et al.
        Anaphylactoid reactions associated with reuse of hollow-fiber hemodialyzers and ACE inhibitors.
        Kidney Int. 1992; 42: 1232-1237
        • Roth V.R.
        • Jarvis W.R.
        Outbreaks of Infection and/or pyrogenic reactions in dialysis patients.
        Semin Dial. 2001; 13: 92-96
        • Rudnick J.R.
        • Arduino M.J.
        • Bland L.A.
        • et al.
        An outbreak of pyrogenic reactions in chronic hemodialysis patients associated with hemodialyzer reuse.
        Artif Organs. 1995; 19: 289-294
        • Gordon S.M.
        • Oettinger C.W.
        • Bland L.A.
        • et al.
        Pyrogenic reactions in patients receiving conventional, high-efficiency, or high-flux hemodialysis treatments with bicarbonate dialysate containing high concentrations of bacteria and endotoxin.
        J Am Soc Nephrol. 1992; 2: 1436-1444
        • Alter M.J.
        • Favero M.S.
        • Miller J.K.
        • Coleman P.J.
        • Bland L.A.
        Reuse of hemodialyzers. Results of nationwide surveillance for adverse effects.
        JAMA. 1988; 260: 2073-2076
        • Feldman H.I.
        • Bilker W.B.
        • Hackett M.H.
        • et al.
        Association of dialyzer reuse with hospitalization and survival rates among U.S. hemodialysis patients: do comorbidities matter?.
        J Clin Microbiol. 1999; 52: 209-217
        • Lowrie E.G.
        • Li Z.
        • Ofsthun N.
        • Lazarus J.M.
        Reprocessing dialysers for multiple uses: recent analysis of death risks for patients.
        Nephrol Dial Transplant. 2004; 19: 2823-2830
        • Lacson Jr., E.
        • Wang W.
        • Mooney A.
        • Ofsthun N.
        • Lazarus J.M.
        • Hakim R.M.
        Abandoning peracetic acid-based dialyzer reuse is associated with improved survival.
        Clin J Am Soc Nephrol. 2011; 6: 297-302
        • Doit C.
        • Loukil C.
        • Simon A.M.
        • et al.
        Outbreak of Burkholderia cepacia bacteremia in a pediatric hospital due to contamination of lipid emulsion stoppers.
        J Clin Microbiol. 2004; 42: 2227-2230
        • Moreira B.M.
        • Leobons M.B.
        • Pellegrino F.L.
        • et al.
        Ralstonia pickettii and Burkholderia cepacia complex bloodstream infections related to infusion of contaminated water for injection.
        J Hosp Infect. 2005; 60: 51-55
        • Abe K.
        • D'Angelo M.T.
        • Sunenshine R.
        • et al.
        Outbreak of Burkholderia cepacia bloodstream infection at an outpatient hematology and oncology practice.
        Infect Control Hosp Epidemiol. 2007; 28: 1311-1313
        • Oyong K.
        • Marquez P.
        • Terashita D.
        • et al.
        Outbreak of bloodstream infections associated with multiuse dialyzers containing O-rings.
        Infect Control Hosp Epidemiol. 2014; 35: 89-91
        • Welbel S.F.
        • Schoendorf K.
        • Bland L.A.
        • et al.
        An outbreak of gram-negative bloodstream infections in chronic hemodialysis patients.
        Am J Nephrol. 1995; 15: 1-4
        • Flaherty J.P.
        • Garcia-Houchins S.
        • Chudy R.
        • Arnow P.M.
        An outbreak of gram-negative bacteremia traced to contaminated O-rings in reprocessed dialyzers.
        Ann Intern Med. 1993; 119: 1072-1078
      1. Rosenberg J. Primary bloodstream infections associated with dialyzer reuse in California dialysis centers. Poster presented at: ISDA 2005; October 6-9, 2005; San Francisco, CA.

      2. Kim CY, Schillie SF, Carmean J, et al. Outbreak of bloodstream infections at an outpatient dialysis center, Ohio, 2008. Poster presented at: SHEA 2009; March 19-22, 2009; San Diego, CA.

        • CDC
        Outbreaks of gram-negative bacterial bloodstream infections traced to probable contamination of hemodialysis machines–Canada, 1995; United States, 1997; and Israel, 1997.
        MMWR. 1998; 47: 55-59
        • Arnow P.M.
        • Garcia-Houchins S.
        • Neagle M.B.
        • Bova J.L.
        • Dillon J.J.
        • Chou T.
        An outbreak of bloodstream infections arising from hemodialysis equipment.
        J Infect Dis. 1998; 178: 783-791
        • Wang S.A.
        • Levine R.B.
        • Carson L.A.
        • 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
        • Grohskopf L.A.
        • Roth V.R.
        • Feikin D.R.
        • et al.
        Serratia liquefaciens bloodstream infections from contamination of epoetin alfa at a hemodialysis center.
        N Engl J Med. 2001; 344: 1491-1497
        • Rice E.W.
        • Bridgewater L.
        • American Public Health Association, American Water Works Association, Water Environment Federation
        Standard Methods for the Examination of Water and Wastewater.
        American Public Health Association, Washington, DC2012
        • Tenover F.C.
        • Arbeit R.D.
        • Goering R.V.
        • et al.
        Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing.
        J Clin Microbiol. 1995; 33: 2233-2239
        • Finelli L.
        • Miller J.T.
        • Tokars J.I.
        • Alter M.J.
        • Arduino M.J.
        National surveillance of dialysis-associated diseases in the United States, 2002.
        Semin Dial. 2005; 18: 52-61
        • Robinson B.M.
        • Feldman H.I.
        Dialyzer reuse and patient outcomes: what do we know now?.
        Semin Dial. 2005; 18: 175-179
        • Denny G.B.
        • Golper T.A.
        Does hemodialyzer reuse have a place in current ESRD care: “to be or not to be?” Semin Dial.
        . 2014; 27: 256-258
        • AAMI
        Reprocessing of Hemodialyzers.
        (Vol RD47:2008/2013) Association for the Advancement of Medical Instrumentation, Arlington, VA2013
        • Bolan G.
        • Reingold A.L.
        • Carson L.A.
        • et al.
        Infections with Mycobacterium chelonei in patients receiving dialysis and using processed hemodialyzers.
        J Infect Dis. 1985; 152: 1013-1019
        • Toniolo A.D.
        • Ribeiro M.M.
        • Ishii M.
        • da Silva C.B.
        • Jenne Mimica L.M.
        • Graziano K.U.
        Evaluation of the effectiveness of manual and automated dialyzers reprocessing after multiple reuses.
        Am J Infect Control. 2016; 44: 719-720