Jackson B M, Beck-Sague C M, Bland L A, Arduino M J, Meyer L, Jarvis W R
Division of Field Epidemiology, Centers for Disease Control and Prevention, Atlanta, Ga.
Am J Nephrol. 1994;14(2):85-9. doi: 10.1159/000168694.
Six episodes of gram-negative bacteremia and seven pyrogenic reactions occurred in 11 patients in one hemodialysis center. Gram-negative bacteremias and/or pyrogenic reactions were not related to reuse and were more likely to occur if dialysis was performed in one unit of the center (8/13 unit 5 vs. 221/1,151 in other units, p < 0.001) and with one type of dialysis machine (10/13 vs. 581/1,151 with other machines, p = 0.05), which was preferentially used in unit 5 (p < 0.01). Bacterial and endotoxin concentrations of water used to prepare dialysate and reprocess hemodialyzers, and of dialysate, exceeded allowable concentrations recommended by the Association for the Advancement of Medical Instrumentation (AAMI). The implicated dialysis machines were disinfected with chemicals daily, but not heat-disinfected daily as suggested by the manufacturer. Results suggest that the outbreak was caused by the use of water that did not meet AAMI standards and inadequate disinfection of one type of dialysis machine.
在一个血液透析中心的11名患者中发生了6次革兰氏阴性菌血症发作和7次发热反应。革兰氏阴性菌血症和/或发热反应与复用无关，并且如果在该中心的一个单元进行透析，则更有可能发生（单元5中为8/13，其他单元为221/1151，p<0.001），以及使用一种类型的透析机时（10/13，使用其他机器时为581/1151，p = 0.05），该类型透析机在单元5中优先使用（p<0.01）。用于制备透析液和再处理血液透析器的水以及透析液中的细菌和内毒素浓度超过了美国医疗仪器促进协会（AAMI）推荐的允许浓度。涉及的透析机每天用化学药品消毒，但未按照制造商的建议每天进行热消毒。结果表明，此次疫情是由使用不符合AAMI标准的水以及一种类型的透析机消毒不充分所致。
