Matthew J Arduino | University of North Carolina at Chapel Hill (original) (raw)

Papers by Matthew J Arduino

Emerging Infectious Diseases, 2004

Four swab materials were evaluated for their efficiency in recovery of Bacillus anthracis spores ... more Four swab materials were evaluated for their efficiency in recovery of Bacillus anthracis spores from steel coupons. Cotton, macrofoam, polyester, and rayon swabs were used to sample coupons inoculated with a spore suspension of known concentration. Three methods of processing for the removal of spores from the swabs (vortexing, sonication, or minimal agitation) and two swab preparations (premoistened and dry) were evaluated. Results indicated that premoistened swabs were more efficient at recovering spores than dry swabs (14.3% vs. 4.4%). Vortexing swabs for 2 min during processing resulted in superior extraction of spores when compared to sonicating them for 12 min or subjecting them to minimal agitation. Premoistened macrofoam and cotton swabs that were vortexed during processing recovered the greatest proportions of spores with a mean recovery of 43.6% (standard deviation [SD] 11.1%) and 41.7% (SD 14.6%), respectively. Premoistened and vortexed polyester and rayon swabs were less efficient, at 9.9% (SD 3.8%) and 11.5% (SD 7.9%), respectively.

Clinical Infectious Diseases, 2009

We report 6 cases of postsurgical endophthalmitis due to gram-negative bacteria associated with c... more We report 6 cases of postsurgical endophthalmitis due to gram-negative bacteria associated with contaminated trypan blue dye from a compounding pharmacy. Unopened trypan blue syringes yielded Pseudomonas aeruginosa and Burkholderia cepacia complex on culture, with pulsed-field gel electrophoresis patterns indistinguishable from patient isolates. Contamination of compounded medications should be considered when investigating outbreaks of postoperative endophthalmitis.

Infection Control and Hospital Epidemiology, 1999

To investigate an outbreak of gram-negative bacteremias at a hemodialysis center (December 1, 199... more To investigate an outbreak of gram-negative bacteremias at a hemodialysis center (December 1, 1996-January 31, 1997). Retrospective cohort study. Reviewed infection control practices and maintenance and disinfection procedures for the water system and dialysis machines. Performed cultures of the water and dialysis machines, including the waste-handling option (WHO), a drain port designed to dispose of saline used to flush the dialyzer before patient use. Compared isolates by pulsed-field gel electrophoresis. A hemodialysis center in Maryland. 94 patients received dialysis on 27 machines; 10 (11%) of the patients had gram-negative bacteremias. Pathogens causing these infections were Enterobacter cloacae (n = 6), Pseudomonas aeruginosa (n = 4), and Escherichia coli (n = 2); two patients had polymicrobial bacteremia. Factors associated with development of gram-negative bacteremias were receiving dialysis via a central venous catheter (CVC) rather than via an arterio-venous shunt (all 10 infected patients had CVCs compared to 31 of 84 uninfected patients, relative risk [RR] undefined; P<.001) or dialysis on any of three particular dialysis machines (7 of 10 infected patients were exposed to the three machines compared to 20 of 84 uninfected patients, RR = 5.8; P = .005). E cloacae, P aeruginosa, or both organisms were grown from cultures obtained from several dialysis machines. WHO valves, which prevent backflow from the drain to dialysis bloodlines, were faulty in 8 (31%) of 26 machines, including 2 of 3 machines epidemiologically linked to case-patients. Pulsed-field gel electrophoresis patterns of available dialysis machine and patient E cloacae isolates were identical. Our study suggests that WHO ports with incompetent valves and resultant backflow were a source of cross-contamination of dialysis bloodlines and patients' CVCs. Replacement of faulty WHO valves and enhanced disinfection of dialysis machines terminated the outbreak.

Letters in Applied Microbiology, 2011

To determine the range of free available chlorine (FAC) required for disinfection of the live vac... more To determine the range of free available chlorine (FAC) required for disinfection of the live vaccine strain (LVS) and wild-type strains of Francisella tularensis. Methods and Results: Seven strains of planktonic F. tularensis were exposed to 0AE5 mgAEl )1 FAC for two pH values, 7 and 8, at 5 and 25°C. LVS was inactivated 2 to 4 times more quickly than any of the wild-type F. tularensis strains at pH 8 and 5°C. Conclusions: Free available chlorine residual concentrations routinely maintained in drinking water distribution systems would require up to two hours to reduce all F. tularensis strains by 4 log 10 . LVS was inactivated most quickly of the tested strains. Significance and Impact of the Study: This work provides contact time (CT) values that are useful for drinking water risk assessment and also suggests that LVS may not be a good surrogate in disinfection studies.

Applied and Environmental Microbiology, 2009

Burkholderia pseudomallei is a select agent and the causative agent of melioidosis. Variations in... more Burkholderia pseudomallei is a select agent and the causative agent of melioidosis. Variations in previously reported chlorine and monochloramine concentration time (Ct) values for disinfection of this organism make decisions regarding the appropriate levels of chlorine in water treatment systems difficult. This study identified the variation in Ct values for 2-, 3-, and 4-log(10) reductions of eight environmental and clinical isolates of B. pseudomallei in phosphate-buffered water. The greatest calculated Ct values for a 4-log(10) inactivation were 7.8 mg.min/liter for free available chlorine (FAC) at pH 8 and 5 degrees C and 550 mg.min/liter for monochloramine at pH 8 and 5 degrees C. Ionic strength of test solutions, culture hold times in water, and cell washing were ruled out as sources of the differences in prior observations. Tolerance to FAC was correlated with the relative amount of extracellular material produced by each isolate. Solid-phase cytometry analysis using an esterase-cleaved fluorochrome assay detected a 2-log(10)-higher level of organisms based upon metabolic activity than did culture, which in some cases increased Ct values by fivefold. Despite strain-to-strain variations in Ct values of 17-fold for FAC and 2.5-fold for monochloramine, standard FAC disinfection practices utilized in the United States should disinfect planktonic populations of these B. pseudomallei strains by 4 orders of magnitude in less than 10 min at the tested temperatures and pH levels.

Letters in Applied Microbiology, 2011

Aims: To evaluate the efficacy of chlorine dioxide (ClO 2 ) against seven species of bacterial th... more Aims: To evaluate the efficacy of chlorine dioxide (ClO 2 ) against seven species of bacterial threat (BT) agents in water. Methods and Results: Two strains of Bacillus anthracis spores, Yersinia pestis, Francisella tularensis, Burkholderia pseudomallei, Burkholderia mallei and Brucella species were each inoculated into a ClO 2 solution with an initial concentration of 2AE0 (spores only) and 0AE25 mg l )1 (all other bacteria) at pH 7 or 8, 5 or 25°C. At 0AE25 mg l )1 in potable water, six species were inactivated by at least three orders of magnitude within 10 min. Bacillus anthracis spores required up to 7 h at 5°C for the same inactivation with 2AE0 mg l )1 ClO 2 . Conclusions: Typical ClO 2 doses used in water treatment facilities would be effective against all bacteria tested except B. anthracis spores that would require up to 7 h with the largest allowable dose of 2 mg l )1 ClO 2 . Other water treatment processes may be required in addition to ClO 2 disinfection for effective spore removal or inactivation. Significance and Impact of Study: The data obtained from this study provide valuable information for water treatment facilities and public health officials in the event that a potable water supply is contaminated with these BT agents.

N Engl J Med, 2001

In a one month period, 10 Serratia liquefaciens bloodstream infections and 6 pyrogenic reactions ... more In a one month period, 10 Serratia liquefaciens bloodstream infections and 6 pyrogenic reactions occurred in outpatients at a hemodialysis center. We performed a cohort study of all hemodialysis sessions on days that staff members reported S. liquefaciens bloodstream infections or pyrogenic reactions. We reviewed procedures and cultured samples of water, medications, soaps, and hand lotions and swabs from the hands of personnel. We analyzed 208 sessions involving 48 patients. In 12 sessions, patients had S. liquefaciens bloodstream infections, and in 8, patients had pyrogenic reactions without bloodstream infection. Sessions with infections or reactions were associated with higher median doses of epoetin alfa than the 188 other sessions (6500 vs. 4000 U, P=0.03) and were more common during afternoon or evening shifts than morning shifts (P=0.03). Sessions with infections or reactions were associated with doses of epoetin alfa of more than 4000 U (multivariate odds ratio, 4.0; 95 percent confidence interval, 1.3 to 12.3). A review of procedures revealed that preservative-free, single-use vials of epoetin alfa were punctured multiple times, and residual epoetin alfa from multiple vials was pooled and administered to patients. S. liquefaciens was isolated from pooled epoetin alfa, empty vials of epoetin alfa that had been pooled, antibacterial soap, and hand lotion. All the isolates were identical by pulsed-field gel electrophoresis. After the practice of pooling epoetin alfa was discontinued and the contaminated soap and lotion were replaced, no further S. liquefaciens bloodstream infections or pyrogenic reactions occurred at this hemodialysis facility. Puncturing single-use vials multiple times and pooling preservative-free epoetin alfa caused this outbreak of bloodstream infections in a hemodialysis unit. To prevent similar outbreaks, medical personnel should follow the manufacturer's guidelines for the use of preservative-free medications.

The Journal of Infectious Diseases, May 1, 1994

Infect Control Hosp Epidemiol, 2000

To identify risk factors associated with an unexpected outbreak of pyrogenic reactions (PR) follo... more To identify risk factors associated with an unexpected outbreak of pyrogenic reactions (PR) following intravenous gentamicin. We conducted two cohort studies. PRs were defined as chills, rigors, or shaking within 3 hours after initiating the gentamicin infusion during the preepidemic (December 1, 1997-January 15, 1998) or epidemic (May 1-June 15, 1998) periods. We tested gentamicin vials for endotoxin using the limulus amebocyte lysate assay. Inpatient services of a large community hospital in Los Angeles, California. During the epidemic period, 22 (15%) of 152 patients developed documented PRs following intravenous gentamicin. PRs were more likely among patients receiving single daily dosing (SDD) than multiple daily dosing gentamicin (20/73 [27%] vs. 2/79 [3%]; relative risk, 10.8; 95% confidence interval, 2.6 44.7). Laboratory analysis of gentamicin vials found endotoxin levels that were higher among Fujisawa-brand gentamicin (implicated brand) than gentamicin used after the outbreak terminated (non-implicated brand). Although endotoxin levels in the vials did not exceed US Pharmacopeia limits (1.7 endotoxin units/mg gentamicin), the use of SDD gentamicin may place patients at greater risk of receiving doses of endotoxin above the threshold for PRs in humans. Reassessment of the acceptable amounts of endotoxin in gentamicin and other parenteral products should be considered when dosing intervals used in clinical practice change.

Infection control and hospital epidemiology, Jan 17, 2015

BACKGROUND In November and December 2012, 6 patients at a hemodialysis clinic were given a diagno... more BACKGROUND In November and December 2012, 6 patients at a hemodialysis clinic were given a diagnosis of new hepatitis C virus (HCV) infection. OBJECTIVE To investigate the outbreak to identify risk factors for transmission. METHODS A case patient was defined as a patient who was HCV-antibody negative on clinic admission but subsequently was found to be HCV-antibody positive from January 1, 2008, through April 30, 2013. Patient charts were reviewed to identify and describe case patients. The hypervariable region 1 of HCV from infected patients was tested to assess viral genetic relatedness. Infection control practices were evaluated via observations. A forensic chemiluminescent agent was used to identify blood contamination on environmental surfaces after cleaning. RESULTS Eighteen case patients were identified at the clinic from January 1, 2008, through April 30, 2013, resulting in an estimated 16.7% attack rate. Analysis of HCV quasispecies identified 4 separate clusters of transmi...

Nephrology news & issues

Testing for the presence or absence of chemical germicides in hemodialysis is a critical componen... more Testing for the presence or absence of chemical germicides in hemodialysis is a critical component to assure patient safety. It is necessary to verify early prepared solutions are being used and rinsed out of devices (water treatment systems, dialysis machines, hemodialyzers), and to make sure equipment is working properly to remove drinking water disinfectants. It is important to use tests and procedures that have FDA clearance for use specifically in hemodialysis or, in the case of chlorine, the recommended test for detecting residual free and total chlorine as referenced in the Standard Methods for the Analysis of Water and Wastewater. Products without specific labeling for dialysis should be avoided. Positive and negative controls should be included to validate testing.

Lymphokine and cytokine research

Aberrant immunologic host defenses associated with uremia may be a cause of the high incidence of... more Aberrant immunologic host defenses associated with uremia may be a cause of the high incidence of sepsis in chronic hemodialysis (CHD) patients. This investigation determined the cytokine response of blood from five nondialyzed chronic renal failure (CRF) patients, five CHD patients, and five healthy controls (HC) after in vitro stimulation with 1 ng/ml Escherichia coli 0113 endotoxin. Concentrations of the cytokines TNF-alpha and IL-1 beta were determined by ELISA and were similar in all baseline and unspiked samples. TNF-alpha concentrations in CRF and CHD spiked samples were similar to each other but significantly greater (p less than 0.01) than in HC spiked samples. IL-1 beta concentrations in CRF, CHD, and HC-spiked samples were not significantly different. We conclude that CRF and CHD patients have enhanced TNF-alpha response, which may be related to uremia and not dialysis-related factors. Uremia does not potentiate IL-1 beta release.

Journal of the American Society of Nephrology

Plasma interleukin-1 9 (lL-1 9) and tumor necrosis factor-a (TNF-a) were determined by ELISA in I... more Plasma interleukin-1 9 (lL-1 9) and tumor necrosis factor-a (TNF-a) were determined by ELISA in I 7 healthy I

Journal of the American Society of Nephrology

Uremia has been associated with immunologic aberrations, including anergy, increased susceptibili... more Uremia has been associated with immunologic aberrations, including anergy, increased susceptibility I

American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 2015

Specific deviations from United States Pharmacopeia standards were analyzed to investigate the fa... more Specific deviations from United States Pharmacopeia standards were analyzed to investigate the factors allowing an outbreak of Serratia marcescens bloodstream infections in patients receiving compounded amino acid solutions. Filter challenge experiments using the outbreak strain of S. marcescens were compared with those that used the filter challenge organism recommended by ASTM International (Brevundimonas diminuta ATCC 19162) to determine the frequency and degree of organism breakthrough. Disk and capsule filters (0.22- and 0.2-μm nominal pore size, respectively) were challenged with either the outbreak strain of S. marcescens or B. diminuta ATCC 19162. The following variables were compared: culture conditions in which organisms were grown overnight or cultured in sterile water (starved), solution type (15% amino acid solution or sterile water), and filtration with or without a 0.5-μm prefilter. Small-scale, syringe-driven, disk-filtration experiments of starved bacterial cultures...

Journal of the American Society of Nephrology : JASN, 1992

Pyrogenic reactions (PR) are a well-recognized complication of hemodialysis and have been associa... more Pyrogenic reactions (PR) are a well-recognized complication of hemodialysis and have been associated with dialyzer reuse, high-flux dialysis, and bicarbonate dialysate. However, the roles of bacteria and endotoxin in dialysate for producing PR are not well defined. To determine the effect of removing most bacteria and endotoxin from the dialysate on the incidence of PR, a cohort of chronic hemodialysis patients receiving high-flux, high-efficiency, or conventional hemodialysis at three centers with bicarbonate dialysis fluids that had been filtered with a polysulfone high-flux hemodialyzer was prospectively studied. Unfiltered bicarbonate concentrate had median bacterial and endotoxin concentrations of 479,000 CFU/mL and 39,800 pg/mL, respectively. After filtration of the bicarbonate concentrate at the central proportioner, dialysate had a median 9.2 CFU/mL of bacteria and 17.8 pg/mL of endotoxin. Dialysate filtered at individual proportioning dialysis machines had a median 0.001 CF...

Nephrology news & issues, 2005

Infections account for the second leading cause of mortality among patients with end-stage renal ... more Infections account for the second leading cause of mortality among patients with end-stage renal disease. Many of these infections are due to sepsis, primarily arising from the vascular access site. Septicemia alone accounts for almost 11% of mortality in hemodialysis patients. Hemodialysis patients are also a sentinel population for the emergence of antimicrobial resistance, especially with regards to gram-positive cocci (vancomycin-resistant enterococci (VRE), methicillin resistant S. aureus (MRSA), Staphylococcus aureus with reduced susceptibility to vancomycin (VISA), and vancomycin resistant S. aureus [VRSA]). It is extremely important to follow infection control recommendations designed to prevent these types of adverse events from occurring in the hemodialysis population. The campaign to prevent antimicrobial resistance in dialysis includes four strategies: Prevent infection; diagnose and treat infection; use antimicrobials wisely; and prevent transmission. In addition, effor...

Nephrology news & issues, 2002

Emerging Infectious Diseases, 2004

Four swab materials were evaluated for their efficiency in recovery of Bacillus anthracis spores ... more Four swab materials were evaluated for their efficiency in recovery of Bacillus anthracis spores from steel coupons. Cotton, macrofoam, polyester, and rayon swabs were used to sample coupons inoculated with a spore suspension of known concentration. Three methods of processing for the removal of spores from the swabs (vortexing, sonication, or minimal agitation) and two swab preparations (premoistened and dry) were evaluated. Results indicated that premoistened swabs were more efficient at recovering spores than dry swabs (14.3% vs. 4.4%). Vortexing swabs for 2 min during processing resulted in superior extraction of spores when compared to sonicating them for 12 min or subjecting them to minimal agitation. Premoistened macrofoam and cotton swabs that were vortexed during processing recovered the greatest proportions of spores with a mean recovery of 43.6% (standard deviation [SD] 11.1%) and 41.7% (SD 14.6%), respectively. Premoistened and vortexed polyester and rayon swabs were less efficient, at 9.9% (SD 3.8%) and 11.5% (SD 7.9%), respectively.

Clinical Infectious Diseases, 2009

We report 6 cases of postsurgical endophthalmitis due to gram-negative bacteria associated with c... more We report 6 cases of postsurgical endophthalmitis due to gram-negative bacteria associated with contaminated trypan blue dye from a compounding pharmacy. Unopened trypan blue syringes yielded Pseudomonas aeruginosa and Burkholderia cepacia complex on culture, with pulsed-field gel electrophoresis patterns indistinguishable from patient isolates. Contamination of compounded medications should be considered when investigating outbreaks of postoperative endophthalmitis.

Infection Control and Hospital Epidemiology, 1999

To investigate an outbreak of gram-negative bacteremias at a hemodialysis center (December 1, 199... more To investigate an outbreak of gram-negative bacteremias at a hemodialysis center (December 1, 1996-January 31, 1997). Retrospective cohort study. Reviewed infection control practices and maintenance and disinfection procedures for the water system and dialysis machines. Performed cultures of the water and dialysis machines, including the waste-handling option (WHO), a drain port designed to dispose of saline used to flush the dialyzer before patient use. Compared isolates by pulsed-field gel electrophoresis. A hemodialysis center in Maryland. 94 patients received dialysis on 27 machines; 10 (11%) of the patients had gram-negative bacteremias. Pathogens causing these infections were Enterobacter cloacae (n = 6), Pseudomonas aeruginosa (n = 4), and Escherichia coli (n = 2); two patients had polymicrobial bacteremia. Factors associated with development of gram-negative bacteremias were receiving dialysis via a central venous catheter (CVC) rather than via an arterio-venous shunt (all 10 infected patients had CVCs compared to 31 of 84 uninfected patients, relative risk [RR] undefined; P<.001) or dialysis on any of three particular dialysis machines (7 of 10 infected patients were exposed to the three machines compared to 20 of 84 uninfected patients, RR = 5.8; P = .005). E cloacae, P aeruginosa, or both organisms were grown from cultures obtained from several dialysis machines. WHO valves, which prevent backflow from the drain to dialysis bloodlines, were faulty in 8 (31%) of 26 machines, including 2 of 3 machines epidemiologically linked to case-patients. Pulsed-field gel electrophoresis patterns of available dialysis machine and patient E cloacae isolates were identical. Our study suggests that WHO ports with incompetent valves and resultant backflow were a source of cross-contamination of dialysis bloodlines and patients' CVCs. Replacement of faulty WHO valves and enhanced disinfection of dialysis machines terminated the outbreak.

Letters in Applied Microbiology, 2011

To determine the range of free available chlorine (FAC) required for disinfection of the live vac... more To determine the range of free available chlorine (FAC) required for disinfection of the live vaccine strain (LVS) and wild-type strains of Francisella tularensis. Methods and Results: Seven strains of planktonic F. tularensis were exposed to 0AE5 mgAEl )1 FAC for two pH values, 7 and 8, at 5 and 25°C. LVS was inactivated 2 to 4 times more quickly than any of the wild-type F. tularensis strains at pH 8 and 5°C. Conclusions: Free available chlorine residual concentrations routinely maintained in drinking water distribution systems would require up to two hours to reduce all F. tularensis strains by 4 log 10 . LVS was inactivated most quickly of the tested strains. Significance and Impact of the Study: This work provides contact time (CT) values that are useful for drinking water risk assessment and also suggests that LVS may not be a good surrogate in disinfection studies.

Applied and Environmental Microbiology, 2009

Burkholderia pseudomallei is a select agent and the causative agent of melioidosis. Variations in... more Burkholderia pseudomallei is a select agent and the causative agent of melioidosis. Variations in previously reported chlorine and monochloramine concentration time (Ct) values for disinfection of this organism make decisions regarding the appropriate levels of chlorine in water treatment systems difficult. This study identified the variation in Ct values for 2-, 3-, and 4-log(10) reductions of eight environmental and clinical isolates of B. pseudomallei in phosphate-buffered water. The greatest calculated Ct values for a 4-log(10) inactivation were 7.8 mg.min/liter for free available chlorine (FAC) at pH 8 and 5 degrees C and 550 mg.min/liter for monochloramine at pH 8 and 5 degrees C. Ionic strength of test solutions, culture hold times in water, and cell washing were ruled out as sources of the differences in prior observations. Tolerance to FAC was correlated with the relative amount of extracellular material produced by each isolate. Solid-phase cytometry analysis using an esterase-cleaved fluorochrome assay detected a 2-log(10)-higher level of organisms based upon metabolic activity than did culture, which in some cases increased Ct values by fivefold. Despite strain-to-strain variations in Ct values of 17-fold for FAC and 2.5-fold for monochloramine, standard FAC disinfection practices utilized in the United States should disinfect planktonic populations of these B. pseudomallei strains by 4 orders of magnitude in less than 10 min at the tested temperatures and pH levels.

Letters in Applied Microbiology, 2011

Aims: To evaluate the efficacy of chlorine dioxide (ClO 2 ) against seven species of bacterial th... more Aims: To evaluate the efficacy of chlorine dioxide (ClO 2 ) against seven species of bacterial threat (BT) agents in water. Methods and Results: Two strains of Bacillus anthracis spores, Yersinia pestis, Francisella tularensis, Burkholderia pseudomallei, Burkholderia mallei and Brucella species were each inoculated into a ClO 2 solution with an initial concentration of 2AE0 (spores only) and 0AE25 mg l )1 (all other bacteria) at pH 7 or 8, 5 or 25°C. At 0AE25 mg l )1 in potable water, six species were inactivated by at least three orders of magnitude within 10 min. Bacillus anthracis spores required up to 7 h at 5°C for the same inactivation with 2AE0 mg l )1 ClO 2 . Conclusions: Typical ClO 2 doses used in water treatment facilities would be effective against all bacteria tested except B. anthracis spores that would require up to 7 h with the largest allowable dose of 2 mg l )1 ClO 2 . Other water treatment processes may be required in addition to ClO 2 disinfection for effective spore removal or inactivation. Significance and Impact of Study: The data obtained from this study provide valuable information for water treatment facilities and public health officials in the event that a potable water supply is contaminated with these BT agents.

N Engl J Med, 2001

In a one month period, 10 Serratia liquefaciens bloodstream infections and 6 pyrogenic reactions ... more In a one month period, 10 Serratia liquefaciens bloodstream infections and 6 pyrogenic reactions occurred in outpatients at a hemodialysis center. We performed a cohort study of all hemodialysis sessions on days that staff members reported S. liquefaciens bloodstream infections or pyrogenic reactions. We reviewed procedures and cultured samples of water, medications, soaps, and hand lotions and swabs from the hands of personnel. We analyzed 208 sessions involving 48 patients. In 12 sessions, patients had S. liquefaciens bloodstream infections, and in 8, patients had pyrogenic reactions without bloodstream infection. Sessions with infections or reactions were associated with higher median doses of epoetin alfa than the 188 other sessions (6500 vs. 4000 U, P=0.03) and were more common during afternoon or evening shifts than morning shifts (P=0.03). Sessions with infections or reactions were associated with doses of epoetin alfa of more than 4000 U (multivariate odds ratio, 4.0; 95 percent confidence interval, 1.3 to 12.3). A review of procedures revealed that preservative-free, single-use vials of epoetin alfa were punctured multiple times, and residual epoetin alfa from multiple vials was pooled and administered to patients. S. liquefaciens was isolated from pooled epoetin alfa, empty vials of epoetin alfa that had been pooled, antibacterial soap, and hand lotion. All the isolates were identical by pulsed-field gel electrophoresis. After the practice of pooling epoetin alfa was discontinued and the contaminated soap and lotion were replaced, no further S. liquefaciens bloodstream infections or pyrogenic reactions occurred at this hemodialysis facility. Puncturing single-use vials multiple times and pooling preservative-free epoetin alfa caused this outbreak of bloodstream infections in a hemodialysis unit. To prevent similar outbreaks, medical personnel should follow the manufacturer's guidelines for the use of preservative-free medications.

The Journal of Infectious Diseases, May 1, 1994

Infect Control Hosp Epidemiol, 2000

To identify risk factors associated with an unexpected outbreak of pyrogenic reactions (PR) follo... more To identify risk factors associated with an unexpected outbreak of pyrogenic reactions (PR) following intravenous gentamicin. We conducted two cohort studies. PRs were defined as chills, rigors, or shaking within 3 hours after initiating the gentamicin infusion during the preepidemic (December 1, 1997-January 15, 1998) or epidemic (May 1-June 15, 1998) periods. We tested gentamicin vials for endotoxin using the limulus amebocyte lysate assay. Inpatient services of a large community hospital in Los Angeles, California. During the epidemic period, 22 (15%) of 152 patients developed documented PRs following intravenous gentamicin. PRs were more likely among patients receiving single daily dosing (SDD) than multiple daily dosing gentamicin (20/73 [27%] vs. 2/79 [3%]; relative risk, 10.8; 95% confidence interval, 2.6 44.7). Laboratory analysis of gentamicin vials found endotoxin levels that were higher among Fujisawa-brand gentamicin (implicated brand) than gentamicin used after the outbreak terminated (non-implicated brand). Although endotoxin levels in the vials did not exceed US Pharmacopeia limits (1.7 endotoxin units/mg gentamicin), the use of SDD gentamicin may place patients at greater risk of receiving doses of endotoxin above the threshold for PRs in humans. Reassessment of the acceptable amounts of endotoxin in gentamicin and other parenteral products should be considered when dosing intervals used in clinical practice change.

Infection control and hospital epidemiology, Jan 17, 2015

BACKGROUND In November and December 2012, 6 patients at a hemodialysis clinic were given a diagno... more BACKGROUND In November and December 2012, 6 patients at a hemodialysis clinic were given a diagnosis of new hepatitis C virus (HCV) infection. OBJECTIVE To investigate the outbreak to identify risk factors for transmission. METHODS A case patient was defined as a patient who was HCV-antibody negative on clinic admission but subsequently was found to be HCV-antibody positive from January 1, 2008, through April 30, 2013. Patient charts were reviewed to identify and describe case patients. The hypervariable region 1 of HCV from infected patients was tested to assess viral genetic relatedness. Infection control practices were evaluated via observations. A forensic chemiluminescent agent was used to identify blood contamination on environmental surfaces after cleaning. RESULTS Eighteen case patients were identified at the clinic from January 1, 2008, through April 30, 2013, resulting in an estimated 16.7% attack rate. Analysis of HCV quasispecies identified 4 separate clusters of transmi...

Nephrology news & issues

Testing for the presence or absence of chemical germicides in hemodialysis is a critical componen... more Testing for the presence or absence of chemical germicides in hemodialysis is a critical component to assure patient safety. It is necessary to verify early prepared solutions are being used and rinsed out of devices (water treatment systems, dialysis machines, hemodialyzers), and to make sure equipment is working properly to remove drinking water disinfectants. It is important to use tests and procedures that have FDA clearance for use specifically in hemodialysis or, in the case of chlorine, the recommended test for detecting residual free and total chlorine as referenced in the Standard Methods for the Analysis of Water and Wastewater. Products without specific labeling for dialysis should be avoided. Positive and negative controls should be included to validate testing.

Lymphokine and cytokine research

Aberrant immunologic host defenses associated with uremia may be a cause of the high incidence of... more Aberrant immunologic host defenses associated with uremia may be a cause of the high incidence of sepsis in chronic hemodialysis (CHD) patients. This investigation determined the cytokine response of blood from five nondialyzed chronic renal failure (CRF) patients, five CHD patients, and five healthy controls (HC) after in vitro stimulation with 1 ng/ml Escherichia coli 0113 endotoxin. Concentrations of the cytokines TNF-alpha and IL-1 beta were determined by ELISA and were similar in all baseline and unspiked samples. TNF-alpha concentrations in CRF and CHD spiked samples were similar to each other but significantly greater (p less than 0.01) than in HC spiked samples. IL-1 beta concentrations in CRF, CHD, and HC-spiked samples were not significantly different. We conclude that CRF and CHD patients have enhanced TNF-alpha response, which may be related to uremia and not dialysis-related factors. Uremia does not potentiate IL-1 beta release.

Journal of the American Society of Nephrology

Plasma interleukin-1 9 (lL-1 9) and tumor necrosis factor-a (TNF-a) were determined by ELISA in I... more Plasma interleukin-1 9 (lL-1 9) and tumor necrosis factor-a (TNF-a) were determined by ELISA in I 7 healthy I

Journal of the American Society of Nephrology

Uremia has been associated with immunologic aberrations, including anergy, increased susceptibili... more Uremia has been associated with immunologic aberrations, including anergy, increased susceptibility I

American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists, 2015

Specific deviations from United States Pharmacopeia standards were analyzed to investigate the fa... more Specific deviations from United States Pharmacopeia standards were analyzed to investigate the factors allowing an outbreak of Serratia marcescens bloodstream infections in patients receiving compounded amino acid solutions. Filter challenge experiments using the outbreak strain of S. marcescens were compared with those that used the filter challenge organism recommended by ASTM International (Brevundimonas diminuta ATCC 19162) to determine the frequency and degree of organism breakthrough. Disk and capsule filters (0.22- and 0.2-μm nominal pore size, respectively) were challenged with either the outbreak strain of S. marcescens or B. diminuta ATCC 19162. The following variables were compared: culture conditions in which organisms were grown overnight or cultured in sterile water (starved), solution type (15% amino acid solution or sterile water), and filtration with or without a 0.5-μm prefilter. Small-scale, syringe-driven, disk-filtration experiments of starved bacterial cultures...

Journal of the American Society of Nephrology : JASN, 1992

Pyrogenic reactions (PR) are a well-recognized complication of hemodialysis and have been associa... more Pyrogenic reactions (PR) are a well-recognized complication of hemodialysis and have been associated with dialyzer reuse, high-flux dialysis, and bicarbonate dialysate. However, the roles of bacteria and endotoxin in dialysate for producing PR are not well defined. To determine the effect of removing most bacteria and endotoxin from the dialysate on the incidence of PR, a cohort of chronic hemodialysis patients receiving high-flux, high-efficiency, or conventional hemodialysis at three centers with bicarbonate dialysis fluids that had been filtered with a polysulfone high-flux hemodialyzer was prospectively studied. Unfiltered bicarbonate concentrate had median bacterial and endotoxin concentrations of 479,000 CFU/mL and 39,800 pg/mL, respectively. After filtration of the bicarbonate concentrate at the central proportioner, dialysate had a median 9.2 CFU/mL of bacteria and 17.8 pg/mL of endotoxin. Dialysate filtered at individual proportioning dialysis machines had a median 0.001 CF...

Nephrology news & issues, 2005

Infections account for the second leading cause of mortality among patients with end-stage renal ... more Infections account for the second leading cause of mortality among patients with end-stage renal disease. Many of these infections are due to sepsis, primarily arising from the vascular access site. Septicemia alone accounts for almost 11% of mortality in hemodialysis patients. Hemodialysis patients are also a sentinel population for the emergence of antimicrobial resistance, especially with regards to gram-positive cocci (vancomycin-resistant enterococci (VRE), methicillin resistant S. aureus (MRSA), Staphylococcus aureus with reduced susceptibility to vancomycin (VISA), and vancomycin resistant S. aureus [VRSA]). It is extremely important to follow infection control recommendations designed to prevent these types of adverse events from occurring in the hemodialysis population. The campaign to prevent antimicrobial resistance in dialysis includes four strategies: Prevent infection; diagnose and treat infection; use antimicrobials wisely; and prevent transmission. In addition, effor...

Nephrology news & issues, 2002