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Dialysis Drains As a Source For Resistant Organisms

Are we ignoring the role of dialysis drains in preventing resistant-organism transmission?

There are a million different ways for germs to spread in health care settings, and there is always room for improvement and better infection prevention practices to stop the spread. Reducing the spread of multidrug-resistant organisms, in particular, is critical. In an attempt to curb the spread of pathogens in the hospital, a team of investigators from the foundation Universitätsmedizin in Essen, Germany, studied dialysis drains and found that when used incorrectly, there is a risk of transmission of multidrug-resistant pathogens, such as Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae, to patients.

Carbapenem-resistant bacteria, such as Enterobacteriaceae, are a worldwide concern as they pose a unique threat to patient and staff in their resistance and are easily transmitted. In infection prevention, we work to understand the vulnerabilities of medical care so that we can prevent transmission.

In March 2016, 4 patients within the intensive care unit (ICU) of a tertiary hospital in Germany were found to be colonized with KPC-producing Enterobacteriaceae. Each patient had a minimum of an 8-day hospitalization prior to the diagnosis of colonization, as well as a medically complex stay (meaning that these were cases of hospital transmission.) KPC-producing Enterobacteriaceae was rarely identified in the hospital, and so the findings were surprising.

In this ICU, like many, patients were screened weekly for multidrug-resistant gram-negative pathogens and in this case, tracheal secretions were cultured on all ventilated patients. Such patients were frequently requiring bronchoscopies, and so the flexible bronchoscopes were the first source considered.

Following this, over 174 samples were taken from outside and within the patients’ rooms. Water-supply systems and high-touch surfaces were given special consideration. “Microorganisms, mainly nonpathogenic microorganisms like coagulase-negative Staphylococci or nonpathogenic Corynebacteriaceae in low or moderate concentrations, were detected on various surfaces, but KPC-producing Enterobacteriaceae could not be identified despite [a] targeted search,” according to the study authors.

Interestingly, though, the investigators found KPC-producing Enterobacteriaceae in the drains of the patient’s rooms—predominantly in the rooms of the dialysis units (5 times in total) and in the siphons of the sinks. This is especially interesting because sampling was not limited to those patients found to be colonized; however, ultimately no samples of KPC-producing Enterobacteriaceae were detected outside the patients’ rooms.

As a result, the investigators posited that the dialysis drains were a reservoir for the KPC-producing Enterobacteriaceae and immediately discontinued their use. Dialysis practices were changed to utilize single-use ultrafiltrate bags, which were discarded into the trash following their use. Sinks and drains in the dialysis unit were disinfected with bleach and follow-up sampling found a significant decrease in bio-burden. In addition to environmental measures, those staff in the unit were trained on hand hygiene and patient rooms were disinfected even if patients were in the rooms, providing additional cleaning during their hospitalization. It was heavily emphasized with staff that if they came into contact with the drain, a glove change and hand hygiene was necessary.

Although having dialysis connection units—including a drainage system—near the patient inside their room can make the care process easier and more convenient for staff, the proximity also poses a risk to patients. When items are not used properly or disinfected frequently, the risk of disease transmission increases in a patient population that is already susceptible. The findings of this study emphasize the importance of continued vigilance of environmental disinfection, greater consideration for infection prevention during patient room design/layout, and continued education for staff on disease transmission and the risks for resistant organism transmission in critically-ill patients.