Dialysis-related Outbreaks: Current

The following includes selected examples of dialysis related outbreaks and events.

This is not an exhaustive list but it serves as a reminder of the serious consequences that can result when basic principles of infection control are not followed.

Adverse Drug and Device Events

2017: Changing microbiology of indwelling venous catheter related Infectionexternal icon.
Shahani, Lokesh, Chad Noggle, and Nancy Khardori. In Clin Res 3.4 (2017): 1-4.

2017: Hemodialyzer Reuse and Gram-Negative Bloodstream Infections.external icon
Edens C, Wong J, et al. in Am J Kidney Dis. 2017 Jun;69(6):726-733.

2014: Outbreak of bloodstream Infections associated with multiuse dialyzers containing O-ringsexternal icon.
OYong, Kelsey, et al. in Infection Control & Hospital Epidemiology 35.1 (2014): 89-91.

2012: Vascular access hemorrhages contribute to deaths among hemodialysis patientsexternal icon.
Ellingson, Palekar, Lucero, Kurjian, Chai, Schlossberg, Vincent, Fink, Davies-Cole, Margi, Arduino, and Patel. In Kidney International. Volume 82, Issue 6, 2 September 2012, Pages 686-692.

2010: Outbreak of adverse reactions associated with contaminated heparin.external icon
Blossom DB, et al. in N Engl J Med. 2008 Dec 18;359(25):2674-84. doi: 10.1056/NEJMoa0806450. Epub 2008 Dec 3. Erratum in: N Engl J Med. 2010 Mar 18;362(11):1056.

2008: Gadolinium-containing magnetic resonance imaging contrast and nephrogenic systemic fibrosis: a case-control study.external icon
Kallen, Alexander J., et al.  in American Journal of Kidney Diseases 51.6 (2008): 966-975.

2008: Acute allergic-type reactions among patients undergoing hemodialysis – multiple state, 2007-2008.
MMWR Morb Mortal Wkly Rep. 2008 Feb 8;57(5):124-5. PubMed PMID: 18256585.

2007: Nephrogenic Fibrosing Dermopathy Associated with Exposure to Gadolinium-Containing Contrast Agents — St. Louis, Missouri, 2002-2006.
MMWR 2007;56(07);137-141.

2006: Outbreak of bloodstream Infection with the mold Phialemonium among patients receiving dialysis at a hemodialysis unitexternal icon.
Clark, Thomas, et al. in Infection Control & Hospital Epidemiology 27.11 (2006): 1164-1170.

Bacterial and Fungal Infections

2019: Outbreak of nonfermentative Gram‐negative bacteria (Ralstonia pickettii and Stenotrophomonas maltophilia) in a hemodialysis centerexternal icon.
K. Thet, May, et al. in Hemodialysis International 23.3 (2019): E83-E89.

2019: A Guide to Investigating Suspected Outbreaks of Mucormycosis in Healthcare.external icon
Hartnett, Kathleen P., et al. in Journal of Fungi 5.3 (2019): 69.

2015: Outbreak of Clostridium difficile Infections at an Outpatient Hemodialysis Facility—Michigan, 2012–2013external icon.
See, Isaac, et al. in Infection Control & Hospital Epidemiology 36.8 (2015): 972-974.

2011: Vital Signs: Central Line–Associated Blood Stream Infections — United States, 2001, 2008, and 2009
MMWR March 4, 2011 / 60(08);243-248

2009: Contaminated product water as the source of Phialemonium curvatum bloodstream Infection among patients undergoing hemodialysis.external icon
Rao, Carol Y., et al. in Infection Control & Hospital Epidemiology 30.9 (2009): 840-847.

2009: Outbreak of Bloodstream Infections at an Outpatient Dialysis Center — Ohio, 2008 pdf icon[PDF – 139 pages].
EIS Conference 2008, March 19-22, Atlanta, GA (2008): 84-85.

2006: Outbreak of Bloodstream Infection With the Mold Phialemonium Among Patients Receiving Dialysis at a Hemodialysis Unitexternal icon.
Clark, Thomas, et al. in Infection Control & Hospital Epidemiology 27.11 (2006): 1164-1170.

2004: Vancomycin intermediate and resistant Staphylococcus aureus. What the nephrologist needs to knowexternal icon.
McDonald LC, Hageman JC.  In Nephrol News Issues. 2004 Oct;18(11):63-4, 66-7, 71-2

Chemical Intoxication

2008: Elevated Serum Aluminum Levels in Hemodialysis Patients Associated with Use of Electric Pumps — Wyoming, 2007.
MMWR 2008; 57(25):689-691.

2004: Epidemic parenteral exposure to volatile sulfur-containing compounds at a hemodialysis centerexternal icon.external icon
Selenic D, Alvarado-Ramy F, et al. in Infect Control Hospital Epidemiol. 2004; 25(3):256-261.


2019Healthcare-Associated Hepatitis B and C Outbreaks (≥ 2 cases) Reported to the CDC 2008-2018
CDC, Viral Hepatitis website, 30 Oct. 2019. Accessed 16 Mar 2020.

2017: Detection, Reporting, and Treatment of Hepatitis C Infections Among Hemodialysis Patients.external icon
Collier MG, Nguyen DB, Patel PR, Moorman AC. in Infect Control Hosp Epidemiol. 2017 Apr;38(4):493-494. doi: 10.1017/ice.2016.317. Epub 2017 Jan 5. No abstract available.

2016: Hepatitis C virus outbreaks in hemodialysis centers: a continuing problemexternal icon.
Weber, David J., William A. Rutala, and Michael W. Fried. In Infection Control & Hospital Epidemiology 37.2 (2016): 140-142.

2016: Hepatitis C virus outbreak in a haemodialysis unit: learning from failuresexternal icon.
Senatore, S., et al. in Journal of Hospital Infection 94.3 (2016): 249-252.

2016: A Large Outbreak of Hepatitis C Virus Infections in a Hemodialysis Clinicexternal icon.
Nguyen, Duc B., et al. in Infection Control & Hospital Epidemiology 37.2 (2016): 125-133.

2014: Reactivation and Transmission of Hepatitis B Virus from an HIV-Positive Hemodialysis Patient— North Carolina, 2013 pdf icon[PDF – 116 pages].
63rd Epidemic Intelligence Service (EIS) Conference, April 28 – May 1, 2014; Atlanta, GA.

2013: Outbreak of hepatitis C virus Infections at an outpatient hemodialysis facility: the importance of Infection control competencies pdf icon[PDF – 14 pages]external icon.
Rao, Agam K., et al. in Nephrology Nursing Journal 40.2 (2013).

2012: Outbreak of hepatitis C virus Infections in an outpatient dialysis facility—Georgia, 2011 pdf icon[PDF – 140 pages].
61st Epidemic Intelligence Service (EIS) Conference; April 16–20, 2012; Atlanta, GA.

2010: Epidemiology, surveillance, and prevention of hepatitis C virus Infections in hemodialysis patientsexternal icon
Patel PR, Thompson ND, Kallen AJ, Arduino MJ. In Am J Kidney Dis. 2010 Aug;56(2):371-8. doi: 10.1053/j.ajkd.2010.01.025. Epub 2010 Jun 8. Review. PMID:20570422

2009: Nonhospital healthcare-associated hepatitis B and C virus transmission: United States, 1998-2008.external icon
Thompson, Nicola D., et al.in Annals of Internal Medicine 150.1 (2009): 33-39.

2009: Hepatitis C virus transmission in hemodialysis units: importance of Infection control practices and aseptic technique.external icon
Thompson, Nicola D., et al. in Infection Control & Hospital Epidemiology 30.9 (2009): 900-903.

2008: Hepatitis C Virus Transmission at an Outpatient Hemodialysis Unit — New York, 2001-2008.
MMWR 2009; 58(08);189-194

Peritoneal Dialysis

2019: Burkholderia cepacia: An Outbreak in the Peritoneal Dialysis Unitexternal icon.
Gleeson, Sarah, et al. in Peritoneal Dialysis International 39.1 (2019): 92-95.

2018: Microbacterium Peritonitis in Peritoneal Dialysis: A Case Report and Reviewexternal icon.
Lam, Philip W., David M. Naimark, and Jerome A. Leis. In Peritoneal Dialysis International 38.1 (2018): 9-13.

2018: Management of a Mycobacterium immunogenum Infection of a peritoneal dialysis catheter siteexternal icon.
Shenoy, Abhishek, et al. in Infection 46.6 (2018): 875-880.

Water Associated

2019: Multicenter Outbreak of Gram-Negative Bloodstream Infections in Hemodialysis Patients.external icon
Novosad SA, et al. in Am J Kidney Dis. 2019 Nov;74(5):610-619. doi: 10.1053/j.ajkd.2019.05.012. Epub 2019 Jul 30.

2019: Investigation of healthcare Infection risks from water-related organisms: Summary of CDC consultations, 2014—2017external icon
Perkins, Kiran M., et al. in Infection Control & Hospital Epidemiology 40.6 (2019): 621-626.

2019: Dialysis drains as a possible source for carbapenem-resistant pathogens causing an ICU outbreak.external icon
Ross, Birgit, et al. in Infection 47.2 (2019): 233-238.