Infections cause substantial morbidity and mortality among patients receiving care in outpatient hemodialysis facilities. We describe comprehensive infection prevention assessments by US public health departments using standardized interview and observation tools. Results demonstrated how facility layouts can undermine infection prevention and that clinical practices often fall short of policies.

Cardiac tumours are uncommon in the general population and even more so in the paediatric population. Here we present a case of an asymptomatic 7-year-old male with history of high-risk neuroblastoma who underwent 1-year post-treatment surveillance scan with an incidental finding of intracardiac lesion found to be an atrial myxoma.

Background: More than 450,000 patients receive outpatient hemodialysis in the United States. Patients on hemodialysis are at high risk of bloodstream infections (BSIs), which are associated with significant morbidity and mortality. National prevention efforts targeting hemodialysis facilities have resulted in widespread changes in practice, including modifications to central venous catheter (CVC) maintenance procedures. We analyzed dialysis event surveillance data submitted to the CDC NHSN to describe changes in BSI rates among hemodialysis outpatients from 2014 to 2018. Methods: Outpatient hemodialysis facilities report BSIs (ie, positive blood cultures collected in the outpatient setting or within 1 calendar day after hospital admission) and the number of hemodialysis outpatients treated during the first 2 working days of each month to the NHSN. For each BSI, the suspected source (ie, vascular access, another site, contamination, or uncertain) and vascular access type are indicated: CVC, arteriovenous fistula (AVF) or arteriovenous graft (AVG). Pooled mean rates (per 100 patient months) were calculated for BSIs, access-related BSIs (ARBSIs), and BSIs and ARBSIs were stratified by vascular access type. Annual BSI rate trends were evaluated using a negative binomial regression model, which treated patient months as an offset variable and included access type, year, and an access-year interaction variable. Results: More than 6,000 outpatient hemodialysis facilities reported 134,961 BSIs from 2014 to 2018. Of these BSIs, 102,505 (76%) were categorized as access related. CVCs were present in 63% of BSIs and 70% of ARBSIs. Pooled mean BSI rates decreased 27% from 0.64 to 0.47 per 100 patient months; rates of ARBSIs decreased 27% from 0.49 to 0.36 per 100 patient months. Significant decreases in event rates occurred across vascular access strata (Fig. 1). The reduction in BSI and ARBSI burden was most pronounced among patients with CVCs. BSI rates in patients with CVCs decreased 32% from 2.16 per 100 patient months to 1.46 (annual average decrease, 9.5%), and ARBSI rates in patients with CVCs decreased 32% from 1.83 per 100 patient months to 1.24 (annual average decrease, 9.4%). Conclusions: Substantial reductions in BSI and ARBSI rates among hemodialysis outpatients occurred during this 5-year period, and these reductions appear to be most prominent among CVC and AVF patients. Improvements in infection prevention and control practices, including CVC care, have likely contributed to these reductions. Additional efforts to increase the uptake of known prevention practices and to identify new strategies for prevention might contribute to continued decreases in infections among this highly vulnerable population.

Funding: None

Disclosures: None

Background: Peritoneal dialysis is a type of dialysis performed by patients in their homes; patients receive training from dialysis clinic staff. Peritonitis is a serious complication of peritoneal dialysis, most commonly caused by gram-positive organisms. During March‒April 2019, a dialysis provider organization transitioned ~400 patients to a different manufacturer of peritoneal dialysis equipment and supplies (from product A to B). Shortly thereafter, patients experienced an increase in peritonitis episodes, caused predominantly by gram-negative organisms. In May 2019, we initiated an investigation to determine the source. Methods: We conducted case finding, reviewed medical records, observed peritoneal dialysis procedures and trainings, and performed patient home visits and interviews. A 1:1 matched case–control study was performed in 1 state. A case had ≥2 of the following: (1) positive peritoneal fluid culture, (2) high peritoneal fluid white cell count with ≥50% polymorphonuclear cells, or (3) cloudy peritoneal fluid and/or abdominal pain. Controls were matched to cases by week of clinic visit. Conditional logistic regression was used to estimate univariate matched odds ratios (mOR) and 95% confidence intervals (CIs). We conducted microbiological testing of peritoneal dialysis fluid bags to rule out product contamination. Results: During March‒September 2019, we identified 157 cases of peritonitis across 15 clinics in 2 states (attack rate≍39%). Staphylococcus spp (14%), Serratia spp (12%) and Klebsiella spp (6.3%) were the most common pathogens. Steps to perform peritoneal dialysis using product B differed from product A in several key areas; however, no common errors in practice were identified to explain the outbreak. Patient training on transitioning products was not standardized. Outcomes of the 73 cases in the case–control study included hospitalization (77%), peritoneal dialysis failure (40%), and death (7%). The median duration of training prior to product transition was 1 day for cases and controls (P = .86). Transitioning to product B (mOR, 18.00; 95% CI, 2.40‒134.83), using product B (mOR, 18.26; 95% CI, 3.86‒∞), drain-line reuse (mOR, 4.67; 95% CI, 1.34‒16.24) and performing daytime exchanges (mOR, 3.63; 95% CI, 1.71‒8.45) were associated with peritonitis. After several interventions, including transition of patients back to product A (Fig. 1), overall cases declined. Sterility testing of samples from 23 unopened product B peritoneal dialysis solution bags showed no contamination. Conclusions: Multiple factors may have contributed to this large outbreak, including a rapid transition in peritoneal dialysis products and potentially inadequate patient training. Efforts are needed to identify and incorporate best training practices, and product advances are desired to improve the safety of patient transitions between different types of peritoneal dialysis equipment.

Funding: None

Disclosures: None

Background: Hepatitis C virus (HCV) transmission at outpatient hemodialysis clinics is well documented, but little is known about HCV transmission risks in long-term care facilities (LTCFs) providing hemodialysis services. LTCFs can provide onsite hemodialysis for residents by contracting with a licensed hemodialysis clinic to either provide its staff to the LTCF or to train LTCF staff as caregivers. In August 2019, the Georgia Department of Public Health (DPH) was notified about an HCV seroconversion in patient A at a LTCF providing onsite hemodialysis. Methods: Three residents (including patient A) were receiving hemodialysis at the LTCF in August 2019; patients B and C had chronic HCV infection upon admission. Records were reviewed for medical history, behavioral risk factors, and healthcare exposures. We conducted onsite infection control assessments and interviewed staff. Serum specimens were collected for all 3 patients in August 2019 and HCV tested for genetic similarity using Global Hepatitis Outbreak Surveillance Technology (GHOST). Results: The facility reported initiating onsite hemodialysis in November 2018; facility staff were trained by a dialysis provider. Patient A, admitted in September 2018, was anti-HCV negative in June 2019 and both anti-HCV and HCV RNA positive in July 2019. Patient B was admitted in December 2018, discharged for 1 month in May 2019, and then readmitted. Patients A and B reported previous injection drug use, and they were not observed by staff to use during their stay and had limited mobility. Patient A was wheelchair confined and B was bed confined. Patient C was admitted in May 2019. HCV samples from patients A and B both had HCV genotype 1b and demonstrated 100% genetic relatedness, indicating that patient B was the likely source. Patient C had HCV genotype 1a. Hemodialysis was provided to residents simultaneously in a converted resident room with 4 hemodialysis stations, and the LTCF operated 2 shifts, 3 times per week. We observed multiple infection control gaps, such as preparation of IV medications and inadequate disinfection in the shared dialysis treatment area. Recommendations addressing gaps were issued, and a follow-up site visit was conducted to validate implementation. With the exception of May 2019, patients A and B received hemodialysis on the same shift and days from December 2018 to September 2019. Conclusions: Phylogenetic and epidemiological results indicate HCV transmission likely occurred during hemodialysis services provided by the LTCF. As the provision of dialysis expands to nontraditional settings such as LTCFs, it is essential that proper infection control procedures and oversight are in place.

Funding: None

Disclosures: None

Among dialysis facilities participating in a bloodstream infection (BSI) prevention collaborative, access-related BSI incidence rate improvements observed immediately following implementation of a bundle of BSI prevention interventions were sustained for up to 4 years. Overall, BSI incidence remained unchanged from baseline in the current analysis.

Infect Control Hosp Epidemiol 2016;37:863–866

Outpatient hemodialysis bloodstream infection rates, now used for performance measurement and were significantly higher for manual compared with automated surveillance (P<.001), largely owing to the absence of blood culture data in the dialysis electronic health record. Improvement in data sharing between hospitals and outpatient dialysis centers is necessary.

Infect. Control Hosp. Epidemiol. 2016;37(4):472–474

Reports of bloodstream infections caused by methicillin-resistant Staphylococcus aureus among chronic hemodialysis patients to 2 Centers for Disease Control and Prevention surveillance systems (National Healthcare Safety Network Dialysis Event and Emerging Infections Program) were compared to evaluate completeness of reporting. Many methicillin-resistant S. aureus bloodstream infections identified in hospitals were not reported to National Healthcare Safety Network Dialysis Event.

Infect. Control Hosp. Epidemiol. 2016;37(2):205–207

Investigation of an outbreak of Clostridium difficile infection (CDI) at a hemodialysis facility revealed evidence that limited intrafacility transmission occurred despite adherence to published infection control standards for dialysis clinics. Outpatient dialysis facilities should consider CDI prevention, including environmental disinfection for C. difficile, when formulating their infection control plans.

Infect. Control Hosp. Epidemiol. 2015;36(8):972–974

We investigated 4 hepatitis C virus (HCV) infection outbreaks at hemodialysis units to identify practices associated with transmission. Apparent failures to follow recommended infection control precautions resulted in patient-to-patient HCV transmission, through cross-contamination of the environment or intravenous medication vials. Fastidious attention to aseptic technique and infection control precautions are essential to prevent HCV transmission.