A multi-center outbreak of Candida tropicalis bloodstream infections associated with contaminated hemodialysis machine prime buckets

Published:February 22, 2021DOI:


      • Candida species seldom cause hemodialysis-related bloodstream infections (BSIs).
      • An outbreak of C. tropicalis BSIs affected 3 hemodialysis units located in 2 cities.
      • Inadequate saline prime bucket disinfection was the primary cause of the outbreak.
      • Continued emphasis on saline prime bucket disinfection is warranted.


      Outbreaks of fungal bloodstream infection (BSI) are uncommon among hemodialysis patients. We investigated an outbreak of Candida tropicalis BSIs involving patients at 3 of 4 affiliated hemodialysis units.


      An investigation included a review of records of patients with C tropicalis BSI, a case-control study, and cultures of medications, hands of personnel, dialysis equipment, and water samples.


      Eight patients developed C tropicalis BSIs in a 3-month period. Compared to controls, cases had a higher proportion of preceding dialyses performed on a machine with a contaminated saline prime bucket (SPB) (P= .02). Observations revealed that SPBs at units A-C were rinsed with tap water, were not routinely disinfected, and that priming tubing was allowed to contact fluid in SPBs. C tropicalis was recovered from the main compartment and hollow handle of SPBs and from other environmental samples. C tropicalis isolates from patients, SPBs and other environmental samples had indistinguishable pulsed-field gel electrophoresis patterns. Following routine disinfection of SPBs, the outbreak terminated.


      This outbreak was likely due to inadequate disinfection of SPBs. The findings emphasize the importance of disinfection of SPBs. Current use of identical SPBs warrants further evaluation of hollow SPB handles as a potential infection risk.

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        • Nguyen DB
        • Shugart A
        • Lines C
        • et al.
        National Healthcare Safety Network (NHSN) dialysis event surveillance report for 2014.
        Clin J Am Soc Nephrol. 2017; 12: 1139-1146
        • Nguyen DB
        • Gutowski J
        • Ghiselli M
        • et al.
        A large outbreak of hepatitis C virus infections in a hemodialysis clinic.
        Infect Control Hosp Epidemiol. 2016; 37: 125-133
        • Edens C
        • Wong J
        • Lyman M
        • et al.
        Hemodialyzer reuse and gram-negative bloodstream infections.
        Am J Kidney Dis. 2017; 69: 726-733
        • Novosad SA
        • Lake J
        • Nguyen D
        • et al.
        Multicenter outbreak of gram-negative bloodstream infections in hemodialysis patients.
        Am J Kidney Dis. 2019; 74: 610-619
        • Colombo AL
        • Melo AS
        • Crespo Rosas RF
        • et al.
        Outbreak of Candida rugosa candidemia: an emerging pathogen that may be refractory to amphotericin B therapy.
        Diagn Microbiol Infect Dis. 2003; 46: 253-257
        • Association for the Advancement of Medical Instrumentation
        Water Treatment Equipment for Hemodialysis Applications (ANSI/AAMI RD62:2001).
        Association for the Advancement of Medical Instrumentation, Arlington, VA2001
        • Arnow PM
        • Garcia-Houchins S
        • Neagle MB
        • Bova JL
        • Dillon JJ
        • Chou T
        An outbreak of bloodstream infections arising from hemodialysis equipment.
        J Infect Dis. 1998; 178: 783-791
        • Zuza-Alves DL
        • Silva-Rocha WP
        • Chaves GM
        An update on Candida tropicalis based on basic and clinical approaches.
        Front Microbiol. 2017; 8: 1927
        • Humar A
        • Oxley C
        • Sample ML
        • Garber G
        Elimination of an outbreak of gram-negative bacteremia in a hemodialysis unit.
        Am J Infect Control. 1996; 24: 359-363
        • Strott K
        ESRD NCC healthcare-associated infection (HAI) Learning and Action Network (LAN) discovery event.
        2016 (Available at:) (Accessed February 19, 2021)
      1. Gualandi N. To boldly go where few have been before: infection control assessment and response in the outpatient dialysis setting. Presented at the Annual Council of State and Territorial Epidemiologists meeting, June 6, 2017, Boise, ID. Available at: Accessed February 19, 2021.

        • Hernandez J
        • Lamm W
        • Ridge H
        The North Carolina dialysis infection control assessment and response (ICAR) experience.
        2018 (Available at:) (Accessed February 19, 2021)
        • Backman LA
        • Dumigan DG
        • Harizaj A
        • et al.
        A cluster of Gram-negative bloodstream infections in Connecticut hemodialysis patients with contaminated wall boxes and priming buckets.
        Open Forum Infect Dis. 2019; 6: S848-S849
        • Centers for Disease Control and Prevention
        Environmental surface disinfection in dialysis facilities: notes for clinical managers.
        2020 (Available at: Accessed February 12, 2021)
        • Wang SA
        • Levine RB
        • Carson LA
        • et al.
        An outbreak of gram-negative bacteremia in hemodialysis patients traced to hemodialysis machine waste drain ports.
        Infect Control Hosp Epidemiol. 1999; 20: 746-751
        • Zhang J
        • Burr RA
        • Sheth HS
        • Piraino B
        Organism-specific bacteremia by hemodialysis access.
        Clin Nephrol. 2016; 86: 141-146
        • Grohskopf LA
        • Roth VR
        • Feikin DR
        • et al.
        Serratia liquefaciens bloodstream infections from contamination of epoetin alfa at a hemodialysis center.
        N Engl J Med. 2001; 344: 1491-1497
        • Tena D
        • Carranza R
        • Barbera JR
        • et al.
        Outbreak of long-term intravascular catheter-related bacteremia due to Achromobacter xylosoxidans subspecies xylosoxidans in a hemodialysis unit.
        Eur J Clin Microbiol Infect Dis. 2005; 24: 727-732