https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1525-1594.1990.tb01601.

Microbial and Endotoxin Contamination in Water and Dialysate in the Central

United States
Elias Klein

Ted Pass

George B. Harding

Rita Wright

Carolyn Million

First published: April 1990

https://doi.org/10.1111/j.1525-1594.1990.tb01601.x

Cited by: 46

Abstract
Abstract: The purified water supplies and randomly selected dialysates of 51
chronic and acute dialysis centers in the central United States were surveyed to
assess the relative risks to dialysis patients from microbial and endotoxin
contamination. A culture medium more sensitive than those generally employed in
routine quality assurance assays was used for recovery of bacteria from water. With
this medium, 35.3% of the water samples and 19% of the dialysate samples were
out of compliance with the Association for the Advancement of Medical
Instrumentation (AAMI) standards: 200 and 2,000 colony forming units (CFU)/ml,
respectively. There was no correlation observed between the type of water
purification system or the frequency of disinfection of the system and the bacterial
and endotoxin contamination levels. There was also no correlation found between
the bacterial and fungal

CFU per ml and the endotoxin concentration per ml (EU/ ml). It is recommended that
more sensitive culturing methods be used to provide adequate bacterial monitoring
of dialysate center water supplies. Dialysis centers should monitor endotoxin in
dialysate on a regular schedule and immediately after any endotoxemic‐like patient
 reactions. Yeast and fungi were observed in 10% and 64% of the water systems,
respectively. Dialysate was contaminated by yeast and fungi in 30% and 70% of the
centers, respectively. The concentrations of these microbes in both fluids were much
lower than bacteria. However, they were observed often enough to warrant further
investigation of their impact on the well‐being of dialysis patients.

https://www.ajkd.org/article/0272-6386(95)90550-2/pdf

Quality of hemodialysis water: A 7-year

multicenter study
Robert A. Laurence, PhD Correspondence information about the author PhD Robert A. Laurence
,

Stephen T. Lapierre, BSc

Laboratoire de santé publique du Québec, Canada

PlumX Metrics
DOI: https://doi.org/10.1016/0272-6386(95)90550-2

 Abstract
 References
Abstract
Since dialysis was introduced 30 years ago, constant progress in technology permitted shortening the length of hemodialysis

(HD) sessions. Through growing concerns about the inadequacy of tap water for dialysate production, hospitals soon opted

for water treatment systems dedicated to HD. Nonetheless, persistent bacterial contamination and the occurrence of

pyrogenic reactions were reported in some HD centers. Several factors contributing to this situation were identified. After

the introduction of highly permeable synthetic membranes in the late 1970s, microbiologic problems reappeared. Thus, in

1977, the Centers for Disease Control and Prevention (CDC) issued proposed guidelines for HD water quality, followed in

1981 by an American National Standard for HD water, issued by the Association for the Advancement of Medical

Instrumentation (AAMI). This Standard was also followed in Canada up to 1986, at which time a National Standard for

Canada was released by the Canadian Standards Association (CSA). This prompted the Laboratoire de santé publique du

Québec (LSPQ) to implement in the Province of Québec a voluntary HD water quality monitoring program. All 36 HD

centers in the Province agreed to participate. The program was launched in February 1987. Water was sampled monthly for
bacteria over a 7-year period (February 1987 to January 1994), and every 3 months for pyrogen and chemicals. Participation
 was more than 95%. Bacteriologic samples were processed in duplicate on heterotrophic plate count agar by the pour plate

technique. Incubation was for 48 ± 3 hours at 35 ± 0.5°C, and the colonies were counted on a Quebec colony counter (New

Brunswick Scientific Co, New Brunswick, NJ). Pyrogen determinations were made using the limulus amebocyte lysate

(LAL) test on 1:20 sample dilution by the gel-clot method. Chemical elements were measured by inductively coupled

plasma emission, graphite furnace absorption, conductivity, ultraviolet light absorption, or colorimetry. Only fully treated

HD water samples were selected from the 11,000 water samples received. Of the 5,820 samples retained for this study, 3,547

were for bacterial, 1,112 for pyrogen, and 1,161 for chemical analyses. Overall compliance to the CSA Standard was 70%

for bacteria, 56% for pyrogen, and 86% for chemistry. The performance of different types of water treatments were

compared and discussed; the best overall compliance was obtained by reverse osmosis combined with deionization (RO +

DI). The type of water treatment that proved most popular was RO alone, which was used by 22 HD centers (61%). It was

concluded that current technology made it possible to produce treated water that regularly met all the requirements of the

CSA Standard for HD purposes. To achieve this, a rigorous disinfection and maintenance program of all the components in

the water treatment system was primordial. We recommend reformulating the maximum acceptable limit of the CSA

Standard for bacteriology, as well as allowing use of nutrient-poor media in an effort to improve bacterial recovery from
treated water samples.

https://academic.oup.com/jid/article-abstract/161/1/85/878007

Mycobacterium chelonae Infection among Patients Receiving High-

Flux Dialysis in a Hemodialysis Clinic in California
Philip W. Lowry Consuelo M. Beck Sague Lee A. Bland Sonia M. AgueroMatthew J.
Arduino Andre N. Minuth Robert A. Murray Jana M. SwensonWilliam R. Jarvis

The Journal of Infectious Diseases, Volume 161, Issue 1, 1 January 1990, Pages 85–
90,https://doi.org/10.1093/infdis/161.1.85

Published:

01 January 1990

Article history

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Abstract
Between July 1987 and January 1988, five patients dialyzed at a hemodialysis
outpatient clinic developed systemic Mycobacterium chelonae abscessus (MCA)
infections. Four of the five patients had arteriovenous graft infections, and two
died during antimicrobial therapy. Case-patients were more likely than control-
patients to have received high-flux dialysis during the 6 mo before their infection
(100% vs, 30%, P = .009). MCA was cultured from the hose connected to a water
spray device used for manual reprocessing of high-flux but not regular dialyzers.
Renalin was the germicide used to manually disinfect dialyzers for reuse and was
prepared at a concentration of2.5%. Laboratory studies documented survival
ofMCA from two high-flux dialyzers that were reprocessed in a manner similar to
that used in the clinic. Early diagnosis with complete rather than partial graft
removal in combination with antimicrobial therapy is recommended for MCA graft
infections. In addition, 2.5% Renalin did not appear to ensure complete killing of
MCA in high-flux dialyzers that were manually reprocessed at this hemodialysis
clinic.