Continuous Quality Improvement

Concurrent Education Session - 60 minutes

1305 - Delftia acidovorans Outbreak in Portable Reverse Osmosis Machines: Interventions to Ensure Safe and Cost-Effective Hemodialysis

Wednesday, June 14
3:00 PM - 4:00 PM
Location: Oregon Convention Center, B 115-116

City water systems are inherently affected by biofilm development and, due to significant variability in metal and bacterial content, potable water cannot be used directly for hemodialysis (HD). Reverse osmosis (RO) technology significantly improves HD water quality and safety. The Association for the Advancement of Medical Instrumentation (AAMI) regulates the quality and safety of HD water via routine monthly culture and endotoxin testing standards. Infection preventionists must monitor their RO water systems and be able to troubleshoot bacterial growth.

In September 2014, infection prevention was notified of an increase in positive RO water cultures in the HD unit. Despite review of disinfection and culture process and repeated disinfection, the RO machines remained positive. Microbiology laboratory and infection prevention conducted an outbreak investigation to determine the source.

The HD unit had 10 portable RO machines. All machines became positive with >100 CFU/ml. Endotoxin testing remained largely negative. All RO machine filters and membranes were replaced and longer disinfectant dwell times were employed with no significant benefit. Sampling from various lines, pumps, and connectors of two different RO machines was submitted for culture and clonality testing.

Cultures predominantly revealed Delftia acidovorans. Confirmation of 17 isolates was performed using 16S rRNA technology. Pulse field gel electrophoresis analysis revealed a very suggestive clonal pattern. Over 2 years, after repeated failed attempts to clear RO machines, a cost-effectiveness analysis was conducted to determine the most effective strategy for moving forward. Decision-making included purchasing new machines and reconfiguring the preparation room to enable better disinfection and culture process flow. Biofilm, once formed, is extremely hard to eradicate. It is our intention to present this data to alert HD units/facilities of the importance of routinely reviewing HD RO cultures as well as disinfection guidelines.

Learning Objectives:

Juliet Ferrelli

Infection Prevention Manager
UPMC Mercy
Pittsburgh, Pennsylvania

Juliet Ferrelli has worked in infection prevention for over 15 years at several Pittsburgh hospitals, including Western Pennsylvania Hospital, UPMC Presbyterian, Children’s Hospital of Pittsburgh of UPMC and is currently the manager of the Infection Prevention department at UPMC Mercy. Juliet has her Masters degree in Clinical Laboratory Science and Bachelors degree in Medical Technology. She is certified in Infection Control (CIC), has been an APIC member since 2002 and most recently received her designation as an APIC Fellow in 2016. Prior to working in infection prevention, Juliet worked in North Dakota as a Microbiology Research Assistant, a Lead Medical Technologist and was an Associate Professor of Hematology at Bismarck State College. Juliet served as Three Rivers Pittsburgh APIC chapter president in 2012 and 2016, currently serving as the Past President. Additionally she is serving as the Three Rivers Pittsburgh APIC fall conference co-chair.


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Gwen Messer

Infection Preventionist
University of Pittsburgh Medical Center Mercy Hospital
Pittsburgh, Pennsylvania

Gwen Messer brings her background as a medical technologist with extensive generalist and microbiology experience at the University of Pittsburgh Medical Center Mercy Hospital to the role of infection prevention, when she transitioned to the role of infection preventionist in January 2015.


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Mohamed Yassin

Medical Director Infection Control -Hospital Epi
UPMC Mercy - University of Pittsburgh
Pittsburgh, Pennsylvania

Mohamed Yassin has been working in infection control since 2011. Mohamed finished the Infectious Diseases Fellowship at Case Western Reserve University in Cleveland, Ohio, worked at the University of Maryland after graduation as a clinical instructor, and then moved to the University of Pittsburgh Physicians in 2008 as an assistant clinical professor and recently associate professor. Mohamed has significant interest in clinical infection control research and is part of a very successful infection prevention team at the University of Pittsburgh Medical Center. In 2016, Mohamed has passion for infection prevention. Mohamed does clinical infectious diseases consultation and teaches infectious diseases fellows and internal medicine residents.


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Carol McLay

Infection Control International
Louisville, Kentucky

Dr. Carol M. McLay, DrPH., MPH, RN, FAPIC, CIC is the CEO of Infection Control International and is a consultant in the fields of healthcare epidemiology, infection prevention and control, and public health. Carol received her BSN from the University of Ottawa in Canada, an MPH from Emory University, and a DrPH in epidemiology at the University of Kentucky.

Dr. McLay serves as the Lead Nurse Planner with the Association for Professionals in Infection Control and Epidemiology (APIC), where she has responsibility for the management of their continuing educational programs.

She is a member of the Board of Directors for the Healthcare Laundry Accreditation Council (HLAC). She currently serves as a member of the Society for Healthcare Epidemiology of America (SHEA)‘s External Affairs Committee. She is the author of The Infection Prevention Competency Review Guide, 4th edition, and APIC’s Certification Study Guide, 5th and 6th edition.


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1305 - Delftia acidovorans Outbreak in Portable Reverse Osmosis Machines: Interventions to Ensure Safe and Cost-Effective Hemodialysis

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