PSEUDOMONAS-CEPACIA PERITONITIS ASSOCIATED WITH CONTAMINATION OF AUTOMATIC PERITONEAL-DIALYSIS MACHINES

During a 3 mo. period, P. cepacia was recovered from the peritoneal fluid of 10 patients having chronic dialysis therapy at a peritoneal dialysis center. Six patients developed clinical evidence of peritonitis; 1 patient developed septicemia. Epidemiologic studies showed that dialysis on specific peritoneal dialysis machines was associated with an increased risk of infection. Laboratory investigation showed contamination of 2 machines with P. cepacia. Inadequacies in the cleaning and disinfection practices of the automatic peritoneal dialysis machines were identified. Cross-contamination between machines probably occurred through the peritoneal fluid discharge from infected patients during dialysis. Also, the intermittent 2 h exposure of the machine to 2% formaldehyde may have been inadequate. P. cepacia has not been isolated from the peritoneal fluid of any peritoneal dialysis patient after machine cleaning and disinfection practices were altered.