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Abstract: SA-PO448

Microbacterium Sepsis due to an Insufficiently Sterilized Dialyzer

Session Information

Category: Dialysis

  • 701 Dialysis: Hemodialysis and Frequent Dialysis


  • Kilpatrick, Mark Duncan, Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States
  • Kidd, Jason M., Virginia Commonwealth University School of Medicine, Richmond, Virginia, United States

Water treatment systems and dialysis machines are susceptible to growth of microorganisms if not sufficiently disinfected. We present a case of Microbacterium sepsis related to insufficient sterilization of a hemodialysis machine when brought back into circulation.

Case Description

A 45-year-old man with ESKD presented to the emergency department after chills and vomiting during hemodialysis. Earlier in the day, a patient using the same hemodialysis machine, which had just been returned to use, developed similar symptoms and was admitted to the ICU. In the ED, our patient was tachycardic and tachypneic with a leukocyte count of 7.0x109/L. Blood cultures were collected in the dialysis unit and ED and he was started on vancomycin and piperacillin-tazobactam empirically. On hospital day 3, cultures grew gram positive rods which later speciated to Microbacterium. Repeat cultures yielded no growth and our patient’s tunneled dialysis catheter was replaced. He was treated with intravenous vancomycin for a 14-day course. Blood cultures in the patient dialyzed before our patient were also positive for Microbacterium. Cultures obtained from the dialysis machine yielded no growth.


This rare case of hemodialysis-associated Microbacterium bacteremia demonstrates the importance of proper hemodialysis machine sterilization. Microbacterium are gram positive rods that rarely cause human infection [1]. Given our patient’s history and the prior patient’s similar history on the same machine, the origin of our patient’s bacteremia is presumably the hemodialysis machine, likely either the tubing or dialysate. These two sources are the most common sites of microbial contamination [2]. Microbacterium bacteremia is also associated with catheter and port access and has been cultured from direct catheter sampling in an infected patient [1]. Although dialysis facilities have varying sterilization procedures, they adhere to strict contamination and monitoring standards for patient benefit. In our case, it is not known if there was a lapse in cleaning protocol or inadvertent material contamination, but thankfully our patient improved with prompt administration of empiric antibiotics and permacath replacement.
[A] Chorost M, et al. 2018.
[B] Pontoriero G, et al. 2003.