Management of Chills During Dialysis with Reused Dialyzer
This patient requires immediate discontinuation of dialysis, blood cultures, and empirical broad-spectrum antibiotics with vancomycin plus gram-negative coverage, while simultaneously investigating both pyrogenic reaction from contaminated dialyzer reuse and catheter-related bloodstream infection as the two most likely causes.
Immediate Actions
Stop Dialysis and Obtain Cultures
- Immediately terminate the dialysis session and obtain blood cultures from the fistula or peripheral site (not from a catheter if present) 1
- Draw at least two sets of blood cultures before initiating antibiotics 1
- If peripheral access is unavailable, blood can be drawn from the bloodlines connected to the dialysis circuit 1
Initiate Empirical Antibiotics
- Start empirical antibiotic therapy immediately with vancomycin plus gram-negative coverage (third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination based on local antibiogram) 1
- This recommendation applies even though the patient has a fistula rather than a catheter, given the 60% infection rate in hemodialysis patients presenting with chills 2
Differential Diagnosis: Two Primary Considerations
1. Pyrogenic Reaction from Dialyzer Reuse
The 6th reuse of this dialyzer with tubings raises significant concern for endotoxin contamination, particularly since no other patients developed symptoms (suggesting an individual dialyzer problem rather than water system contamination) 3
Key features supporting pyrogenic reaction:
- Chills occurring 2 hours into dialysis (typical timing for endotoxin exposure) 3
- Isolated case (other patients unaffected) suggests individual dialyzer contamination rather than water system issue 3
- Multiple reuses increase risk of bacterial/endotoxin accumulation in dialyzer 3, 4
Investigation required:
- Test the specific dialyzer and reprocessing water for endotoxin levels (should be <6 ng/mL) and bacterial counts (should be <10^4 CFU/mL) 3
- Review the reprocessing protocol for this specific dialyzer 3
- Immediately discontinue reuse of this patient's dialyzer 3
2. Fistula-Related or Systemic Infection
Despite having a fistula (lower risk than catheter), infection remains highly prevalent in dialysis patients with chills 2
Risk stratification based on clinical features:
- Fever present: Odds ratio 1.6 for bacteremia 2
- Leukocytosis: Odds ratio 1.265 for any infection 2
- Hypoalbuminemia: Additional risk factor for bacteremia 2
- Fistula access WITHOUT fever, leukocytosis, or hypoalbuminemia: Only 6% bacteremia risk 2
However, given the acute presentation during dialysis, empirical antibiotics should NOT be withheld pending these laboratory results, as the 60% overall infection rate in this population mandates immediate treatment 2
Diagnostic Workup
Essential Laboratory Tests
- Complete blood count with differential (assess for leukocytosis) 2
- Serum albumin level 2
- Temperature measurement (fever significantly increases bacteremia risk) 2
- Two sets of blood cultures before antibiotics 1
Fistula Examination
- Inspect fistula site for erythema, warmth, purulent drainage, or tenderness 1
- Examine for signs of infection at cannulation sites 1
Water Quality Assessment
- Test dialysis water and dialysate for endotoxin and bacterial contamination 1, 3
- Review water treatment system maintenance logs 1
- Inspect dialyzer reprocessing procedures and documentation 3, 4
Antibiotic Management Algorithm
Initial Empirical Therapy
Vancomycin PLUS gram-negative coverage 1
- Vancomycin: Dosed according to dialysis schedule
- PLUS one of: third-generation cephalosporin, carbapenem, or β-lactam/β-lactamase combination based on local resistance patterns 1
Modification Based on Culture Results
If methicillin-susceptible S. aureus identified:
- Switch to cefazolin 20 mg/kg (actual body weight), rounded to nearest 500-mg increment, after dialysis 1
If cultures negative at 48-72 hours AND symptoms resolved:
- Discontinue antibiotics if no other infection source identified 1
- Likely pyrogenic reaction from dialyzer contamination 3
If cultures positive:
- Continue targeted antibiotics for 10-14 days for uncomplicated infection 1
- Extend to 4-6 weeks if persistent bacteremia >72 hours, endocarditis, or suppurative thrombophlebitis 1
Prevention Measures Going Forward
Dialyzer Reuse Considerations
- Single-use dialyzers are preferable to reuse based on medical criteria and risk assessment 4
- If reuse continues, ensure strict compliance with AAMI standards 4
- Implement enhanced monitoring of water treatment systems (monthly microbial testing minimum) 1
- Consider discontinuing reuse for this patient given this complication 3, 4
Water Quality Monitoring
- Monthly bacteriologic monitoring of dialysis water and dialysate is mandatory 1
- Maintain bacterial counts <10^4 CFU/mL and endotoxin <6 ng/mL 3
- Daily disinfection of hemodialysis machine internal pathways 1
Fistula Care Protocol
- Wash fistula with soap and water before each session 1
- Disinfect with alcohol-based chlorhexidine (>0.5%) for at least 60 seconds before cannulation 1
- Staff must perform hand hygiene and wear gloves during all access procedures 1
Critical Pitfalls to Avoid
Do not delay antibiotics while awaiting culture results in symptomatic patients—the 60% infection rate mandates immediate treatment 2
Do not assume pyrogenic reaction alone—even with fistula access and suspected dialyzer contamination, infection must be ruled out with cultures and clinical monitoring 2, 3
Do not continue using the same dialyzer—immediately switch to new dialyzer (preferably single-use) for subsequent sessions 3, 4
Do not overlook water system contamination—although only this patient was affected, water quality testing is essential to rule out broader contamination 1, 3
Do not use dialysate temperature as explanation—while temperature changes can cause chills, infectious causes must be excluded first 5