Company's Dialysis Centers Are Implicated in Outbreaks of Infection

Times Staff Writers

Seven people have been hospitalized and at least 12 more became ill after contracting infections at one firm's dialysis centers in Los Angeles, San Diego and Orange counties, according to county and state health officials.

The centers involved are the Norwalk Dialysis Center, the Covina Dialysis Center in West Covina, the Mission Dialysis Center in Chula Vista and the Santa Ana Dialysis Center in Santa Ana. The company that owns the centers, El Segundo-based Davita, is one of the largest providers of dialysis services nationwide, with nearly 500 outlets.

The separate outbreaks of infection occurred between May and mid-November, and involved various types of bacteria and yeast. No patients died and at least one remained hospitalized this week.

State and county health authorities have found violations and ordered written plans of correction related to the outbreaks.

In a statement, Davita officials said the company was cooperating with health inspectors and that no further evidence of infection had been found at its centers in L.A. County or elsewhere.

"The affected patients have been successfully treated with antibiotics and anti-microbial agents, as necessary," the statement said. "We feel confident that the suspected problem has been addressed."

On Nov. 17, an anonymous caller notified the Los Angeles County Department of Health Services of several infections involving the bacteria Stenotrophomonas maltophila at the Norwalk facility. Dr. Jonathan Fielding, director of public health, said inspectors visited the facility the following day and discovered four previous cases dating back to May.

Symptoms of infection include nausea, fever and dizziness, Fielding said. He was unable to describe individual patients' cases.

Dialysis machines remove blood from patients -- often diabetics -- whose kidneys no longer filter impurities. The machines cleanse the blood and reintroduce it into the patient. Many of the patients would die without the treatments. Infections can seriously complicate their conditions.

Local, state and federal officials all play a role in oversight of dialysis centers.

Fielding said the infections at the Norwalk center seemed to be transmitted through a dialysis machine's filter, which the center had been reusing for multiple patients.

Reuse of the filter does not violate health regulations, he said, and the center already had taken corrective steps and switched to a disposable filter before the county inspection. Nonetheless, the county is citing Davita for not having informed it of the outbreak -- defined as three or more cases -- as required by county regulations.

Davita subsequently told the county of three other possible infections -- all at its West Covina site. A county inspection found that at least seven patients had suffered bacterial or yeast infections between August and November, all of them believed to be acquired from the equipment.

The facility also was cited, because of the delay in notifying the county of the outbreak.

"They did instigate this investigation, but these cases started on the first of August," Fielding said. "I would think certainly by mid-September we would have expected them to have enough information to call and report to us."

He said that his department was continuing to look into the matter.

"So far we have a total of 14 infections [involving Davita facilities] and that may wind up being more," Fielding said.

The Los Angeles County citations do not involve a fine. They require Davita to submit a plan of correction to health officials and to give written notification of the outbreaks to patients who use the West Covina and Norwalk facilities.

Separately, five people became ill with yeast infections contracted in a Davita dialysis center in San Diego County, said Dr. Nancy Bowen, the county's public health officer. Robert Miller, a state health department spokesman, identified the center as Mission Dialysis of Chula Vista.

Bowen said that two people were hospitalized and that all five recovered with no long-term effects. In addition, Hildy Myers, Orange County medical director of assessment and epidemiology, said as many as 10 people may have become sick in the Santa Ana facility. Four types of bacteria were involved, said Dr. Jon Rosenberg, a medical epidemiologist with the state Department of Health Services.

The state can issue only a notice of deficiencies, requiring a dialysis center to correct the problems in 90 days. If the center fails to, the state can recommend to a federal agency that it not receive Medicare payments, Miller said. He said the Chula Vista and Santa Ana centers already have fixed the problems.

It is not unusual for the dialysis process to lead to infections, particularly of the skin, said Dr. Laurene Mascola, director of the Los Angeles County Acute Communicable Disease Control Unit.

"People who have dialysis get bacteria in their blood -- it's part and parcel of the process," Mascola said

But she said three cases of infection qualify as an outbreak and must be reported.

In Davita's defense, she said, it is not always easy to determine the type or severity of infections common to dialysis patients.

"To this dialysis center's credit," she said, referring to the Norwalk center, "they did know they'd had infections but thought they were skin contaminants -- something that is almost part of the process."

The spate of infections in Southern California comes in the wake of a report this month by the U.S. General Accounting Office finding serious lapses in quality in dialysis facilities nationally.

The GAO determined that only nine states consistently met federal regulations to inspect one-third of their centers annually. Of 4,011 facilities nationwide, 216 went nine or more years without an inspection.

Also, 15% of facilities had problems of such severity that if left uncorrected, the facilities would become ineligible for Medicare payments.

Each of the Davita centers in Southern California where clusters of infections occurred was inspected within the past three years.

Rosenberg, of the state health department, said that early next week he planned to send a notice to dialysis centers throughout the state notifying them of the infections, so they remain on guard.

He said he will include recommendations of how such outbreaks can be recognized and reported.

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