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P M Arnow

Publications and source records attributed to P M Arnow.

At least 19 recordsLinked to original sources
PubMed2001

Epidemiology and clinical consequences of vancomycin-resistant enterococci in liver transplant patients.

BACKGROUND: Vancomycin-resistant enterococci (VRE) are increasingly important as pathogens in liver transplant patients. To guide control efforts, we conducted an epidemiological study of the frequency, source, and modes of transmission of VRE at our center. METHODS: During September 1998 through August 1999, we obtained weekly surveillance cultures from consenting liver transplant patients and surfaces in their rooms. Pooled handwash specimens from personnel also were obtained. Specimens were processed on selective media to detect VRE, and isolates were typed by pulsed field gel electrophoresis. Information was collected from patient records concerning in-hospital treatment and clinical course. RESULTS: Serial cultures were obtained during 33 admissions of 29 patients. VRE were detected in initial specimens from 6 admissions, and nosocomial acquisition of VRE occurred in 12 (44%) of the remaining 27 admissions. Seven different strain types of VRE were detected. The initial site of acquisition was stool in all cases; bile became culture-positive in only two patients. Overall, 16 (55%) of the 29 patients became colonized, usually after transplantation. VRE were detected in environmental cultures during 10 admissions and in 2 of 21 pooled handwashes. No statistically significant differences in clinical status or treatment were found when colonized patients were compared to noncolonized controls. The only VRE infection resulted from a choledochojejunostomy anastomotic leak. CONCLUSION: Alimentary tract colonization by VRE occurred commonly in liver transplant patients, probably by cross-transmission. The clinical consequences were modest in the patients studied, but colonized transplant patients provide a substantial reservoir for continued VRE transmission in hospitals.

Adult↗
PubMed2000

Endemic contamination of clinical specimens by Mycobacterium gordonae.

Contamination of clinical specimens by Mycobacterium gordonae is a significant endemic problem in many laboratories. To investigate this problem, 84 cases at 1 hospital were retrospectively identified during 20 months. The overall rate of specimen contamination was 2. 4%, and 72 of the contaminated specimens were respiratory. A case-control comparison showed that the risk of respiratory specimen contamination was significantly increased if the specimen was expectorated (odds ratio [OR], 3.62; 95% confidence interval [CI], 1. 36-9.50) or if the patient consumed fluids within 2 days before specimen collection (OR, 8.92; 95% CI, 1.40-71.20). Cultures of tap water, ice, and iced drinking water all yielded M. gordonae at 10(-2)-10(0) cfu/mL. A culture survey of consenting patients showed contamination of 8 (24%) of 34 sputum specimens collected immediately after a tap water mouth rinse. These findings demonstrate that endemic specimen contamination arises from mycobacteria in hospital tap water and provide a foundation for control efforts.

Adult↗
PubMed2000

Clinical efficacy of intravenous followed by oral azithromycin monotherapy in hospitalized patients with community-acquired pneumonia. The Azithromycin Intravenous Clinical Trials Group.

The purpose of this study was to evaluate intravenous (i.v.) azithromycin followed by oral azithromycin as a monotherapeutic regimen for community-acquired pneumonia (CAP). Two trials of i.v. azithromycin used as initial monotherapy in hospitalized CAP patients are summarized. Clinical efficacy is reported from an open-label randomized trial of azithromycin compared to cefuroxime with or without erythromycin. Bacteriologic and clinical efficacy results are also presented from a noncomparative trial of i.v. azithromycin that was designed to give additional clinical experience with a larger number of pathogens. Azithromycin was administered to 414 patients: 202 and 212 in the comparative and noncomparative trials, respectively. The comparator regimen was used as treatment for 201 patients; 105 were treated with cefuroxime alone and 96 were given cefuroxime plus erythromycin. In the comparative trial, clinical outcome data were available for 268 evaluable patients with confirmed CAP at the 10- to 14-day visit, with 106 (77%) of the azithromycin patients cured or improved and 97 (74%) of the comparator patients cured or improved. Mean i.v. treatment duration and mean total treatment duration (i.v. and oral) for the clinically evaluable patients were significantly (P < 0.05) shorter for the azithromycin group (3.6 days for the i.v. group and 8.6 days for the i.v. and oral group) than for the evaluable patients given cefuroxime plus erythromycin (4.0 days for the i.v. group and 10.3 days for the i.v. and oral group). The present comparative study demonstrates that initial therapy with i.v. azithromycin for hospitalized patients with CAP is associated with fewer side effects and is equal in efficacy to a 1993 American Thoracic Society-suggested regimen of cefuroxime plus erythromycin when the erythromycin is deemed necessary by clinicians.

Administration, Oral↗
PubMed2000

Cefepime versus ceftazidime as empiric therapy for fever in neutropenic patients with cancer.

OBJECTIVE: To compare the efficacies of cefepime and ceftazidime as empiric therapy during the management of fever in cancer patients with chemotherapy-induced neutropenia. METHODS: A prospective, double-blind, randomized study of cefepime 2 g every eight hours and ceftazidime 2 g every eight hours was performed in 276 adult neutropenic (absolute neutrophil count < 500/mm3) cancer patients with fever. RESULTS: Median duration of neutropenia was five days. Sixty-one percent (n = 188) of the patients were evaluable. Treatment was successful in 57% (58/101) of cefepime-treated patients and 60% (52/87) of ceftazidime-treated patients (95% CI -18 to 12; p = 0.77). Bacteremic clearance occurred in 71% (12/17) of cefepime-treated patients and 40% (6/15) of ceftazidime-treated patients (p = 0.3). Both drugs were well tolerated. CONCLUSIONS: Cefepime appears to be as effective as ceftazidime in the initial treatment of febrile episodes in adult cancer patients with chemotherapy-associated neutropenia of modest duration.

Adolescent↗
PubMed1999

Safety of peripheral intravenous catheters in children.

OBJECTIVES: To determine the overall and per-day risk of complications of short peripheral intravenous (PIV) catheters placed for indefinite periods. DESIGN: During 5 months, general pediatric patients receiving intravenous therapy through short PIV catheters were monitored. Patient and catheter characteristics were recorded, complications were noted, and rolled semiquantitative cultures of removed catheters were performed. Major endpoints were infection and phlebitis. Per-day risk of complications and catheter colonization (>15 colony-forming units) were calculated. SETTING: University children's hospital. PATIENTS: General pediatric ward inpatients with PIV. RESULTS: We studied 642 Teflon catheters in place >24 hours (mean, 3.7 days) in 525 patients. There were no cases of catheter sepsis (0%; 95% confidence interval [CI95], 0%-0.6%), one possible insertion-site infection (0.2%; CI95, 0.004%-0.9%), and seven cases of phlebitis (1.1%; CI95, 0.4%-2.3%). Catheter colonization occurred in 92 (26%) of 348 catheters cultured. Neither the per-day risk of phlebitis nor of catheter colonization increased significantly with placement >3 days. CONCLUSION: Current guidelines recommend replacement of PIV catheters in adults within 2 to 3 days; no recommendations are made for children. Our findings and those of others indicate that the overall risk of PIV catheter complications in children is extremely low and would not be reduced substantially by routine catheter replacement.

Bacteria↗
PubMed1999

The incidence of and clinical variables associated with vancomycin-resistant enterococcal colonization in mechanically ventilated patients.

STUDY OBJECTIVES: (1) To determine in our ICU the incidence of vancomycin-resistant enterococcus (VRE) colonization in mechanically ventilated patients without a history of VRE infection or colonization; and (2) to determine the risk factors and outcome variables associated with VRE colonization in these patients. DESIGN: A prospective cohort study conducted between January 1996 and March 1998. SETTING: Medical and cardiac critical care units in a tertiary care urban university hospital. PATIENTS: Mechanically ventilated patients without evidence of pneumonia at the onset of ventilation. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Patients underwent rectal cultures by standard methods on day 1, day 3 or 4, day 6 or 7, and day 14 of intubation to detect VRE. Thirteen of 83 patients (16%) had rectal cultures positive for VRE (VRE+) at some point while being mechanically ventilated during their stay in the ICU. In comparison, approximately 15 of 2,100 medical ICU patients (0.7%) had clinical VRE infections as determined by the hospital's infection control program during a 2-year period. VRE+ patients had a higher incidence of immunosuppression than patients who had rectal cultures negative for VRE (VRE-) (9 of 13 [69%] vs 16 of 70 [23%], respectively; p < 0.01) and neutropenia (4 of 13 [31%] vs 5 of 70 [7%], respectively; p < 0.01). Hospital length of stay (LOS) was longer in VRE+ patients than in VRE- patients (27+/-17 days vs 17+/-14 days, respectively; p = 0.05), whereas pre-ICU hospital LOS and ICU LOS were similar in both patient groups. Five of 67 patients (7%) were VRE+ on day 1 of intubation, suggesting colonization at a prior site of care. Three of 29 patients who had subsequent rectal cultures converted to VRE+ while in the ICU. This group had a higher incidence of immunosuppression and neutropenia, and received more vancomycin compared with the patients who remained VRE- (p < 0.01). However, there was no significant difference in the use of other broad-spectrum antibiotics (such as antipseudomonal penicillins, third-generation cephalosporins, quinolones, and clindamycin), enteral tube feedings, or sucralfate between the two groups. In addition, a topical antibiotic paste (a gentamicin, nystatin, polymixin slurry) that was placed in the oropharynx to prevent bacterial overgrowth was not found to increase the incidence of VRE colonization in this patient population. CONCLUSIONS: The incidence of VRE colonization was surprisingly high: 16% in mechanically ventilated patients in a hospital in which VRE was not previously known to be endemic. Risk factors for the acquisition of VRE colonization included immunosuppression, neutropenia, and vancomycin use. Increased LOSs and hospital costs were seen in VRE+ patients compared to VRE- patients. Whether VRE colonization is a contributor to severe disease that leads to prolonged hospitalization and increased resource allocation or whether it is simply a marker of disease severity cannot be determined from this study. To the extent that specific antibiotic protocols are used to reduce antibiotic-resistant flora in the ICU, monitoring the incidence of VRE in the stool specimens of immunocompromised, mechanically ventilated patients can be a simple and useful tool to assess one effect of these strategies.

Anti-Bacterial Agents↗
PubMed1998

Pathogenesis of early operative site infections after orthotopic liver transplantation.

BACKGROUND: We hypothesized that operative site infections after orthotopic liver transplantation arise from bacteria in bile or jejunum. METHODS: To ascertain the validity of this hypothesis and to assess the effect of systemic antibiotic prophylaxis, we obtained intraoperative cultures of peritoneum, fascia, explant and donor liver bile, and jejunal lumen in 77 liver transplantations, and we monitored outcome. RESULTS: Pathogens were recovered from peritoneum, fascia, or bile in 11 cases. By univariate analysis, a positive culture was significantly associated with choledochojejunostomy (P=0.0002), previous liver transplantation (P=0.0002), and previous hepatobiliary surgery (P=0.002). Operative site infections during the first 2 weeks after transplantation occurred only in cases with positive intraoperative cultures, and three of the four infections were caused by the same bacteria detected intraoperatively. Antibiotic susceptibility of intraoperative isolates was tested in nine cases; infection occurred in two of three cases in which the isolates were resistant to the systemic antibiotic prophylaxis and in none of six cases with susceptible isolates. CONCLUSIONS: Our findings suggest that systemic antibiotic prophylaxis for more than 2 days may be beneficial in cases with bacterial contamination of the operative site but may not be necessary in other cases.

Amoxicillin↗
PubMed1998

Incidence and outcome of infection by vancomycin-resistant Enterococcus following orthotopic liver transplantation.

Vancomycin-resistant Enterococcus (VRE) has become a significant nosocomial pathogen. For this study, the records of 325 patients who underwent orthotopic liver transplantation (OLT) were reviewed. Thirty-four patients were infected by VRE (incidence of 10.5%, 14% in adults vs. 5% in children, P < 0.01). Common features of patients who developed infections with VRE included previous antibiotic use (25 patients, 15 of whom received vancomycin), co-infection by other pathogens (28 patients), and relaparotomy following OLT (20 patients). Pulmonary and/or renal failure preceded infection by VRE in 11 and 4 adult patients, respectively. Biliary complications were exceedingly common in patients infected by VRE (28 patients) and significantly increased the risk of infection by VRE (21.5% vs. 3.1% for patients without biliary complications, P < 0.0001). Mortality associated with VRE infections was high (56% vs. 19% for patients not infected by VRE, P < 0.0005). The most frequent cause of death was sepsis (16 of 19 patient deaths), often polymicrobial. The high incidence of infection by VRE following OLT, the lack of effective antibiotics for the treatment of VRE, and the association of VRE with patient mortality emphasizes the need to define the risk factors associated with VRE infection. We suggest early surgical intervention to treat complications that may predispose patients to infection by VRE.

Adult↗
PubMed1998

Performance measurement in pneumonia care: beyond report cards.

OBJECTIVE: To compare the medical management of bacteremic pneumococcal pneumonia at a university-based and a community-based teaching hospital and evaluate strategies for performance measurement and subsequent improvement. DESIGN: We conducted a retrospective cohort study involving a 450-bed university hospital in the inner city and a 400-bed private hospital in a rural community. MATERIAL AND METHODS: The medical records of all adults with bacteremic pneumococcal pneumonia admitted to a university and a community hospital during a 5-year period were reviewed. Information about patient age, sex, underlying medical condition, severity of disease, health-care insurance, management, and outcome was collected and analyzed. RESULTS: Patients at the two hospitals were similar in underlying illnesses and severity of disease. In comparison with the community hospital, resource expenditure was greater at the university hospital, where all 11 identified diagnostic measures and treatment resources were used more often. This difference was statistically significant for sputum cultures, all cultures, and lumbar punctures. Despite the greater intensity of care, in-hospital mortality was higher at the university hospital (26%) than at the community hospital (12%) (P>0.1). CONCLUSION: The outcome of bacteremic pneumococcal pneumonia did not differ significantly at a university hospital in comparison with a community teaching hospital, even though resource expenditure at the university hospital was greater. Our findings suggest that hospital "report cards" based solely on outcome comparisons provide inadequate information. In contrast, examination of variations in profiles of resource utilization can detect important differences in hospitals and can be used to guide continuous quality improvement efforts and ultimately improve hospital care.

APACHE↗
PubMed1998

An outbreak of bloodstream infections arising from hemodialysis equipment.

An outbreak of 29 cases of bloodstream infection by 16 pathogens occurred during 8 months at two chronic hemodialysis centers. Consequences included 21 hospital admissions and removal of 23 dialysis catheters. An epidemiologic investigation comparing case-patients with uninfected controls showed that risk was significantly (P < .05) associated with having a catheter for vascular access; receiving treatment on a Monday, Wednesday, Friday schedule; and receiving treatment on one heavily contaminated dialysis machine. Culture studies and mock trials showed that bloodstream pathogens were present in a recently installed, commercially marketed attachment for disposal of spent priming saline and could enter blood line tubing directly or indirectly during dialyzer priming and tubing assembly. The outbreak was halted by measures directed at the attachment. Investigation of this problem demonstrated that microbial overgrowth in the attachment caused bloodstream infections and underscores the importance of microbiologic considerations in the design and use of hemodialysis equipment.

Candidiasis↗
PubMed1997

Invasive aspergillosis in liver transplant recipients in the 1990s.

Invasive aspergillosis occurred in 26 liver transplant recipients since 1990 at five liver transplant centers. The median time to onset was 17 days after transplantation. Twenty-seven percent of the patients had undergone retransplantation. Invasive aspergillosis occurred significantly earlier after transplantation in smokers than in nonsmokers (P=0.017). Patients with late-onset aspergillosis (occurring after posttransplant day 90) were more likely to have had prior cytomegalovirus infection than those with early-onset aspergillosis (occurring within 90 days of transplantation) (67% vs. 10%, respectively, P=0.013). Only 8% of the patients had received additional corticosteroids or OKT3, which suggests that augmented immunosuppression may not be a relevant risk factor for invasive aspergillosis in the 1990s due to less frequent use of these agents. The median serum bilirubin level of the patients was 21.8 mg/dl, 85% of the patients had renal insufficiency, and 54% were on dialysis before the onset of invasive aspergillosis, which suggest that overall severity of illness, including poorly functioning hepatic allograft and renal failure may be the major determinants of disease occurrence. Overall mortality was 92% (24/26). No difference in mortality could be shown for the patients who received amphotericin B versus liposomal amphotericin B preparations (100% vs. 89%); however, the mean time to death after the initiation of therapy was 20 days in patients who received amphotericin B and 43 days in those who received liposomal amphotericin B preparations.

Adolescent↗
PubMed1996

Randomized controlled trial of selective bowel decontamination for prevention of infections following liver transplantation.

Nonabsorbable antibiotics for selective bowel decontamination (SBD) sometimes are administered to liver transplant patients to prevent postoperative infections, but the efficacy of SBD is not known. Accordingly, we prospectively studied 69 patients randomly assigned to receive conventional prophylaxis with systemic antibiotics (control patients) or conventional prophylaxis plus oral nonabsorbable antibiotics for SBD (SBD patients). Overall rates of bacterial and/or yeast infections were nearly equal among control patients (42%) and SBD patients (39%). However, the infection rate at SBD key sites (abdomen, bloodstream, surgical wound, and lungs) was lower among patients who received the SBD regimen > or = 3 days before transplantation (23%) than among control patients (36%). Administration of the SBD regimen was complicated by gastrointestinal intolerance and noncompliance but not by increased stool colonization with antibiotic-resistant gram-negative bacilli. Practical problems associated with administering an SBD regimen to patients awaiting cadaver liver transplants limit the regimen's usefulness, but we found a trend toward reduced key site infection when the regimen was given > or = 3 days before transplantation.

Ampicillin↗
PubMed1996

Potential hazards of deionization systems used for water purification in hemodialysis.

This study was conducted to determine the efflux of specific ions, including fluoride, from a deionization (DI) water purification system (WPS) when the WPS was operated beyond exhaustion of the DI resin. Effluent from the DI WPS was monitored for resistivity, total dissolved solids, pH, and concentrations of silica, fluoride, potassium, and sodium. After 16,000 L of water was purified, the resistivity declined to 0.492 omega Ohm-cm, and silica was released from the DI WPS. Fluoride ions were released after an additional 8,000 L water was treated, and the resistivity fell to 0.07 omega Ohm-cm. The fluoride efflux reached a peak of 32 mg/L, 28 times greater than the original fluoride concentration in the city water. Sodium and potassium ions were released after approximately 26,000 and 32,000 L of water had been treated and reached peaks of 76 and 47 mg/L, respectively. This study confirms that the minimum resistivity standard of 1 omega Ohm-cm for DI water used for hemodialysis should provide an adequate safety margin. Once resistivity fell to 1 omega Ohm-cm, more than 8,000 L of water was treated before fluoride efflux occurred. Accordingly, hemodialysis centers should be attentive to the calculated capacity of their DI WPS and reliably monitor the resistivity to prevent patient illness related to exhaustion of DI resins.

Fluorides↗
PubMed1995

Intraluminal antibiotic treatment of central venous catheter infections in patients receiving parenteral nutrition at home.

We carried out an open, uncontrolled, prospective study to evaluate intraluminal antibiotic therapy for bloodstream infections arising from subcutaneously tunneled central venous catheters in patients receiving parenteral nutrition therapy at home. Seven bacterial infections were treated with intraluminal antibiotics (mean duration, 8.6 days) sometimes accompanied by systemic antibiotics (mean duration, 2.1 days). All seven infections were cured. Two infections caused by Candida species were treated with intraluminal amphotericin B. Fungal infections was suppressed during treatment but later relapsed, as confirmed by pulsed field DNA electrophoresis typing of bloodstream isolates. The concentration of antibiotic was assayed in intraluminal fluid from catheters of patients receiving treatment with vancomycin or gentamicin. The concentration was initially approximately 5 mg/mL, and it remained at > or = 2.5 mg/mL throughout the period that the solution was locked in the catheter. Our findings show that intraluminal therapy is effective against selected bacterial infections and can suppress fungal infections in subcutaneously tunneled catheters.

Adult↗
PubMed1995

Prevention of bacterial infection in the transplant recipient. The role of selective bowel decontamination.

Bacterial infections during the first month after liver transplantation remain a serious problem despite perioperative administration of systemic broad-spectrum antibiotics. These infections usually have been caused by aerobic gram-negative bacilli from the alimentary tract, and the most promising approach during the past decade is to eliminate or suppress these organisms by SBD. Several centers that have used SBD for prophylaxis have reported favorable results, but only one of the studies has been prospective and randomized. Based on the limited information now available, it seems that the efficacy of SBD is dependent on eliminating or suppressing aerobic gram-negative bacilli by the time of transplant surgery. This is an especially important point because successful SBD requires at least several days of treatment, and there are practical problems initiating and maintaining SBD in advance of unscheduled cadaver liver transplantation. Key areas for investigation are to establish by appropriately designed studies the efficacy of SBD and to examine the importance of achieving SBD prior to transplantation surgery.

Anti-Bacterial Agents↗
PubMed1994

An outbreak of fatal fluoride intoxication in a long-term hemodialysis unit.

OBJECTIVE: To determine the cause of an outbreak of acute illness and death in a long-term hemodialysis unit. DESIGN: A retrospective cohort and case-control study of patients receiving hemodialysis and a laboratory study of a model deionization system to purify water for hemodialysis. SETTING: An outpatient hemodialysis unit of a university hospital. PATIENTS: 12 patients who became severely ill after hemodialysis treatment and 20 patients who did not become ill after receiving hemodialysis treatment in the same unit. MEASUREMENTS: Medical and dialysis unit records were reviewed to identify and characterize cases. Fluids for dialysis were tested for toxic substances, and fluoride was measured in patients' serum. Resistivity and fluoride were measured in effluent from a model deionization system operated in the same way as the system associated with illness. RESULTS: During five consecutive hemodialysis shifts, 12 of 15 patients receiving dialysis treatment in one room became acutely ill, with severe pruritus, multiple nonspecific symptoms, and/or fatal ventricular fibrillation (3 patients). None of 17 patients treated in the adjacent room became ill (P < 0.0001). Death was associated with longer hemodialysis time and increased age compared with other patients who became ill. Serum concentrations of fluoride in the sick patients were markedly increased to as high as 716 mumol/L, and the source of fluoride was the temporary deionization system used to purify water for hemodialysis only in the affected room. Operation of a model deionization system showed how fluoride was adsorbed and then displaced in a massive efflux. CONCLUSIONS: Because deionization systems are used widely in hemodialysis and can cause fatal fluoride intoxication, careful design and monitoring are essential.

Adult↗
PubMed1993

An outbreak of gram-negative bacteremia traced to contaminated O-rings in reprocessed dialyzers.

OBJECTIVE: To investigate an outbreak of gram-negative bacteremia in an outpatient hemodialysis unit and to identify the source of contaminating bacteria and the route by which bacteria gained access to the bloodstream. DESIGN: A matched-pair, case-control study and a bacteriologic investigation of the hemodialysis unit and the implicated dialyzers. SETTING: A university outpatient hemodialysis unit. PATIENTS: Eleven patients receiving long-term hemodialysis who had a total of 12 episodes of primary gram-negative bacteremia and 12 matched controls. MEASUREMENTS: Clinical and demographic data were obtained for patients and controls. Dialysis unit procedures were observed for compliance with aseptic technique. Cultures of potential environmental sources of bacteria were obtained. Hemodialyzers from bacteremic and nonbacteremic patients were dismantled, and the component parts were cultured. Inoculation of O-rings (from Hemoflow F-80 dialyzer) with bacteria and simulated dialysis were done. RESULTS: During January to October 1988, 12 episodes of primary gram-negative bacteremia caused by Pseudomonas cepacia, Xanthomonas maltophilia, Citrobacter freundii, Acinetobacter calcoaceticus var. anitratus, or Enterobacter cloacae occurred in 11 patients. In 11 episodes, symptoms developed within 3 hours of starting hemodialysis. Intravenous antibiotics were administered for 11 episodes, 3 episodes resulted in hospitalization, and all patients recovered. Case patients were more likely to have received high-flux dialysis with Hemoflow F-80 dialyzers (odds ratio congruent to 11) than were controls. O-rings from dialyzers used by bacteremic patients were culture positive for the organism responsible for bacteremia. Three of the four dialyzers were disinfected using the standard automated method and were recultured 72 hours later; the O-rings of all three dialyzers remained culture positive. Simulated dialysis using dialyzers with contaminated O-rings caused blood pathway contamination despite intervening reprocessing. When the disinfection method for F-80 dialyzers included removal and complete disinfection of the O-rings, O-ring and blood pathway cultures were consistently negative. After this procedure was made routine, no episodes of primary gram-negative bacteremia occurred during the next 6 months. CONCLUSIONS: Because dialyzers with removable headers and O-rings are widely used in patients receiving long-term hemodialysis, disinfection procedures should include measures to ensure adequate disinfection of O-rings.

Adult↗