Airlangga University Hospital

Dialysis Unit
Viable Bacteria/Endotoxin （ET） Measurement Results

RO RO Line Dial. Unit

RO Water
Tap Water Membrane （Post- RO Water
Tank
Exit ETRF） Line
Viable Bacteria
>100 >279 >73.9 >16 >33
(CFU/ml)
Endotoxins
41.5 1.96 2.93 3.18 3.37
(EU/ml)
JSDT
Recommended n/a Viable Bacteria 0.1cfu/ml ： ET 0.001 EU/ml  
Value
JSDT Maximum
n/a Viable Bacteria 100cfu/ml ： ET 0.05 EU/ml  
Value

※ Values in red exceed JSDT Maximums Collection Date：2018.08.10

 ① Tap Water Tank
Viable Bacteria： ≧ 100cfu/ml
（measurement of exact value impossible）
ＥＴ： 41.5EU/ml

Indonesia’ s public water

supply is not potable,
and its use as a source
of water for the RO
equipment poses a
constant problem of
contamination.

For comparison, values of tap

water at St. Mary’
s Hospital are:

Viable Bacteria: 20cfu/ml

ＥＴ: 1.4EU/ml
 ② RO Membrane Exit
Viable Bacteria： ≧ 279cfu/ml
（measurement of exact value impossible）
ＥＴ： 1.96EU/ml
Tap water is highly
contaminated;
possible leakage of
viable bacteria from
RO membrane.
However, the removal
rate of viable bacteria
is 95.3％, meaning the
membrane is
functioning at a
③ RO Tank decent level.
Viable Bacteria： ≧ 73.9cfu/ml
（measurement of exact value impossible）
ＥＴ： 2.93EU/ml
Although viable bacteria
count in the RO tank is
decreasing, ET are on the
rise. There is a germicidal
lamp attached to the
pipeline, so this rise is
possibly due to the
influence of ETs excreted
by the destroyed bacteria.
 ④ RO Line Post-ETRF
Viable Bacteria： ≧ 16cfu/ml
（measurement of exact value impossible）
ＥＴ： 3.18EU/ml

Viable bacteria count

is lower post-ETRF but
ET values are high,
possibly from leakage
due to overburdening.

⑤ Dialysis Unit ＲＯ Water Pipe

Viable Bacteria： ≧ 33cfu/ml
（measurement of exact value impossible）
ＥＴ： 3.37EU/ml
Contamination is present
in the fluid line from the
machine room to the
dialysis department,
possibly due to its
excessive length.
ＥＴ values are likely
continually high.
 Thoughts on Current Measurements of Endotoxins and Viable Bacteria Culture Results
During our previous visit to RS Unair in April we conducted a viable bacteria culture test of
the RO Tank and RO Line, and during this visit we measured levels of both endotoxins (ET)
and viable bacteria in five samples from different locations, ranging from the source tap
water to inside the dialysis unit itself. As you saw in the table on the first slide, the viable
bacteria count in one location exceeded the maximum limit established by JSDT, and ET
levels far exceeded maximum limits in all locations except the tap water itself. Causes of
these excessively high values could include the tap water being severely tainted with
biological contaminants, exceeding the rejection rate of the RO equipment which then
leads to leaks. In addition, both the RO tank and the pipe are thought to suffer from latent
contamination, and although the RO line is equipped with ETRF, its rejection capacity is
most likely saturated.
A germicidal lamp is installed, but when viable bacteria are destroyed by the lamp they
release ETs, which explains the relatively high ET values compared to viable bacteria count.
Using this biologically contaminated dialysis fluid means that patients are constantly
exposed to low levels of inflammatory agents, and depending on original patient condition
this could result in a number of symptoms including chills, tremors, fever, etc. It is a
concern that this dialysis fluid is negatively affecting patient prognoses.
The first concrete control measure is to install ETRFs on every dialysis machine. We would
like to discuss moving in this direction with NIPRO. In addition, to control contamination it is
necessary to consistently clean/disinfect the RO water pipeline, but this is a large-scale
project that warrants special attention around residual disinfectant in the line. This is an
issue for the future that should be addressed.
Moving forward, we would like to formulate a plan for reducing viable bacteria and
endotoxins while offering support on basic management of dialysis fluid purification.

Department of Clinical Engineering, St. Mary’

s Hospital