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Nosocomial Transmission of Imipenem-Resistant Pseudomonas Aeruginosa Following Bronchoscopy Associated With Improper Connection to the STERIS SYSTEM 1 Processor

Published online by Cambridge University Press:  02 January 2015

Mircea Sorin ,
Sorana Segal-Maurer ,
Noriel Mariano ,
Carl Urban ,
Anna Combest  and
James J. Rahal
Mircea Sorin
Affiliation:
Department of Medicine, Division of Infectious Diseases, Division of Infection Control, the New York Hospital Medical Center of Queens, Flushing, New York
Sorana Segal-Maurer*
Affiliation:
Department of Medicine, Division of Infectious Diseases, Division of Infection Control, the New York Hospital Medical Center of Queens, Flushing, New York
Noriel Mariano
Affiliation:
Infectious Diseases Research Laboratory, Division of Infection Control, the New York Hospital Medical Center of Queens, Flushing, New York
Carl Urban
Affiliation:
Infectious Diseases Research Laboratory, Division of Infection Control, the New York Hospital Medical Center of Queens, Flushing, New York
Anna Combest
Affiliation:
Department of Nursing, Division of Infection Control, the New York Hospital Medical Center of Queens, Flushing, New York
James J. Rahal
Affiliation:
Department of Medicine, Division of Infectious Diseases, Division of Infection Control, the New York Hospital Medical Center of Queens, Flushing, New York
*
The New York Hospital Medical Center of Queens, Division of Infectious Diseases, 56-45 Main St, Flushing, NY 11355
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Abstract

Objective:

To assess nosocomial transmission of imipenem-resistant Pseudomonas aeruginosa (IRPA) following bronchoscopy during August through October 1998.

Design:

Traditional and molecular epidemiological investigation of a case series.

Setting:

University-affiliated community hospital.

Patients:

18 patients with IRPA bronchial-wash isolates.

Interventions:

We reviewed clinical data, performed environmental cultures and molecular analysis of all IRPA isolates, and observed disinfection of bronchoscopes.

Results:

Of 18 patients who had IRPA isolated from bronchoscopic or postbronchoscopic specimens, 13 underwent bronchoscopy for possible malignancy or undiagnosed pulmonary infiltrates. Following bronchoscopy, 3 patients continued to have IRPA isolated from sputum and demonstrated clinical evidence of infection requiring specific antimicrobial therapy. The remaining 15 patients had no further IRPA isolated and remained clinically well 3 months following bronchoscopy. Pulsed-field gel electrophoresis revealed that all strains except one were >95% related. STERIS SYSTEM 1 had been implemented in July 1998 as an automatic endoscope reprocessor (AER) for all endoscopes and bronchoscopes. Inspection of bronchoscope sterilization cycles revealed incorrect connectors joining the bronchoscope suction channel to the STERIS SYSTEM 1 processor, obstructing peracetic acid flow through the bronchoscope lumen. No malfunction warning was received, and spore strips remained negative.

Conclusions:

The similarity of diverse connectors and limited training by the manufacturer regarding AER for bronchoscopes were the two factors responsible for the outbreak. Appropriate connections were implemented, and there was no further bronchoscope contamination. We suggest active surveillance of all bronchoscopy specimen cultures, standardization of connectors of various scopes and automated processors, and systematic education of staff by manufacturers with periodic on-site observation.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 22 , Issue 7 , July 2001 , pp. 409 - 413
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2001

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