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Investigation of a Pseudo-Outbreak of Orthopedic Infections Caused by Pseudomonas aeruginosa

Published online by Cambridge University Press:  02 January 2015

Wendy Forman ,
Peter Axelrod ,
Keith St. John ,
Jay Kostman ,
Christina Khater ,
John Woodwell ,
Rose Vitagliano ,
Allan Truant ,
Vilas Satishchandran  and
Thomas Fekete
Wendy Forman
Affiliation:
Section of Infectious Diseases, Temple University School of Medicine, Philadelphia, Pennsylvania
Peter Axelrod*
Affiliation:
Section of Infectious Diseases, Temple University School of Medicine, Philadelphia, Pennsylvania Department of Infection Control, Temple University School of Medicine, Philadelphia, Pennsylvania
Keith St. John
Affiliation:
Department of Infection Control, Temple University School of Medicine, Philadelphia, Pennsylvania
Jay Kostman
Affiliation:
Division of Infectious Diseases, Robert Wood Johnson Medical School, Cooper Hospital-University Medical Center, Camden, New Jersey
Christina Khater
Affiliation:
Division of Infectious Diseases, Robert Wood Johnson Medical School, Cooper Hospital-University Medical Center, Camden, New Jersey
John Woodwell
Affiliation:
Section of Infectious Diseases, Temple University School of Medicine, Philadelphia, Pennsylvania
Rose Vitagliano
Affiliation:
Department of Infection Control, Temple University School of Medicine, Philadelphia, Pennsylvania
Allan Truant
Affiliation:
Department of Pathology, Temple University School of Medicine, Philadelphia, Pennsylvania
Vilas Satishchandran
Affiliation:
Department of Pathology, Temple University School of Medicine, Philadelphia, Pennsylvania
Thomas Fekete
Affiliation:
Section of Infectious Diseases, Temple University School of Medicine, Philadelphia, Pennsylvania
*
Section of Infectious Diseases, Temple University Hospital, 3401 N. Broad Street, Philadelphia, PA 19140
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Abstract

Objectives:

To report a pseudoepidemic of Pseudomonas aeruginosa infections discovered during an investigation of postoperative joint infections.

Design:

A retrospective review of case patients’ hospital charts, operative reports, and laboratory data, as well as environmental culturing, polymerase chain reaction (PCR) ribotyping of outbreak isolates, and in vitro analysis of P aeruginosa growth characteristics.

Setting:

A 510-bed, university-affiliated adult tertiary care hospital.

Results:

Between October 1 and December 1, 1992, seven postsurgical joint infections were diagnosed, including four caused by P aeruginosa. A bottle of “sterile” saline used to process tissue specimens was found to be contaminated with P aeruginosa. Further investigation revealed that P aeruginosa had grown from seven additional tissue cultures, all of which had been processed with the contaminated saline. PCR ribotypes of the contaminant matched those of the clinical isolates. In vitro, P aeruginosa strains were viable in commercial nonbacteriostatic saline, but never caused visible turbidity.

Six patients received antibiotics for their presumed infections; four patients had peripherally inserted central catheters placed, and one experienced severe anaphylactic reactions to several antibiotics.

Conclusions:

Pseudoepidemics due to common organisms are often difficult to detect, and delayed recognition can result in substantial morbidity. This outbreak investigation illustrates the potential for contamination of diluents in the microbiology laboratory and emphasizes the need for meticulous quality control.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 15 , Issue 10 , October 1994 , pp. 652 - 657
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1994

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