Outbreak of cystoscopy related infections with Pseudomonas aeruginosa: New Mexico, 2007

Personnel at the New Mexico Department of Health investigated a Pseudomonas aeruginosa outbreak potentially associated with outpatient cystoscopy performed by a urologist during January 1 to April 22, 2007.

We compared infection rates with baseline rates, reviewed infection control procedures and performed environmental sampling at the urologist office. We also performed a case-control study. Cases had blood or urine cultures positive for P. aeruginosa during January 1 to April 22, 2007. Controls had blood or urine cultures ordered through the same laboratory. Clinical and environmental isolates were typed by pulsed field gel electrophoresis.

A total of 23 case-patients were identified, including 17 with urinary tract infections alone, 2 with bacteremia alone and 4 with urinary tract infections plus bacteremia. Seven case-patients experienced P. aeruginosa infection after cystoscopy was performed by this urologist. On multivariate analysis cystoscopy done by this urologist was the strongest risk factor for positive P. aeruginosa culture (OR 46.5, 95% confidence limits 3.1, 705). Recent hospitalization, having a urinary catheter and age 75 years or older were also independently associated with case status. Multiple breaches in cystoscope reprocessing procedures were identified. The urologist cystoscope was culture positive for P. aeruginosa. All 4 available clinical isolates from patients in whom cystoscopy was done by this urologist had pulsed field gel electrophoresis patterns identical to those of specimens from the cystoscope. The implementation of proper reprocessing methods terminated the outbreak.

Our investigation implicated a contaminated cystoscope as the likely source of these infections. Health care personnel who disinfect cystoscopes should follow manufacturer recommendations and guidelines on reprocessing flexible endoscopes. The development of cystoscope specific guidelines might promote increased compliance with correct reprocessing procedures.