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Published on: May 4, 2018
Outbreak of Pseudomonas aeruginosa surgical site infections after arthroscopic procedures: Texas, 2009
Pritish K Tosh1, Maureen Disbot, Jonathan M Duffy
1Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. tosh.pritish@mayo.edu
Setting:
Seven organ/space surgical site infections (SSIs) that occurred after arthroscopic procedures and were due to Pseudomonas aeruginosa of indistinguishable pulsed-field gel electrophoresis (PFGE) patterns occurred at hospital X in Texas from April 22, 2009, through May 7, 2009.
Objective:
To determine the source of the outbreak and prevent future infections.
Design:
Infection control observations and a case-control study.
Methods:
Laboratory records were reviewed for case finding. A case-control study was conducted. A case patient was defined as someone who underwent knee or shoulder arthroscopy at hospital X during the outbreak period and subsequently developed organ/space SSI due to P. aeruginosa. Cultures of environmental and surgical equipment samples were performed, and selected isolates were analyzed by PFGE. Surgical instrument reprocessing practices were reviewed, and surgical instrument lumens were inspected with a borescope after reprocessing to assess cleanliness.
Results:
The case-control study did not identify any significant patient-related or operator-related risk factors. P. aeruginosa grew from 62 of 388 environmental samples. An isolate from the gross decontamination sink had a PFGE pattern that was indistinguishable from that of the case patient isolates. All surgical instrument cultures showed no growth. Endoscopic evaluation of reprocessed arthroscopic equipment revealed retained tissue in the lumen of both the inflow/outflow cannulae and arthroscopic shaver handpiece. No additional cases occurred after changes in instrument reprocessing protocols were implemented. After this outbreak, the US Food and Drug Administration released a safety alert about the concern regarding retained tissue within arthroscopic shavers.
Conclusions:
These SSIs were likely related to surgical instrument contamination with P. aeruginosa during instrument reprocessing. Retained tissue in inflow/outflow cannulae and shaver handpieces could have allowed bacteria to survive sterilization procedures.
Insights
Pseudomonas aeruginosa surgical site infections were linked to contaminated arthroscopic instruments. Inadequate reprocessing allowed bacteria to survive sterilization, highlighting the need for improved cleaning protocols for surgical equipment.
Area of Science:
- Infectious Diseases
- Hospital Epidemiology
- Surgical Infection Prevention
Background:
- An outbreak of seven organ/space surgical site infections (SSIs) caused by Pseudomonas aeruginosa occurred following arthroscopic procedures.
- The infections were linked to indistinguishable pulsed-field gel electrophoresis (PFGE) patterns, suggesting a common source.
Purpose of the Study:
- To identify the source of the Pseudomonas aeruginosa outbreak.
- To implement measures to prevent future infections.
Main Methods:
- Conducted infection control observations and a case-control study.
- Reviewed laboratory records and performed cultures of environmental and surgical equipment samples.
- Analyzed isolates by PFGE and inspected surgical instrument lumens post-reprocessing.
Main Results:
- No significant patient or operator risk factors were identified.
- Pseudomonas aeruginosa was isolated from environmental samples, including a decontamination sink.
- Retained tissue was found in arthroscopic cannulae and shaver handpieces after reprocessing.
Conclusions:
- Surgical instrument contamination during reprocessing was the likely cause of SSIs.
- Retained tissue in instruments may have protected bacteria from sterilization.
- Changes in reprocessing protocols successfully halted the outbreak.
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