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Mycobacterium gordonae pseudoinfection associated with a contaminated antimicrobial solution
J I Tokars1, M M McNeil, O C Tablan
1Hospital Infections Program, Centers for Disease Control, Atlanta, Georgia 30333.
Journal of Clinical Microbiology
|December 1, 1990
Summary
Contaminated BACTEC PANTA PLUS kits caused a pseudoepidemic of Mycobacterium gordonae infections. Laboratories should monitor unusual organism isolation rates to detect contamination promptly.
Area of Science:
- Clinical Microbiology
- Infectious Diseases
- Laboratory Diagnostics
Background:
- Mycobacterium gordonae, an acid-fast bacterium (AFB) of low pathogenicity, was identified in 46 specimens from 34 patients at Yale-New Haven Hospital over 8 weeks.
- Four patients received unnecessary antimycobacterial therapy due to misidentification of M. gordonae isolates.
Purpose of the Study:
- To investigate a pseudoepidemic of Mycobacterium gordonae at Yale-New Haven Hospital.
- To identify the source of M. gordonae contamination in clinical specimens.
Main Methods:
- Retrospective analysis of mycobacterial cultures.
- Manufacturer investigation of BACTEC PANTA PLUS kits.
- National survey of M. gordonae isolation rates in clinical laboratories.
Main Results:
- M. gordonae isolation was significantly associated with the use of BACTEC TB systems and a specific lot of BACTEC PANTA PLUS.
- Laboratories using the contaminated PANTA lot showed a 4-fold increase in M. gordonae isolation rates.
- Contamination was traced to ineffective sterilization during PANTA manufacturing.
Conclusions:
- Intrinsic contamination of BACTEC PANTA PLUS kits led to a pseudoepidemic of M. gordonae.
- Clinical laboratories must remain vigilant for abrupt increases in unusual organism isolation rates to detect contamination events.
- Quality control measures in diagnostic kit manufacturing should include AFB cultures.