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[Outbreak with Ralstonia pickettii caused by contaminated magnesium vials]
B Ross1, J Steinmann2, J Buer2
1Krankenhaushygiene, Universitätsklinikum Essen.
Deutsche Medizinische Wochenschrift (1946)
|February 6, 2014
Summary
Contaminated magnesium vials caused Ralstonia pickettii bloodstream infections in six intensive care unit patients. This highlights the importance of considering medication contamination as a source of unusual pathogens in blood cultures.
Area of Science:
- Microbiology
- Infectious Diseases
- Patient Safety
Background:
- Ralstonia pickettii is an opportunistic pathogen that can cause healthcare-associated infections.
- Bloodstream infections (BSIs) are a serious concern in intensive care units (ICUs).
Observation:
- Six patients in an ICU developed positive blood cultures for Ralstonia pickettii within a week.
- All affected patients received intravenous therapy, including glucose 5% and magnesium.
- Initial investigations ruled out failures in intravenous therapy preparation.
Findings:
- Ralstonia pickettii was detected in samples from magnesium vials administered to patients.
- Contaminated magnesium vials were identified as the likely source of the bloodstream infections.
- A nationwide recall of the contaminated magnesium vials was initiated.
Implications:
- This case underscores the critical need to consider medication contamination as a potential cause of unusual pathogens in BSIs.
- Healthcare facilities must maintain stringent quality control measures for intravenous medications.
- Prompt identification and removal of contaminated products are essential to prevent further patient harm.
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