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An epidemic of Pseudomonas cepacia bacteraemia in Ramathibodi Hospital

Insights

A P. cepacia bacteraemia outbreak in 16 patients was linked to contaminated intravenous drugs. Improved hygiene and single-dose preparations stopped the spread.

Area of Science:

  • Medical Microbiology
  • Infectious Diseases
  • Hospital Epidemiology

Background:

  • An outbreak of P. cepacia bacteraemia occurred at Ramathibodi Hospital.
  • The outbreak involved 16 patients between February and May 1988.

Purpose of the Study:

  • To identify the source and transmission route of the P. cepacia bacteraemia outbreak.
  • To determine the interventions necessary to control and terminate the outbreak.

Main Methods:

  • Retrospective analysis of patient cases and drug preparation procedures.
  • Investigation of the anaesthetic preparation room environment and drug handling practices.

Main Results:

  • The outbreak was traced to contaminated intravenous succinyl choline and metaraminol.
  • Multiple-dose preparations of these drugs, prepared in bulk under unhygienic conditions, were the likely source of contamination.
  • Contamination occurred during or after the drug preparation process.

Conclusions:

  • Enhanced hygiene in the anaesthetic preparation room and discontinuation of multiple-dose drug preparations are crucial for outbreak control.
  • Strict adherence to aseptic techniques during drug preparation is essential to prevent hospital-acquired infections.

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