An outbreak of Staphylococcus epidermidis septicemia

Area of Science:

• Infectious Diseases
• Medical Device Engineering
• Hospital Epidemiology

Background:

• Catheter sepsis is a serious complication in patients receiving intravenous hyperalimentation.
• An unexplained rise in catheter sepsis rates was observed between August 1980 and June 1981.

Purpose of the Study:

• To investigate the cause of increased catheter sepsis rates.
• To identify the causative organism and its source.
• To recommend solutions to prevent future occurrences.

Main Methods:

• Retrospective analysis of patient records and catheter cultures.
• Microbiological analysis of blood and catheter-tip cultures, including antibiograms.
• Review of nursing notes to identify potential breaches in aseptic technique.
• Examination of intravenous tubing connectors for defects.

Main Results:

• Catheter sepsis rates increased from 2% to 34%, with Staphylococcus epidermidis identified as the primary pathogen.
• S. epidermidis was consistently found on both blood cultures and catheter tips of infected patients.
• A manufacturing defect in the intravenous tubing connection (loose fit) was identified as the source of contamination.
• Switching to Luer-lok attachments initially reduced sepsis, but subsequent manufacturing defects in Luer-lok connectors led to recurrent sepsis.

Conclusions:

• Manufacturing defects in intravenous hyperalimentation tubing connectors are a significant risk factor for catheter sepsis.
• Staphylococcus epidermidis is a common cause of catheter-related bloodstream infections.
• Robust quality control measures by medical device manufacturers are crucial to prevent patient harm.
• Prompt catheter removal is effective in resolving sepsis, even without antibiotics.