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Nosocomial infections by chlorhexidine solution contaminated with Pseudomonas pickettii (Biovar VA-I)
The Journal of Infection
|November 1, 1983
Abstract:
Over a period of 10 days, six patients in a cardiac intensive care unit developed Pseudomonas pickettii (biovar VA-I) septicaemia after installation of a venous catheter. The organism was also recovered from all the vials of the aqueous solution of 0.05 per cent chlorhexidine ('Hibitane') prepared with contaminated bidistilled water. There were no further cases of infection when the use of this water was prohibited.
Insights
Pseudomonas pickettii bloodstream infections in a cardiac ICU were linked to contaminated chlorhexidine solutions. Preventing the use of contaminated bidistilled water stopped further cases, highlighting the importance of water purity in healthcare settings.
Area of Science:
- Infectious Diseases
- Hospital Epidemiology
- Microbiology
Background:
- Cardiac intensive care units (ICUs) are high-risk environments for healthcare-associated infections.
- Venous catheterization is a common procedure associated with potential infectious complications.
Observation:
- Six patients in a cardiac ICU developed Pseudomonas pickettii (biovar VA-I) septicemia over 10 days following venous catheter insertion.
- The causative organism, Pseudomonas pickettii, was isolated from chlorhexidine solutions used in patient care.
Findings:
- The Pseudomonas pickettii infections were traced to the use of 0.05% chlorhexidine ('Hibitane') solutions prepared with contaminated bidistilled water.
- Implementing a prohibition on the use of this contaminated water source led to the cessation of new infection cases.
Implications:
- This outbreak underscores the critical role of water quality in the preparation of antiseptic solutions within healthcare facilities.
- Strict control over water sources and preparation protocols for medical solutions is essential to prevent Pseudomonas infections in vulnerable patient populations.
- Enhanced surveillance and microbial testing of hospital water systems and solutions are recommended to prevent similar outbreaks.