An outbreak of Achromobacter xylosoxidans related to diagnostic tracer procedures

In December, 1978, an investigation was undertaken to determine the source of infection in five patients in one hospital with hospital-associated bacteremia due to Achromobacter xylosoxidans. Review of their records showed that each had a diagnostic tracer procedure preceding the bacteremia and that no other procedures were common to all. Further investigation revealed that patients from three other hospitals were studied using diagnostic tracer materials from the index hospital. Five patients with confirmed A. xylosoxidans bacteremia and four suspected cases were identified in these hospitals, and all had a scan before the bacteremia was detected. No other A. xylosoxidans isolates were identified in any of the hospitals in the preceding two years. Although not confirmed, the source appeared to be stored non-bacteriostatic saline. Effective control measures included a sterility testing program and use of pre-packaged single dose vials of saline. Diagnostic tracer studies should be added to the list of procedures known to cause hospital-acquired bacteremias.