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A suspected hospital outbreak of pseudobacteremia due to Pseudomonas stutzeri
Abstract:
Pseudomonas stutzeri was recovered from blood cultures of 24 patients from 1977 through 1979 at one Mayo Clinic-affiliated hospital. During the investigation it was determined that aqueous green soap--used throughout the hospital to prepare the skin for iv insertions--had probably become contaminated with P. stutzeri. The use of aqueous green soap was discontinued, but eight additional cases of pseudobacteremia occurred in 1980-1981 and one case occurred in 1982. With one exception, all of the patients appeared to have pseudobacteremia rather than true bacteremia; the outbreak ceased only after aqueous green soap was deleted as a standard stock item from the hospital formulary.
Insights
Contaminated aqueous green soap likely caused Pseudomonas stutzeri pseudobacteremia in 24 patients. Discontinuing the soap reduced cases, but the outbreak only stopped when it was removed from the hospital formulary.
Area of Science:
- Medical Microbiology
- Infectious Diseases
- Hospital Epidemiology
Background:
- Pseudomonas stutzeri is an opportunistic pathogen.
- Pseudobacteremia can arise from contaminated medical supplies.
- A hospital experienced a cluster of P. stutzeri blood culture isolates.
Purpose of the Study:
- To investigate the source of Pseudomonas stutzeri in patient blood cultures.
- To determine the cause of a pseudobacteremia outbreak.
- To identify effective control measures for hospital-acquired infections.
Main Methods:
- Retrospective review of patient blood cultures.
- Microbiological investigation of hospital disinfectants.
- Epidemiological analysis of case distribution over time.
Main Results:
- Twenty-four cases of P. stutzeri were identified between 1977-1979.
- Aqueous green soap used for skin preparation was identified as the likely contaminant.
- Pseudobacteremia cases continued after initial discontinuation of the soap, ceasing only upon its complete removal from the formulary.
Conclusions:
- Contaminated aqueous green soap was the probable source of P. stutzeri pseudobacteremia.
- Thorough review and removal of contaminated materials are crucial for outbreak control.
- Hospital formulary management is vital for preventing recurrent contamination events.