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Abstract:
20 (11%) of 181 nosocomial epidemics investigated by the Center for Disease Control during 1956-75 were actually false outbreaks. In each pseudoepidemic, on-site investigation showed that errors in specimen processing (11), surveillance artefacts (6), or clinical misdiagnosis (3) had resulted in real clusters of false infections or artefactual clusters of real infections. Specimen-processing errors included contamination during collection or transport, cross-contamination in the laboratory, and incorrect identification of organisms. Prevention of pseudoepidemics depends on quality control aimed at avoiding such errors and on close cooperation between laboratory workers and clinicians, to ensure systematic review of incongruous laboratory results.
Insights
A significant portion of investigated nosocomial epidemics were false outbreaks due to errors. Improving laboratory quality control and clinician collaboration can prevent these pseudoepidemics.
Area of Science:
- Infectious Disease Epidemiology
- Clinical Microbiology
- Healthcare Quality Improvement
Background:
- Nosocomial epidemics pose a significant threat to patient safety.
- Accurate identification of outbreaks is crucial for effective public health interventions.
- Previous investigations have not fully quantified the occurrence of false outbreaks.
Purpose of the Study:
- To determine the proportion of investigated nosocomial epidemics that were false outbreaks.
- To identify the common causes of false outbreaks (pseudoepidemics).
- To recommend strategies for preventing pseudoepidemics.
Main Methods:
- Retrospective analysis of 181 nosocomial epidemics investigated by the Center for Disease Control between 1956 and 1975.
- On-site investigations to identify the root causes of reported outbreaks.
- Categorization of causes into specimen processing errors, surveillance artefacts, and clinical misdiagnosis.
Main Results:
- 20 (11%) of 181 investigated nosocomial epidemics were identified as false outbreaks.
- Specimen processing errors were the most frequent cause (11 cases), including contamination and misidentification.
- Surveillance artefacts accounted for 6 cases, and clinical misdiagnosis for 3 cases.
Conclusions:
- Pseudoepidemics are a notable issue in nosocomial outbreak investigations.
- Enhancing laboratory quality control and interdisciplinary communication is essential for prevention.
- Systematic review of incongruous laboratory results can help avoid misclassification of outbreaks.