An outbreak of Serratia marcescens infections related to contaminated chlorhexidine

Area of Science:

• Infectious Diseases
• Hospital Epidemiology
• Antimicrobial Stewardship

Background:

• Serratia marcescens outbreaks pose significant risks in healthcare settings.
• Contamination of antiseptic solutions can lead to widespread patient infections.
• Identifying the source of healthcare-associated infections is critical for control.

Purpose of the Study:

• To investigate the cause of a Serratia marcescens outbreak in a tertiary-care hospital.
• To determine the relationship between patient isolates and antiseptic solutions.
• To evaluate the efficacy of product recall in controlling the outbreak.

Main Methods:

• Pulsed-field gel electrophoresis (PFGE) was used to compare bacterial DNA.
• Patient clinical isolates and chlorhexidine solution isolates were analyzed.
• Epidemiological data on infection rates before and after product recall were collected.

Main Results:

• Serratia marcescens was identified as the causative agent of the outbreak.
• Similar PFGE banding patterns were observed between patient and chlorhexidine strains.
• Following the recall of alcohol-free chlorhexidine, S marcescens isolation rates returned to baseline.

Conclusions:

• Alcohol-free chlorhexidine solutions were implicated as the source of Serratia marcescens contamination.
• The use of alcohol-free chlorhexidine as an antiseptic is not recommended due to contamination risks.
• Product recall effectively controlled the hospital-acquired infection outbreak.