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Gram-Negative Bacteremia in Open-Heart–Surgery Patients Traced to Probable Tap-Water Contamination of Pressure-Monitoring Equipment

Published online by Cambridge University Press:  02 January 2015

Judith R. Rudnick ,
Consuelo M. Beck-Sague ,
Roger L. Anderson ,
Barbara Schable ,
J. Michael Miller  and
William R. Jarvis
Judith R. Rudnick
Affiliation:
Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, US Public Health Service, Department of Health and Human Services, Atlanta, Georgia
Consuelo M. Beck-Sague
Affiliation:
Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, US Public Health Service, Department of Health and Human Services, Atlanta, Georgia
Roger L. Anderson
Affiliation:
Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, US Public Health Service, Department of Health and Human Services, Atlanta, Georgia
Barbara Schable
Affiliation:
Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, US Public Health Service, Department of Health and Human Services, Atlanta, Georgia
J. Michael Miller
Affiliation:
Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, US Public Health Service, Department of Health and Human Services, Atlanta, Georgia
William R. Jarvis*
Affiliation:
Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, US Public Health Service, Department of Health and Human Services, Atlanta, Georgia
*
Hospital Infections Program, Centers for Disease Control and Prevention, 1600 Clifton Rd, Mailstop E-69, Atlanta, GA 30333
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Abstract

Objective: To determine the cause(s) of an outbreak of gram-negative bacteremia (GNB) in open-heart–surgery (OHS) patients at hospital A.

Design: Case-control and cohort studies and an environmental survey.

Results: Nine patients developed GNB with Enterobacter cloacae (6), Pseudomonas aeruginosa (5), Klebsiella pneumoniae (3), Serratia marcescens (2), or Klebsiella oxytoca (1) following OHS; five of nine patients had polymicrobial bacteremia. When the GNB patients were compared with randomly selected OHS patients, having had the first procedure of the day (8 of 9 versus 12 of 27, P=.02), longer cardiopulmonary bypass (median, 122 versus 83 minutes, P=.01) or cross-clamp times (median, 75 versus 42 minutes, P=.008), intraoperative dopamine infusion (9 of 9 versus 15 of 27, P=.01), or exposure to scrub nurse 6 (6 of 9 versus 4 of 27, P=.001) were identified as risk factors. When stratified by length of the procedure, only being the first procedure of the day and exposure to scrub nurse 6 remained significant. First procedures used pressure-monitoring equipment that was assembled before surgery and left open and uncovered overnight in the operating room, whereas other procedures used pressure-monitoring equipment assembled immediately before the procedure. At night, operating rooms were cleaned by maintenance personnel who used a disinfectant-water solution sprayed through a hose connected to an automatic diluting system. Observation of the use of this hose documented that this solution could have contacted and entered uncovered pressure-monitoring equipment left in the operating room. Water samples from the hose revealed no disinfectant, but grew P aeruginosa. The outbreak was terminated by setting up pressure-monitoring equipment immediately before the procedure and discontinuing use of the hose-disinfectant system.

Conclusions: This outbreak most likely resulted from contamination of uncovered preassembled pressure-monitoring equipment by water from a malfunctioning spray disinfectant device. Pressure-monitoring equipment should be assembled immediately before use and protected from possible environmental contamination.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 17 , Issue 5 , May 1996 , pp. 281 - 285
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1996

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