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Association of Bacillus cereus Infection with Contaminated Alcohol Prep Pads

Published online by Cambridge University Press:  02 January 2015

Susan A. Dolan ,
Cynthia Littlehorn ,
Mary P. Glodé ,
Elaine Dowell ,
Karen Xavier ,
Ann-Christine Nyquist  and
James K. Todd
Susan A. Dolan*
Affiliation:
Department of Epidemiology, Children's Hospital Colorado, Aurora, Colorado
Cynthia Littlehorn
Affiliation:
Department of Microbiology, Children's Hospital Colorado, Aurora, Colorado
Mary P. Glodé
Affiliation:
Section of Infectious Diseases, Children's Hospital Colorado, Aurora, Colorado Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
Elaine Dowell
Affiliation:
Department of Microbiology, Children's Hospital Colorado, Aurora, Colorado
Karen Xavier
Affiliation:
Colorado Department of Public Health and Environment, Denver, Colorado
Ann-Christine Nyquist
Affiliation:
Department of Epidemiology, Children's Hospital Colorado, Aurora, Colorado Section of Infectious Diseases, Children's Hospital Colorado, Aurora, Colorado Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
James K. Todd
Affiliation:
Department of Epidemiology, Children's Hospital Colorado, Aurora, Colorado Department of Microbiology, Children's Hospital Colorado, Aurora, Colorado Section of Infectious Diseases, Children's Hospital Colorado, Aurora, Colorado Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
*
Department of Epidemiology, Children's Hospital Colorado, 13123 East 16th Avenue, Aurora, CO 80045 ([email protected])
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Abstract

Background.

Bacillus species have caused healthcare-associated outbreaks of invasive disease as well as pseudo-outbreaks. We report an outbreak investigation of blood cultures positive for Bacillus cereus associated with alcohol prep pads (APPs) contaminated with B. cereus and Bacillus species resulting in a rapid internal product recall and subsequent international product recall.

Design.

Epidemiologic and microbiologic outbreak investigation.

Setting.

A 300-bed tertiary care children's hospital in Aurora, Colorado.

Patients.

Patients with blood or cerebrospinal fluid cultures positive for B. cereus.

Methods.

Three patients with blood cultures positive for B. cereus were identified in late 2010. Breaches in procedural and surgical techniques, common interventions, and products were explored. The following 3 common products were cultured: sterile saline syringes, chlorhexidine/alcohol skin preparation solution, and APPs. Repetitive sequence-based polymerase chain reaction (Rep-PCR) was used to compare isolates obtained from patients and from APPs and was confirmed by independent pulsed-field gel electrophoresis.

Results.

There appeared to be a significant increase in blood cultures positive for B. cereus during 2009-2010. B. cereus and other Bacillus species were cultured from the internal contents of 63.3% of APPs not labeled as sterile, and 8 of the 10 positive lots were manufactured after 2007. None of the isolates obtained from the patients matched strains isolated from the APPs. However, some lots of APPs had strains that were indistinguishable from one another.

Conclusions.

APPs that were not labeled as sterile were contaminated with Bacillus species. The product was immediately recalled internally and replaced with APPs from another manufacturer that were labeled as sterile. On January 3, 2011, the manufacturer voluntarily recalled its APPs. Healthcare facilities, healthcare providers, and users of APPs should avoid the use of APPs not specifically labeled as sterile.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 33 , Issue 7 , July 2012 , pp. 666 - 671
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2012

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