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Synopsis: Environmental contamination led to 2 nosocomial infection outbreaks.
Sources: Berrouane YF, et al. Clin Infect Dis. 2000;31:1331-1337; Weist K, et al. Infect Control Hosp Epidemiol. 2000;21: 761-764.
Both of these articles describe infection outbreaks that were the result of poor infection control. In the first article, 7 patients with hematologic malignancies developed serious infections that were traced back to a contaminated drain in a whirlpool bathtub. The infections occurred over a 14-month period. Using culture surveys and pulsed-field gel electrophoresis (PFGE), Berrouane and colleagues from the University of Iowa Hospital found that the whirlpool drain was contaminated with Pseudomonas aeruginosa. The design of the drain was such that it closed about 1 in below the drain’s strainer, allowing for a contaminated reservoir. Berrouane et al also performed a literature search and found another report of 17 bathtubs in 16 nursing homes that were contaminated with P aeruginosa.
Berrouane et al noted that the particular type of whirlpool found at the University of Iowa Hospital was a common one and may be an unrecognized source of nosocomial infections. Either a design change or thorough disinfection between patients is needed to prevent recurrence.
In the second article, 10 neonates who had Staphylococcus aureus pyodermas were compared with 31 newborns born at the same university hospital in Germany who did not have signs of pyoderma or S aureus colonization. They determined that in the infected patients, symptoms began 2-5 days after hip-joint sonography. It was determined that the spatula used to apply the sonography gel was being reused, contrary to the hospital’s infection control policy. Cultures of it and the gel yielded S aureus that was indistinguishable from the S aureus isolated from the neonates as confirmed by PFGE and amplified polymorphic DNA polymerase chain reaction (PCR) patterns.
Comment by Thomas g. Schleis, MS, RPh
Both of these articles reaffirm the need for ongoing effective and diligent infection control programs. There are other reports in the literature1,2 in which a breakdown in infection control procedures resulted in outbreaks of infection. In The Netherlands, infection and colonization of the pleural space in 3 patients was traced to contaminated thoracic drain equipment.1 In their review, it was determined that a delay in replacement of the drainage bottle jar was the main factor responsible. In Denmark, an outbreak of Pontiac fever among children and adults was linked to a contaminated whirlpool at a holiday home.2 Culture and PCR of tracheal aspirate for legionellae was used to confirm the source of contamination.
It is obvious that breakdowns in infection control are problems worldwide, and there is a need for active involvement of infectious diseases experts in infection control programs. Every program should actively review the literature to proactively determine potential sources of nosocomial infections, such as whirlpools, and perform ongoing surveillance of their programs to ensure effectiveness. Funding requests for such programs should include the savings that can be achieved by prevention of nosocomial infections.
Another important message from these articles is how the use of technology can pinpoint the source of contamination. PFGE and randomly amplified polymorphic DNA PCR (RAPD-PCR) can be used to track the source of the infection and help in implementation of corrective plans. As Berrouane et al and Weist et al pointed out, there may be a number of outbreaks that are not thoroughly investigated. These methods can assist in identifying the source of outbreaks that involve small numbers of patients.
1. Jacobs JA, Stobberingh EE. J Hosp Infect. 1993;24(1): 23-28.
2. Luttichau HR, et al. Ugeskr Laeger. 1999;161(23): 3458-3462.