Abstract：
BACKGROUND:Burkholderia cepacia complex (Bcc) is well-known for intrinsic resistance to certain antiseptics. We experienced a sudden rise in Bcc bloodstream infections in a 786-bed hospital. An investigation was conducted to identify the source and to intervene in the ongoing infections. METHODS:The cases were defined as patients with positive blood cultures for Bcc from October 10, 2013-December 16, 2013. We reviewed medical records, interviewed health care workers, and audited the clinical laboratory. A microbiologic culture for a suspected antiseptic was performed, and interventions were instituted. RESULTS:During the outbreak period, Bcc were isolated from 46 blood cultures from 40 patients. The temporal and spatial distributions did not reveal common factors. The clinical features of the case patients suggested pseudobacteremia. A 0.5% chlorhexidine solution product was found to be contaminated with Bcc and had been misused as a skin antiseptic during blood culture. After withdrawal of the product and staff education, the outbreak was terminated. CONCLUSION:The pseudobacteremia was caused by contaminated 0.5% chlorhexidine from a single company. This contamination was permitted by multiple breaches of infection control principles that could have caused significant outbreaks of true infections. Regulatory actions at the government level are needed to ensure the sterility of antiseptics.
journal_name
Am J Infect Controljournal_title
American journal of infection controlauthors
Ko S,An HS,Bang JH,Park SWdoi
10.1016/j.ajic.2014.11.010subject
Has Abstractpub_date
2015-03-01 00:00:00pages
266-8issue
3eissn
0196-6553issn
1527-3296pii
S0196-6553(14)01331-5journal_volume
43pub_type
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journal_title：American journal of infection control
pub_type： 杂志文章,多中心研究
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journal_title：American journal of infection control
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journal_title：American journal of infection control
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journal_title：American journal of infection control
pub_type： 杂志文章,评审
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journal_title：American journal of infection control
pub_type： 杂志文章
doi：10.1016/j.ajic.2014.06.003
更新日期：2014-10-01 00:00:00
