Outbreak of Pseudomonas aeruginosa Surgical Site Infections after Arthroscopic Procedures: Texas, 2009
Вспышка инфекций области хирургического вмешательства, вызванных Pseudomonas aeruginosa, после артроскопических процедур: Техас, 2009 год
2011-11-11
SCID: 54.1/xqtry35v
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Pseudomonas aeruginosaarthroscopic proceduresinstrument reprocessingpulsed-field gel electrophoresissurgical site infections
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Abstract (AI)
SETTING: Seven organ/space surgical site infections (SSIs) that occurred after arthroscopic procedures and were due to Pseudomonas aeruginosa of indistinguishable pulsed-field gel electrophoresis (PFGE) patterns occurred at hospital X in Texas from April 22, 2009, through May 7, 2009. OBJECTIVE: To determine the source of the outbreak and prevent future infections. DESIGN: Infection control observations and a case-control study. METHODS: Laboratory records were reviewed for case finding. A case-control study was conducted. A case patient was defined as someone who underwent knee or shoulder arthroscopy at hospital X during the outbreak period and subsequently developed organ/space SSI due to P. aeruginosa. Cultures of environmental and surgical equipment samples were performed, and selected isolates were analyzed by PFGE. Surgical instrument reprocessing practices were reviewed, and surgical instrument lumens were inspected with a borescope after reprocessing to assess cleanliness. RESULTS: The case-control study did not identify any significant patient-related or operator-related risk factors. P. aeruginosa grew from 62 of 388 environmental samples. An isolate from the gross decontamination sink had a PFGE pattern that was indistinguishable from that of the case patient isolates. All surgical instrument cultures showed no growth. Endoscopic evaluation of reprocessed arthroscopic equipment revealed retained tissue in the lumen of both the inflow/outflow cannulae and arthroscopic shaver handpiece. No additional cases occurred after changes in instrument reprocessing protocols were implemented. After this outbreak, the US Food and Drug Administration released a safety alert about the concern regarding retained tissue within arthroscopic shavers. CONCLUSIONS: These SSIs were likely related to surgical instrument contamination with P. aeruginosa during instrument reprocessing. Retained tissue in inflow/outflow cannulae and shaver handpieces could have allowed bacteria to survive sterilization procedures.
Key Findings
1
Borescope inspection identified retained tissue inside reprocessed arthroscopic inflow/outflow cannulae and shaver handpieces, despite negative cultures from surgical instruments.
2
Pseudomonas aeruginosa was recovered from 62 of 388 environmental samples, including a gross decontamination sink isolate matching patient isolates by PFGE.
3
Seven organ/space surgical site infections caused by indistinguishable Pseudomonas aeruginosa strains occurred after arthroscopic procedures in Texas during April–May 2009.
4
The investigation found no significant patient-related or operator-related risk factors in the case-control study.
5
The outbreak likely resulted from instrument contamination during reprocessing; no further cases occurred after reprocessing protocols were changed, prompting an FDA safety alert.
Research Object
Pseudomonas aeruginosa organ/space surgical site infections following knee or shoulder arthroscopy at a Texas hospital
Research Subject
The outbreak source and the role of contaminated, inadequately reprocessed arthroscopic instruments with retained tissue in infection transmission
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