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Serratia Marcescens Outbreak Associated With Extrinsic Contamination of 1% Chlorxylenol Soap

Published online by Cambridge University Press:  02 January 2015

Lennox K. Archibald ,
Ann Corl ,
Bhavesh Shah ,
Myrna Schulte ,
Matthew J. Arduino ,
Sonia Aguero ,
Donna J. Fisher ,
Barbara W. Stechenberg ,
Shailen N. Banerjee  and
William R. Jarvis
Lennox K. Archibald*
Affiliation:
Hospital Infections Program, Centers for Disease Control and Prevention (CDC)
Ann Corl
Affiliation:
Atlanta, Georgia, and Baystate Medical Center, Springfield, Massachusetts
Bhavesh Shah
Affiliation:
Atlanta, Georgia, and Baystate Medical Center, Springfield, Massachusetts
Myrna Schulte
Affiliation:
Atlanta, Georgia, and Baystate Medical Center, Springfield, Massachusetts
Matthew J. Arduino
Affiliation:
Hospital Infections Program, Centers for Disease Control and Prevention (CDC)
Sonia Aguero
Affiliation:
Hospital Infections Program, Centers for Disease Control and Prevention (CDC)
Donna J. Fisher
Affiliation:
Atlanta, Georgia, and Baystate Medical Center, Springfield, Massachusetts
Barbara W. Stechenberg
Affiliation:
Atlanta, Georgia, and Baystate Medical Center, Springfield, Massachusetts
Shailen N. Banerjee
Affiliation:
Hospital Infections Program, Centers for Disease Control and Prevention (CDC)
William R. Jarvis
Affiliation:
Hospital Infections Program, Centers for Disease Control and Prevention (CDC)
*
Hospital Infections Program, Centers for Disease Control and Prevention, Mailstop E-55, 1600 Clifton Rd, Atlanta, GA 30333
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Abstract

Objectives:

To determine risk factors for Serratia marcescens infection or colonization, and to identify the source of the pathogen and factors facilitating its persistence in a neonatal intensive-care unit (NICU) during an outbreak.

Design:

Retrospective case-control study; review of NICU infection control policies, soap use, and hand-washing practices among healthcare workers (HCWs); and selected environmental cultures.

Setting:

A university-affiliated tertiary-care hospital NICU.

Patients:

All NICU infants with at least one positive culture for S marcescens during August 1994 to October 1995. Infants who did not develop S marcescens infection or colonization were selected randomly as controls.

Results:

Thirty-two patients met the case definition. On multivariate analysis, independent risk factors for S marcescens infection or colonization were having very low birth weight (<1,500 g), a patent ductus arteriosus, a mother with chorioamnionitis, or exposure to a single HCW. During January to July 1995, NICU HCWs carried their own bottles of 1% chlorxylenol soap, which often were left standing inverted in the NICU sink and work areas. Cultures of 16 (31%) of 52 samples of soap and 1 (8%) of 13 sinks yielded S marcescens. The 16 samples of soap all came from opened 4-oz bottles carried by HCWs. DNA banding patterns of case infant, HCW soap bottle, and sink isolates were identical.

Conclusions:

Extrinsically contaminated soap contributed to an outbreak of S marcescens infection. Very-low-birth-weight infants with multiple invasive procedures and exposures to certain HCWs were at greatest risk of S marcescens infection or colonization.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 18 , Issue 10 , October 1997 , pp. 704 - 709
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1997

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