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

  • Lennox K. Archibald (a1), Ann Corl (a2), Bhavesh Shah (a2), Myrna Schulte (a2), Matthew J. Arduino (a1), Sonia Aguero (a1), Donna J. Fisher (a2), Barbara W. Stechenberg (a2), Shailen N. Banerjee (a1) and William R. Jarvis (a1)...



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.


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


A university-affiliated tertiary-care hospital NICU.


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.


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.


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.


Corresponding author

Hospital Infections Program, Centers for Disease Control and Prevention, Mailstop E-55, 1600 Clifton Rd, Atlanta, GA 30333


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

  • Lennox K. Archibald (a1), Ann Corl (a2), Bhavesh Shah (a2), Myrna Schulte (a2), Matthew J. Arduino (a1), Sonia Aguero (a1), Donna J. Fisher (a2), Barbara W. Stechenberg (a2), Shailen N. Banerjee (a1) and William R. Jarvis (a1)...


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