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Caveat Emptor: The Role of Suboptimal Bronchoscope Repair Practices by a Third-Party Vendor in a Pseudo-Outbreak of Pseudomonas in Bronchoalveolar Lavage Specimens

Published online by Cambridge University Press:  02 January 2015

Sara E. Cosgrove ,
Polly Ristaino ,
Anne Caston-Gaa ,
Donna P. Fellerman ,
Elaine F. Nowakowski ,
Karen C. Carroll ,
Jonathan B. Orens ,
Trish M. Perl  and
Lisa L. Maragakis
Sara E. Cosgrove*
Affiliation:
Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
Polly Ristaino
Affiliation:
Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
Anne Caston-Gaa
Affiliation:
Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
Donna P. Fellerman
Affiliation:
Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
Elaine F. Nowakowski
Affiliation:
Department of Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
Karen C. Carroll
Affiliation:
Department of Pathology, Division of Medical Microbiology, Johns Hopkins Hospital, Baltimore, Maryland
Jonathan B. Orens
Affiliation:
Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
Trish M. Perl
Affiliation:
Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
Lisa L. Maragakis
Affiliation:
Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
*
Osler 425, The Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287 (scosgro1@jhmi.edu)
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Abstract

Objective.

To describe a pseudo-outbreak associated with loose bronchoscope biopsy ports caused by inadequate bronchoscope repair practices by third-party vendors and to alert healthcare personnel to assess bronchoscope repair practices.

Design.

Outbreak investigation.

Setting.

A 925-bed tertiary care hospital in Baltimore, Maryland.

Patients.

Patients who underwent bronchoscopy with certain bronchoscopes after they had been repaired by a third-party vendor.

Methods.

An epidemiologic investigation was conducted to determine the cause of Pseudomonas putida growth in 4 bronchoalveolar lavage (BAL) specimens within a 3-day period in May 2008. All bronchoscopes were inspected, and cultures were obtained from bronchoscopes and the environment. Bronchoscope cleaning and maintenance practices were reviewed. Microbiologic results from BAL specimens and medical records were reviewed to find additional cases.

Results.

All 4 case patients had undergone bronchoscopy with one of 2 bronchoscopes, both of which had loose biopsy ports. Bronchoscope cultures grew P. putida, Pseudomonas aeruginosa, and Stenotrophomonas. The P. putida strains from the bronchoscopes matched those from the patients. Specimens from 12 additional patients who underwent bronchoscopy with these bronchoscopes grew P. putida, P. aeruginosa, or Stenotrophomonas. No patients developed clinical signs or symptoms of infection, but 7 were treated with antibiotics. Investigation revealed that the implicated bronchoscopes had been sent to an external vendor for repair; examination by the manufacturer revealed irregularities in repairs and nonstandard part replacements.

Conclusions.

Third-party vendors without access to proprietary information may contribute to mechanical malfunction of medical devices, which can lead to contamination and incomplete disinfection.

Infect Control Hosp Epidemiol 2012;33(3):224-229

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 33 , Issue 3 , March 2012 , pp. 224 - 229
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2012

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