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Outbreak of Pseudomonas aeruginosa Surgical Site Infections after Arthroscopic Procedures: Texas, 2009

Published online by Cambridge University Press:  02 January 2015

Pritish K. Tosh ,
Maureen Disbot ,
Jonathan M. Duffy ,
Marc L. Boom ,
Gary Heseltine ,
Arjun Srinivasan ,
Carolyn V. Gould  and
Sandra I. Berríos-Torres
Pritish K. Tosh*
Affiliation:
Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia Division of Healthcare Quality Promotion, Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Maureen Disbot
Affiliation:
The Methodist Hospital, Houston, Texas
Jonathan M. Duffy
Affiliation:
Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia Division of Healthcare Quality Promotion, Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Marc L. Boom
Affiliation:
The Methodist Hospital, Houston, Texas
Gary Heseltine
Affiliation:
Texas Department of State Health Services, Austin, Texas
Arjun Srinivasan
Affiliation:
Division of Healthcare Quality Promotion, Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Carolyn V. Gould
Affiliation:
Division of Healthcare Quality Promotion, Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
Sandra I. Berríos-Torres
Affiliation:
Division of Healthcare Quality Promotion, Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
*
Mayo Clinic Division of Infectious Diseases, 200 First Street SW, Rochester, MN 55905 (tosh.pritish@mayo.edu)
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Abstract

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 toP. 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.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 32 , Issue 12 , December 2011 , pp. 1179 - 1186
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2011

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Footnotes

a

Pritish K. Tosh, MD, Mayo Clinic Division of Infectious Diseases

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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