Nosocomial Pseudomonas pickettii bacteremias traced to narcotic tampering. A case for selective drug screening of health care personnel

Three patients in a university hospital developed nosocomial infusion-related Pseudomonas pickettii bacteremia. Investigation identified six additional patients who had received intravenous fluid contaminated by P pickettii but did not become ill. All nine patients had had surgery, and each of these patients but only nine of 19 operated-on control patients had received intravenous fentanyl citrate in the operating room; the mean dose given to the nine case patients was far greater than that given to control patients. Fentanyl in 20 (40%) of 50 predrawn 30-mL syringes was shown to be contaminated by P pickettii. Contamination was caused by theft of fentanyl from predrawn synringes and replacement by distilled water contaminated by P pickettii. Narcotic theft by health care personnel may cause patients to suffer pain needlessly and can also result in dire unanticipated consequences, such as nosocomial bacteremia. Whereas drug testing in the workplace is highly controversial, we believe that testing of health care personnel is indicated when drug abuse or theft is suspected.     

Pseudomonas cepacia colonization and infection in intensive care units.

Pseudomonas cepacia has become a prominent epidemic nosocomial pathogen over the past 15 years. Between December 1982 and September 1983 it was isolated from 29 patients in two intensive care units (ICUs) at one hospital. Twelve infections--five bacteremias, four pneumonias and three urinary tract infections--occurred. Most of the isolates (25/29) were from the respiratory tract, and most (23/29) had the same antibiogram as the only environmental isolate, which was cultured from a contaminated ventilator thermometer, a previously unrecognized source of nosocomial infection. The ventilator thermometers were calibrated in a bath whose water had not been changed for months and contained P. cepacia. Despite elimination of this reservoir, P. cepacia was eradicated from the ICUs only after intensive infection control efforts were instituted.     

Nosocomial Pseudomonas aeruginosa urinary tract infections

Two separate outbreaks of Pseudomonas aeruginosa urinary tract infections (UTIs) were associated with cystoscopy or transurethral prostate resection. The first outbreak was identified after routine bacteremia surveillance demonstrated four cases of P aeruginosa septicemia in a three-month period. A six-month retrospective review of the microbiology records identified 14 cases of P aeruginosa UTI associated with urologic surgery instrumentation. The outbreak terminated after the implementation of two major control measures: (1) replacement of hexachlorophene solution with an iodophor solution for preparing patients and cleaning instruments before disinfection, and (2) weekly gas sterilization of cystoscopy instruments. The second outbreak, consisting of 11 cases of P aeruginosa UTI after transurethral resection of the prostate gland, occurred in a 187-bed community hospital. All available patient isolates were serotype 011, and culture of a rubber adaptor attached to the resectoscope also yielded growth of that serotype. The outbreak promptly terminated when the rubber adaptor was sterilized between cases.     

Legionnaires' disease caused by Legionella dumoffii in distilled water.

Five cases of Legionnaires' disease caused by Legionella dumoffii were identified within an 11-month period in a hospital in the Quebec City area. In four cases bacterial isolates were obtained from clinical specimens, and in one case seroconversion was demonstrated. All the patients had been admitted to hospital within 10 days before diagnosis. Two of the patients were immunosuppressed children. Only 1 of the 40 hot water samples from the hospital yielded L. dumoffii; however, 6 of 11 distilled water samples contained the bacterium. All the patients had been exposed to distilled water, four through respiratory therapy equipment and one through a room humidifier. Following the use of sterile distilled water in the apparatus, no further cases were identified. This is the first reported outbreak of Legionnaires' disease caused by L. dumoffii, and it is the first time that nosocomial legionellosis has been linked to contaminated distilled water in Canada.     

Bacteraemia after manipulation of the urinary tract. The importance of pre-existing urinary tract disease and compromised host defences.

The factors related to the occurrence of bacteraemia following urinary tract manipulation were studied in a large community hospital. During a 3-year period, forty-six of 326 episodes of hospital-acquired bacteraemia were associated with urinary tract manipulation. All thirty of forty-six cases felt to be definitely related to urinary tract manipulation (other obvious sources of bacteraemia being absent) had pre-existing urinary tract disease, especially of an obstructive type; only one in this group died from sepsis. The remaining sixteen patients had other possible sources of bacteraemia besides urinary tract manipulation and had disorders associated with defects in host defences; twelve (75%) in this group died from overwhelming sepsis. Thus, if bacteraemia occurs in a patient having had urinary tract manipulation but without any underlying urinary tract abnormality or impairment in host defences, its source should be searched for in other areas of the body.     

Epidemiology of campylobacter diarrhoea

Campylobacter diarrhoea was diagnosed bacteriologically in 535 patients. Most of these patients required hospitalization, but no fatalities were recorded. The age-specific incidence of campylobacter enteritis showed a trimodal distribution. Overseas travel was a factor in 14% of all cases. Food, including "fast food", may be an important source of infection. Campylobacter enteritis was more prevalent during summer than winter. Campylobacter bacteraemia was detected in only four cases. Biotyping was performed on 285 of the strains that were isolated. Biotype analysis showed that there was a clustering of cases of certain biotypes, even though community-wide outbreaks were not recognized in the period of review.     

Risk factors for typhoid outbreak in Sungai Congkak Recreational Park, Selangor 2009

Typhoid fever continues to pose public health problems in Selangor where cases are found sporadically with occasional outbreaks reported. In February 2009, Hospital Tengku Ampuan Rahimah (HTAR) reported a cluster of typhoid fever among four children in the pediatric ward. We investigated the source of the outbreak, risk factors for the infection to propose control measures. We conducted a case-control study to identify the risk factors for the outbreak. A case was defined as a person with S. typhi isolated from blood, urine or stool and had visited Sungai Congkak recreational park on 27th January 2010. Controls were healthy household members of cases who have similar exposure but no isolation of S. typhi in blood, urine or stool. Cases were identified from routine surveillance system, medical record searching from the nearest clinic and contact tracing other than family members including food handlers and construction workers in the recreational park. Immediate control measures were initiated and followed up. Twelve (12) cases were identified from routine surveillance with 75 household controls. The Case-control study showed cases were 17 times more likely to be 12 years or younger (95% CI: 2.10, 137.86) and 13 times more likely to have ingested river water accidentally during swimming (95% CI: 3.07, 58.71). River water was found contaminated with sewage disposal from two public toilets which effluent grew salmonella spp. The typhoid outbreak in Sungai Congkak recreational park resulted from contaminated river water due to poor sanitation. Children who accidentally ingested river water were highly susceptible. Immediate closure and upgrading of public toilet has stopped the outbreak.     

Nosocomial outbreak of Pseudomonas aeruginosa folliculitis associated with a physiotherapy pool.

Outbreaks of community-acquired Pseudomonas aeruginosa folliculitis have recently been described in association with health spa whirlpools. In February 1984 we detected an outbreak of Pseudomonas folliculitis among hospital staff and patients using a swimming pool in a newly constructed physiotherapy unit. A rash developed in 5 (45%) of the 11 physiotherapists who had used the pool, as compared with 0 of the 17 who had not (p less than 0 005). Pseudomonas folliculitis also developed in 6 (21%) of 29 outpatients and 4 (33%) of 12 inpatients who had used the facility; Pseudomonas infection of a surgical wound also developed in 1 of the 4 inpatients. The epidemic curve was consistent with a continuing common-source outbreak. P. aeruginosa, serotype O:10, was isolated from three physiotherapists, the patient with an infected surgical wound and the pool. A case-control study of pool users did not identify risk factors for infection, although the physiotherapists had spent longer in the pool than had the patients. After hyperchlorination and structural repairs to the pool, no further cases were identified among pool users. This outbreak is the first reported nosocomial outbreak of Pseudomonas folliculitis. Further investigation is needed to determine the risk of serious Pseudomonas infections in hospitalized patients using physiotherapy pools.     

Hepatitis B in general practice: epidemiology, clinical and serological features, and control

In an outbreak of hepatitis B virus infection in a south Wales village 31 cases were identified over 16 months. Spread of the infection was by sharing needles and by sexual contact. Twenty seven patients were known to have symptoms, of whom nine had an anicteric illness. Generally the illness was mild with no deaths, and there was only one chronic carrier. Two patients were only transiently positive for hepatitis B surface antigen. The outbreak was controlled by vigorous contact tracing and counselling. Despite an enormous increase in workload for the general practitioner and problems including disposal of contaminated needles, outbreaks of hepatitis B virus infection may adequately be treated in the community.     

Epidemiological survey and analysis on an outbreak of gastroenteritis due to water contamination

Objective

To document the investigation and control of an outbreak of gastroenteritis in City G, South China, and provide a reference for preventing future outbreaks.

Methods

An ambispective cohort study was designed. Attack rate (AR) and relative risks (RR) were calculated to identify the causes of gastroenteritis. Investigations using questionnaires included personal interviews with patients and doctors, reviews of medical records, laboratory examinations of fecal specimens and continuous hygiene monitoring of water samples from the waterworks.

Results

Overall, 427/71534 (AR=5.97%) cases were identified between October 31 and November 12 2010. Geographic distribution was highly localized, with 80% of cases occurring in the areas supplied by waterworks-A. Consumption of water provided solely by waterworks-A was found to be associated with illness (RR=8.20, 95 CI%:6.12-10.99) compared with that from waterworks-B. Microbiological analyses confirmed the presence of Norovirus in six of eight fecal samples from symptomatic patients, two water samples from waterworks-A and two sewage samples. After taking effective measures, the hygienic indices of waterworks-A met health criteria again on November 9 and no cases were reported 3 days later.

Conclusion

The outbreak reported here was caused by drinking tap water contaminated with sewage at the source. Early identification of possible contamination sources and awareness of changes that might negatively impact water quality are important preventive measures to protect public health.