Document Detail


Pseudomonas aeruginosa respiratory tract infections associated with contaminated ultrasound gel used for transesophageal echocardiography - Michigan, December 2011-January 2012.
MedLine Citation:
PMID:  22513528     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
In late December 2011, the Department of Epidemiology at Beaumont Health System (BHS) in Royal Oak, Michigan, noted an increase in the number of positive respiratory cultures in one surgical intensive-care unit (ICU), prompting further investigation. The increase in positive cultures was attributed entirely to Pseudomonas aeruginosa. Investigation by BHS staff members found that all of these positive cultures were related to use of ultrasound transmission gel from a single manufacturer during transesophageal echocardiography. Seven patients were infected with P. aeruginosa based on National Healthcare Safety Network (NHSN) criteria, and nine were colonized. Cultures from one open and one unopened bottle of the gel grew P. aeruginosa closely related to the outbreak strain based on molecular typing via repetitive extragenic palindromic polymerase chain reaction (rep-PCR). The Oakland County Health Department, the Michigan Department of Community Health, and the Food and Drug Administration (FDA) were notified of the findings. On January 23, all implicated ultrasound gel in multiuse bottles was removed from BHS facilities and replaced with a single-use, sterile ultrasound gel for all potentially invasive procedures. On April 18, FDA issued a Safety Communication* advising health-care professionals and facilities not to use certain lot numbers of the ultrasound transmission gel and further advising that the only ultrasound gel that is sterile is unopened gel in containers labeled as sterile. To date, no further respiratory cultures have been positive for P. aeruginosa.
Authors:
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  MMWR. Morbidity and mortality weekly report     Volume:  61     ISSN:  1545-861X     ISO Abbreviation:  MMWR Morb. Mortal. Wkly. Rep.     Publication Date:  2012 Apr 
Date Detail:
Created Date:  2012-04-19     Completed Date:  2012-06-04     Revised Date:  2012-10-19    
Medline Journal Info:
Nlm Unique ID:  7802429     Medline TA:  MMWR Morb Mortal Wkly Rep     Country:  United States    
Other Details:
Languages:  eng     Pagination:  262-4     Citation Subset:  IM    
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MeSH Terms
Descriptor/Qualifier:
Cardiovascular Surgical Procedures
Echocardiography, Transesophageal / adverse effects*
Equipment Contamination*
Gels*
Humans
Michigan / epidemiology
Population Surveillance
Pseudomonas Infections / transmission*
Pseudomonas aeruginosa / genetics,  isolation & purification*
Respiratory Tract Infections / microbiology,  transmission*
Chemical
Reg. No./Substance:
0/Gels
Comments/Corrections
Comment In:
Ann Emerg Med. 2012 Sep;60(3):374-6; discussion 376-7

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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