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Pseudooutbreak of Stenotrophomonas maltophilia bacteremia in a general ward.

Park YS, Kim SY, Park SY, Kang JH, Lee HS, Seo YH, Cho YK

Division of Infectious Diseases, Gachon University, Gil Medical Center, Incheon, Korea. karmacho@gilhospital.com

BACKGROUND: Stenotrophomonas maltophilia is a significant nosocomial pathogen and is commonly isolated in the hospital environment. We investigated the risk factors for a bloodstream pseudooutbreak of S maltophilia in a general ward. METHODS: On November 24 and 25, 2005, 7 patients without evidence of sepsis were reported as positive for blood culture with S maltophilia from blood samples collected on November 21 and 22, 2005. We conducted an epidemiologic investigation and a case-control study of this pseudooutbreak. RESULTS: All 7 S maltophilia showed the same antibiogram and an indistinguishable pattern on pulsed-field gel electrophoresis. The observational study revealed multiple lapses in infection control, including multiple use of a single bottle of saline for dilution of antibiotics. A case-control study showed that one health care worker, who collected blood samples from 6 of 7 patients, was a significant risk factor for the pseudooutbreak of S maltophilia (P < .05). CONCLUSION: We suggest that the combination of multiple lapses in infection control and the blood-collecting behavior of a health care worker might be the cause of the pseudooutbreak of S maltophilia.

Published 4 February 2008 in Am J Infect Control, 36(1): 29-32.
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